Diana R. Mager, DNP, RN-BC, and Sheila Grossman, PhD, APRN, FNP-BC, FAAN

Transcription

1 2.1 HOURS Promoting Nursing Students' Understanding and Reflection on Cultural Awareness With Older Adults in Home Care It is important for nursing programs to use culturally focused activities to increase student preparation in caring for diverse older adults in their homes. The purpose of this study was to examine strategies that promote students' reflection on cultural awareness using home care focused case studies, simulations, and self-reflective writing activities. Cases and simulations were designed to depict diverse patients living at home with a variety of demographic characteristics, such as health history, age, culture, religion, dietary preferences, marital status, family involvement, and socioeconomic status. Qualitative data regarding student perceptions of cultural awareness was gathered via written surveys, and findings suggest that junior- and senior-year nursing students enhanced the depth and Diana R. Mager, DNP, RN-BC, and Sheila Grossman, PhD, APRN, FNP-BC, FAAN 582 Home Healthcare Nurse

2 breadth of how they defined cultural competence after participating in culturally focused classroom and clinical laboratory activities. Levels of reflective writing using N. Hatton and D. Smith's (1995) framework also improved by the semester's end for both groups of students. Background The Institute of Medicine (IOM) reports increasing racial and ethnic diversity in the United States as well as exponentially higher numbers of older adults that nurses are caring for in 2013 than ever before (IOM, 2008; IOM, 2010). Given the diversity nurses face, a lack of cultural knowledge can contribute to suboptimal patient care and miscommunications along with potential health disparities (Dorrejo & Wilson, 2012; Momeni et al., 2008). With increased health challenges of older adults, increasingly scarce financial resources, and growing numbers of people for whom English is not their primary language (Young, 2013), educating nurses about cultural care for this population is critical. Many older adults desire to stay in their homes and be cared for by their own family/ significant others with support from home care clinicians and home health aides as needed (Averill, 2012; Davis & Smith, 2013). For nurses to render holistic care to patients in their homes, they require specific skills to meet patient cultural needs in this setting (Hines, 2012; Young, 2012; Young, 2013). Enhancing cultural competence at the undergraduate level allows nursing students the opportunity to gain more knowledge about older adults healthcare and cultural needs at home or in any setting. Nursing programs need to promote culturally focused activities to increase student knowledge in preparation for caring for the older adult in all healthcare settings. The challenge involves determining ways to incorporate productive learning to increase students cultural competence. Purpose To examine strategies that promote students reflection on cultural awareness using home care focused case studies and/or simulations; enhance their definition of cultural competence; and increase their level of reflective writing in regards to culture. Literature Review The literature reflects that multiple methods have been employed to teach cultural competence to students, including integrating culture across curricula, and offering cultural courses and international exchanges (Kardong-Edgren & Campinha- Bacote, 2008). Cultural care has also been incorporated into high-fidelity simulations (Grossman et al., 2010; Reese et al., 2011) and case study analyses (Mihalic et al., 2010; Prosser et al., 2012). Although it is imperative for healthcare professionals to embrace culture in any setting, Prosser et al. concluded that ethical and cultural dilemmas require introspection of personal and professional values to provide culturally congruent care (p. 585). Reflective writing assignments were one method used in the current study to promote such introspection and awareness. Evidence suggests that incorporating cultural diversity into curricula using reflective writing maximizes students cultural competence (Schuessler et al., 2012). The value of reflective writing is to stimulate thoughts on theoretical or clinical concepts and not on fact memorization (Taylor-Haslip, 2010). Langley and Brown (2010) found reflective writing also strengthened student maturation. Hatton and Smith (1995) have defined reflective writing in four levels: (a) descriptive: describes events but lacks critical thinking; (b) descriptive reflection: provides reasons for events based on learned alternate viewpoints; (c) dialogic reflection: demonstrates a conversation with self, using judgment, and role of self; and (d) critical reflective: expresses extensive understanding of events. The current study used a combination of teaching and learning methods to promote nursing students reflection on culturally competent care for older adults in their home and for those in acute care settings being discharged back to their homes. The use of simulation with high-fidelity human patient simulators is often incorporated into curriculum at schools of nursing. Although much of the literature focuses on simulation in acute care settings, there has been a recent trend to incorporate both home and community settings into the simulation arena. Yeager and Gotwals (2010) used simulation to teach nursing students about the care of older adults in the community. Findings revealed that postsimulation, students had less anxiety and increased knowledge about providing care in the home. Similarly, Smith and vol. 31 no. 10 November/December 2013 Home Healthcare Nurse 583

