14. TEACHING TRANSCULTURAL CARE

This chapter examines the practical issues involved with the development of transcultural nursing curriculum and recruitment of nurses from diverse populations. A major aim of transcultural nursing is to understand and assist diverse cultural groups and members of such groups with their nursing and health care needs. Problems often occur when persons from two cultural backgrounds with conflicting values meet, unless at least one of the persons is willing and able to recognize and adapt to the values of the other. One method of reducing potential misunderstandings is to sensitize nurses to their own cultural biases and behaviors as well as to those of their clients.

Byerly (1997) outlined four multicultural curriculum models that can be used to educate transcultural nurses:

Integrative approach: one in which cultural concepts and constructs are unified with other content in such a manner that students are encouraged to discover, create and think about rather than accumulate, more facts. Transcultural concepts pervade the total curriculum in this approach.
Course approach: requires educationally prepared faculty (with background in anthropology or social science) to provide a concentrated emphasis on cultural aspects in health and illness.
Interdisciplinary approach: which introduces cultural components in conjunction with classes offered by departments of anthropology or social science.
Unit-construction approach: specific learning units deal primarily with cultural components in health and nursing care.

Although she recommends a combination of the first three approaches, she concludes that what is possible to offer ultimately depends on available resources, the size and educational preparation of faculty, level at which students enter the nursing program, and the degree of voluntary or required affirmative action to meet the needs of various racial/cultural groups.

On the other hand, Leininger (1995) believes that a unit-construction approach can be an effective method of teaching transcultural nursing at both an undergraduate and graduate level. Leininger published sample transcultural undergraduate and graduate nursing course syllabi as a means to encourage development of coursework designed to teach transcultural nursing concepts, principles, theories, research, and practices.

The introductory transcultural nursing course description for undergraduate students focuses on transcultural nursing as the central base to promote health and well-being and help students learn about cultural care beliefs, values, and practices of specific cultures and subcultures. Within course objectives are goals for students to examine tendencies for ethnocentrism, culture and gender biases, cultural blindness, and imposition practices that set barriers towards providing culturally congruent and competent nursing care across the lifespan.

Leininger suggests that nursing faculty use a great variety of teaching-learning methods for the course, such as;

direct observation, participation and interaction accounts, reflective analysis and discussion of daily cultural life events, use of client-student encounters or situations, use of cultural and transcultural films, open discussion on cultural heritage and life experiences, storytelling and narratives related to a particular culture, panel presentations on specific cultures or subcultures, use of biographies across cultures, and use of ethnonursing field journal data.

The graduate course proposal focuses on theoretical perspectives, anthropological concepts, and diverse research methods, with the goal of improving the quality of nursing care to diverse populations. Suggested nursing knowledge domains include the use of qualitative and quantitative comparative research methods to study transcultural nursing phenomena and the ethical, moral, and legal issues related to transcultural nursing research, and practice.

The concept of culture should be addressed, together with an examination of stereotypes and genuine differences that may exist between groups. Nursing students need to develop an increased awareness of their own culture as well as that of the profession in order to become sensitive to the interface between themselves and the nursing profession. Developing an awareness of his or her own culture will enable the nurse to examine issues such a prejudice, discrimination, values, beliefs, attitudes, and social mores. Ideas about health and illness and the expectations clients may have of professionals can also be explored and compared. The culture of Western professional health care needs to be examined and compared with that of other cultures so nurses can be made aware of the potential for culture clash and culture shock.

Sue and Sue (1990) maintain that counseling training programs need to train helping professionals to accomplish the following three objectives. These can also be applied to transcultural nursing educational programs.

Counselor (Nurse) Awareness: see self as a cultural being by developing a multicultural identity, understanding one's own world view, ability to understand and deal with the complexities and ambiguities of oneself.
Entering the Worldview of Clients: Understanding the complexities of working with culturally diverse clients, not only the language and knowledge of a specific culture, but the ability to discover the rules and norms that guide individuals within that culture.
Intervention Strategies: The ability to be eclectic, flexible, adaptable, and to incorporate a variety of dimensions in the helping process such as; the affective, cognitive, behavioral, and spiritual domains. The ability to work effectively at the individual, family, community, organizational, and political level, when appropriate.

