Federal Grant Helps Nursing Students Boost Their Cultural Sensitivity

By Elizabeth O. Cooper

Embroiled in an abusive relationship, a woman reluctantly confides in you, her healthcare provider. How do you respond?

An older woman consistently refuses to have a mammogram. How do you convince her to be tested?

A homeless man has been diagnosed with a mental illness. How do you ensure that he is treated with dignity and compassion?

A man refuses treatment for a potentially life-threatening medical condition because of his religious convictions. How do you show respect for his religion while persuading him to accept treatment?

These are just a few examples of situations many nurse practitioners are facing as the country’s population becomes increasingly culturally diverse. By 2010, two out of five people in the United States will be minorities. Despite this rapid increase, many healthcare providers are unprepared to deal with the different needs of diverse populations. Insensitive responses or an unwillingness to acknowledge and understand different cultural beliefs could prevent patients from accessing the care they need.

To counter that, Old Dominion University’s School of Nursing has obtained a $533,000 federal grant to enhance students’ cultural competency. The Educating Culturally Competent Nurse Practitioners in Virginia project is a comprehensive effort to teach students in the school’s family, women’s health and pediatric nurse practitioner program how to better serve more diverse patients. The grant will also be used to attract culturally diverse undergraduate and graduate students and faculty to the school. This push for cultural sensitivity comes on the heels of an Institute of Medicine Quality Chasm report showing that minorities are often treated differently in the healthcare system. In response, new guidelines from the Nurse Practitioner Primary Care Competencies of the U.S. Department of Health and Human Services require programs nationwide to teach nursing students how to be more culturally sensitive.

“What we are doing is applicable to other programs across the country,” says Laurel Garzon, graduate program director for nursing and the grant’s project director. “This is an opportunity to provide leadership in understanding diverse populations. All practitioner programs in the country are dealing with this and might want to adopt this method.”

According to Garzon, a variety of factors come into play when healthcare providers show insensitivity toward other cultures. “Some of it is related to bias on the part of the provider. Some of it’s related to a lack of knowledge. It’s very easy to make somebody a stereotype, but we have to ensure we have provided students with the competency to work with multicultural groups.”

Assessing and Strengthening Cultural Competency
In the first year of the grant, nursing faculty are measuring students’ levels of cultural competency to determine their attitudes about various populations. They are also developing ways—such as panel discussions, guest speakers, lectures and class assignments—to incorporate cultural sensitivity into the curriculum. Those methods will be implemented during the next academic year.

Using a self-assessment tool, students reflect on their attitudes regarding a variety of groups, including the elderly, homosexuals, those from other cultures and domestic violence survivors. The survey also asks about students’ own cultural groups to give them a better sense of the group with which they identify. “A lot of diversity is invisible,” says Stacey Plichta, associate professor of community and environmental health. “If you don’t think about diversity in broad terms, you don’t think to look for it or ask for it.”

In developing the curriculum, Old Dominion is conducting focus groups using people from diverse populations, who represent various ethnic, economic, religious, gender and sexual preference situations, as well as special health needs such as mental illness, HIV and AIDS. “We want to find out their perceptions of healthcare providers, their experiences and how we can help providers be more sensitive,” says Richardean Benjamin, associate professor of nursing.

The focus groups are also a way for the nursing school to diversify its student and faculty populations, as well as to help abate the nationwide nursing shortage. “We are seeking to increase the diversity of our applicant pool,” Garzon says, noting that only 10 percent of the school’s graduate students are non-white females, and only 12 percent to 15 percent of undergraduate students are minorities. “We want to be sure we get the message out using some of these community groups. As we reach out to diverse populations, they start to think about health careers.”

Acting Out Diversity
Nursing students have already been honing their cultural sensitivity skills by participating in standardized cases using professional actors as patients. This role-playing is part of a program with Eastern Virginia Medical School’s Thomas Center. Actors represent patients from various socioeconomic backgrounds, and students are evaluated on how well they work with the “patients.” Although most cases take place in Norfolk, the patient actors drive to several of Old Dominion’s TELETECHNET sites to play roles with distance learning nursing students, many of whom only see patients from their own cultural group.

“These standardized patients are excellent at giving students feedback,” says Carolyn Rutledge, associate professor of nursing. “The students have been positive about the standardized patients and ask for more sessions. They are finding out that understanding patient care isn’t about the provider. You have to separate yourself from your biases.”

One recent mock situation focused on the unique healthcare needs of a lesbian. “After the encounter, there was quite a bit of surprise about how open the patient could be, and all the information the nurses should consider,” Rutledge says, noting that “alternative lifestyles are tough for many students.”

Improving Knowledge and Communication
Often, stereotypical views of diverse cultures arise from a lack of knowledge and poor communication on both the part of the practitioner and the patient. “We really don’t talk well together,” Garzon says. “We don’t listen. We don’t hear.” In addition, many patients from diverse backgrounds distrust healthcare providers and have difficulty accessing medical care due to cost and other factors.

“A lot of times it’s simply ignorance,” Plichta adds. “If a nurse practitioner doesn’t understand the dynamics of working with women in violent relationships and asks ‘Why don’t you just leave him?’ that’s the worst thing he or she can say. Women who survive violence will be walking in with physical and mental health problems. If a healthcare provider doesn’t know, he or she may be ordering all kinds of unnecessary procedures.”

Rutledge recalls the time a patient came to her office complaining of an ear infection, when in fact she was a victim of domestic abuse. “A lot of times, patients don’t know who is taking the call at the front desk and won’t give the correct information because of the shame tied to it.”

Embarrassment often plays a role with older women when it comes to breast health. “Older women are less likely to get mammograms,” Garzon notes. “They feel like healthcare providers are not interested in what they have to say. They are not comfortable talking about breasts or other private issues.”

In other cases, diseases, such as hypertension, are treated differently based on the ethnicity of the patient. “Different medications such as diuretics are found to have better outcomes in African Americans than in whites,” Rutledge says.

She suggests nurse practitioners take time to learn about a patient’s family history, country of origin, educational level, socioeconomic class, religious affiliation, native language, participation in ethnic and neighborhood activities and spouse’s ethnic history. However, it is difficult to fit all of that into one visit, especially with the steadily declining amount of time healthcare providers spend with individual patients.

“We really emphasize to students that they might not get all the information in one visit, and that they can have patients come back for a follow-up if they have issues they need to explore,” Rutledge adds, noting that in addition to dialogue, healthcare workers can find out the information through assessment sheets and other formats. “The picture grows as you get more information. We’re trying to give the students a lot of tools to help them better assess their patients.”

However, some patients resist giving a lot of personal information, maintaining that the provider is prying into areas that have nothing to do with their health.

“As a provider the best you can do is be open, be caring, and try to develop a connection with them,” Rutledge says. “It’s the patient’s choice to come in and reach out. We just have to open the door for them.”

Benjamin adds that while patients may initially believe the questions are intrusive, many will open up if they are reassured that the provider is not making judgments about them. “If a patient feels the provider cares enough to ask certain questions, they are more apt to open up.”

Plichta adds that many healthcare providers have not encountered diverse groups and base their attitudes and response on their life experiences. “There’s no reason to think that just because someone is in health care, they are any more or any less knowledgeable about different cultures. Our students are representative of the communities they come from, and everybody comes with attitudes when they walk in the door. There may be some natural growth in cultural competency as they go through the nurse practitioner program. The question is to what extent there is natural growth and how can we help the students really grow.”