A pluralistic educational organization is required to effectively train helping professionals. Within the pluralistic organization are culturally diverse faculty and students. Faculty in this organization recognize that internal awareness and cultural awareness is an on-going process and are committed to make the necessary efforts to ensure progress. Both faculty and students continue to seek internal awareness regarding prejudice, discrimination, and racism. There are five levels of internal awareness. They are as follows:

Naive: This individual is not aware of any biases and prejudices (classism, bigotry, discrimination) they may have, nor their impact. Naive individuals have usually come from a homogeneous background and lack experience with culturally diverse groups.
Perpetuator: The perpetrator is aware of his or her biases and prejudices and is likely to reinforce negative stereotypes despite contrary evidence. This individual concentrates on negative media coverage and is likely to label all persons within that culture as having the same characteristics as the individual (individuals) covered in the media.
Avoider: Aware of the biases, problems of prejudices in faculty, students, and administration, this person will play it safe and do nothing to change the prejudicial attitudes and discriminatory actions displayed in the organization.
Cultural Awareness: This individual continues to seek knowledge and understanding about other cultures and races. He or she recognizes that cultural awareness begins with self awareness i.e.; becoming aware of one's biases, monitoring attitudes and behaviors, and correcting faulty assumptions when appropriate.
Change Agent: This individual is willing to take a risk and take action to address prejudicial statements (including stereotypes) and discriminatory actions, when appropriate.

The following are important questions to ask when educating nurses to work across cultures:

Where are the faculty on the spectrum? How does their level of internal awareness affect instruction?
On what level are the students who come into the training program?
What can be done to move students toward cultural awareness?

Any form or teaching about race and culture issues will probably have a positive effect compared with not addressing them at all. The manner in which these issues are addressed is also very important if entrenched attitudes and stereotypes are to be effectively challenged. Is it possible for faculty to honestly present to students the experiences of an ethnic minority or racial group of which he or she is not a member? Can faculty present the lived experience of being on the receiving-end of prejudice and discrimination? How can faculty best support racially/culturally diverse students? There are no easy answers to these questions. The study of racism is not simply academic. It inevitably involves challenging attitudes and beliefs.

Students need to be aware of the multitude of ways to identify prejudice, discrimination and racism in order to start the process of change. Subtle forms of racism can be seen in a variety of attitudes and behaviors. For example:

Denial: pretending institutional racism does not exist and looking for tokens to reinforce the pretense.
Tokenism: implying that there is freedom and equality between dominating and repressed groups by giving opportunities to succeed to a limited number of individuals.
Displacement: defining dominating-suppressing problems as "their problem".
Exemption: defining minority persons who succeed, as an "exception to the rule".
Sheer Omission: the nursing department states that it wants diverse students to seek admission and fails to outreach in their communities.

The following characteristics are more evident and yet, can be seen throughout America's institutions, i.e., educational and healthcare organizations.

Patronization: an adoption of an air of superiority and condescension toward an individual or a group.
Paternalism: the attitude that the repressed individual or group is at best, irresponsible and should have important decisions made by members of the power group.
Compartmentalization: holding on to broad principles of equality on an institutional basis, yet avoiding personal contact with diverse populations.
Negative-Paired Associations: expounding cultural clichés that reinforce stereotypes, for example; "drunken" Indian, equating black with bad and white with good.
Finesse: subtle manipulation of an individual or entire group by subtle diversion such as; a task group that has no power to make change.
Self-fulfilling Prophecy: the practice of deciding something is true and then making it come true, as assuming that all students speaking English as a second language will have problems succeeding in the nursing program and offering little in the way of services to ensure success.
Put Down: overt or subtle ways of keeping a person or group from experiencing competence or success as equals, i.e., "You are a credit to your race."

The overall effect is to create a reality gap that lowers white consciousness and loss of humanity by not treating others as one would want to be treated. The second loss faced when racism is evident is a loss of resources. One is locked in his or her own culture and becomes blinded to the potential leadership and talents of the oppressed group. The ultimate result is guilt and fear as racism makes the possibility of equality impossible and the power group may then be held responsible for events of the past.

There appears to be no ideal approach to the teaching of transcultural care. Education of transcultural nurses needs to deal with issues of racism because the clients they will be serving are products of the prejudice and discrimination that occurs on a personal, cultural and institutional level. Recruiting diverse faculty and students, designing and offering transcultural nursing curriculum, inviting culturally diverse representatives to participate in various awareness projects; give presentations to nursing students in the classroom, panel discussions, and mentoring, are just a few methods that can lead to cultural awareness.

The first consideration is how the institution can recruit and keep diverse nursing students. Outreach needs to be appropriate, seeking students through culturally diverse organizations, high-schools, and community based media. The educational institution needs to have a philosophy that encourages diverse students and students that are culturally sensitive to apply for admissions. For example, the Century College Nursing Student Supplemental Information Packet requests that the student briefly summarize factors which the student feels will enhance his or her ability to work with individuals or families from different cultures or ethnic groups. Students are then asked to back their statement with educational background, work/volunteer experiences, family experiences, and/or languages spoken. The mission statement is clearly presented on this form and states that the program is designed to "serve and graduate culturally sensitive individuals with multicultural experiences."

The second consideration must be what is practical, particularly in relation to pre-registration or part-time students, whose classroom time is limited. The amount of time available needs to be considered realistically. The amount of tutoring needed for students for whom English is a second language, and the amount of personal student contact needed to ensure success with culturally diverse nursing students. Many of these activities, which arc designed to support minority students throughout a rigorous two-year RN program at Century College in Minnesota, was made possible by a grant funded by the 1993 and 1995 Minnesota Legislature. There is a commitment by the college to continue these activities in order to recruit, encourage, and train culturally diverse nurses, so sorely needed in the community.

Project activities (as they relate to student success) include:

Student contact - Nursing Diversity Project Coordinators focus much attention and effort on maintaining close contact with students, including keeping a file for each student and quarterly grade sheets, notes on student contacts, and bimonthly meetings held to discuss concerns, share stories and give information regarding available resources.
ESL (English as a Second Language) students are given the option of taking their exams separate from the large group in an area where vocabulary or grammar usage questions could be asked of the proctor. These exams are supervised by either the Transcultural Nursing Coordinator or other nursing faculty.
Students are encouraged to form study groups to prepare for exams.
Faculty are encouraged to increase the diversity content of their classes.
Mentor - diversity students can choose to be paired with a professional nurse mentor. These mentors are recruited by the Coordinators and Nursing Program Directors.
Financial Aid - A separate source of funding students, the "Grants for Persons of Color" is awarded to those who meet the required specifications. When appropriate, diverse students are also encouraged to apply for scholarships and grants that are available through Century Foundation and the community at large.
Health Partnership - The Director of Nurses, and the Transcultural Nursing Coordinator, as well as the nursing faculty have formed a coalition of public employers who are aware of grant activities and students of color who are graduating as potential employees.

Because the grant necessitated focusing attention on students of color for recruitment and retention there was initially some resentment and complaints of reverse discrimination from non-minority students. This was a dilemma for minority students as well, as some of them felt ostracized from their classmates for receiving "special attention." In all cases the extra efforts and the opportunity for alternate testing was strictly voluntary. Some chose to take advantage of the opportunities and others did not. Only ESL (English as a Second Language) students were offered the separate testing and extra time, but if others requested that accommodation it was granted.

It is important to note that students of color met the same requirements of admission as all other students and were required to meet the same passing standards within the program. It was interesting, too, that fewer complaints were noted with incoming nursing students who had the supplemental questionnaire as part of the admission process. Perhaps this difference occurred because the values of the program were made clear up front and admitted students were more sensitive to the needs of diverse students.

In the final report of the grant, the Century College nursing faculty concluded that the nursing program was greatly enriched by the increased presence of students of color. It is the intention of the program to continue efforts to recruit, maintain and graduate students of color. Students benefit, the college benefits, and ultimately the community benefits as diverse nurses enter the profession. Perhaps it is time for all college programs to commit the resources necessary to give priority to training transcultural nursing across all populations of incoming nursing students.