3 Barry (2012) used simulation as a teaching method to prepare nursing students for home care visits, and found positive outcomes in both student satisfaction and self-confidence for those who took part in the simulations as compared to those in the control group. Simulation was one method used in the current study to improve student awareness about culture, specifically relating to patients in home care settings whose conditions eventually required their hospitalization. Research Questions The following research questions were used to guide this study: 1. Do nursing students enhance the depth/ breadth of their cultural competence definition after completing two course activities: writing culturally focused reflective journals and participating in culturally focused classroom activities centered on older adults? 2. What do students perceive as best methods to reach cultural competence? 3. Is there a difference between junior/senior students level of reflective writing using Hatton and Smith s (1995) criteria over one semester? Methodology Sample: After internal review board authorization was obtained, junior (n = 59) and senior (n = 55) nursing students at a private university in the United States were asked to participate. Although assignments were mandatory for course grading purposes, study participation was voluntary, and n = 114 students signed informed consent and participated in the study. Data Collection Qualitative surveys were used to collect data regarding student definitions and ideas about cultural competence. Surveys were distributed at semester s start and end, were coded for anonymity, and consisted of two questions: (a) How do you define cultural competence; and (b) how do you best increase your level of cultural competence? Reflective writing journal entries were assigned to both groups at mid and end of semester, and consisted of structured questions based on cultural aspects of care with older adults. Written instructor feedback on midsemester entries was provided before students completed their qualitative surveys at the end of the semester. To promote internal consistency the same researcher interpreted all surveys for themes and all reflective writing entries for themes and levels of reflection. Instruments Demographic forms, reflective writing templates, qualitative surveys, and debriefing guidelines were developed by the researchers and face validity was established by having three experts in the area of simulation and instrument development review materials. Classroom Activities Seniors participated in two faculty-developed simulations involving older adults. Patient background information included culture, age, religion, race, marital status, dietary preferences, and family involvement at home, whereas high-fidelity simulators were embellished to depict diverse patients who had been living at home, but whose health had deteriorated to the point where they required admission to a hospital intensive care unit. These scenarios were run in class in small groups of four to five students and included discussions about discharge planning followed by structured debriefings. Juniors working in small groups analyzed faculty-developed culturally based case studies focused on patients in a home care setting. Patient background information included health history, age, culture, religion, dietary preferences, marital status, family involvement, and socioeconomic status. Cases were analyzed by the groups, followed by in-class discussions using identical debriefing guidelines as used with the seniors. (See Box 1.) Data Analysis and Results Demographic Data There were no significant differences in demographic data between the student groups regarding age (97% = years), race (96% = Caucasian), or marital status (99% = single). Research Question 1 Do nursing students enhance the depth/breadth of their cultural competence definition after completing two course activities: Writing culturally focused reflective journals and participating in culturally focused classroom activities centered on older adults? Data gathered via qualitative surveys suggest that both groups enhanced the depth/breadth of their cultural competence definitions over time, 584 Home Healthcare Nurse

4 especially regarding older adults, as evidenced by the increased number of variables included in definitions by semester s end. For example, qualitative data (words used to define cultural competence) were entered by student ID number and content analysis was performed to determine trends (which were similar across groups). The trends are noted as follows: Juniors: Initially juniors predominantly used three words to define cultural competence: having knowledge about... ethnicity, race, and religion. By semester s end, definitions increased to include four to six variables including predominantly: gender, age, socioeconomic status, spirituality, sexuality, family roles, and dietary preferences. Seniors: Initially 22 seniors defined cultural competency as the ability to communicate effectively with others who are different than oneself. Many stated that culture embodies... more than just ethnicity and race and they included variables such as religion, family values, and socioeconomic status. At semester s end, seniors expanded definitions to include four to eight variables including family roles, age, belief about sickness, health, exercise, death and dying, spirituality, and socioeconomic status and environment. Many felt their definition was evolving and that they had more to learn. Research Question 2 What do students perceive as best methods to reach cultural competence? Responses varied within and between groups, and ideas evolved from midsemester to the end of semester. At midsemester, juniors expressed the need for more opportunities to communicate with diverse older adults, and for more clinical experience including both home and acute care, to help promote competence. At semester s end some stated that reaching competency is a lifelong, continuously evolving journey ; and that I need an awareness of my own beliefs and values before I can be totally competent ; and It will be important to practice communication skills with culturally diverse people in their homes. Seniors felt that exposure to older adults of various cultures was essential, and by midsemester several had stated that they were already culturally competent but could definitely enhance (their) competence fur- Box 1. Sample Home Care Case Study Mr. Hernandez is an 82-yearold widow of Puerto Rican descent, who lives in an underserved region of Connecticut with his 44-year-old daughter who is a single mother with three young children. He speaks limited English, and his daughter is needed to interpret for him when the nurses visit. Mr. Hernandez is a devout Catholic, and within the home there are many religious artifacts. His daughter often leaves religious candles lit for him when she goes to work. She also cooks for her father, who prefers Puerto Rican cooking such as deep fried empanadas, plantains, and yellow rice with refried beans. He has not adhered to a lowsodium diet. Mr. Hernandez has a history of a myocardial infarction in 2011, and emphysema since He has smoked 1.5 packs per day for more than 30 years and continues to smoke and use chewing tobacco. He drinks socially. He is homebound and his home care nursing visits are billed to Medicare. Lately, he has not had enough money to pay for all of his prescriptions so he reports that he has been skipping some doses. His recent home care visit revealed: BP: 166/92; P: 88 (irregular): RR: 22; Temperature: 99.1 F; Lungs with diminished breath sounds bilaterally and course crackles throughout. Productive frequent cough with thick yellow mucus. Slight shortness of breath at rest. Patient denied chest pain or pressure. Bowel sounds active in all quadrants. Lower extremities with 1+ edema to lower calf bilaterally, feet cool with positive weak pulses. You are the visiting nurse who is going to make a home visit for Mr. Hernandez. How would you prioritize your visit? What are some of the safety issues that need to be addressed? What are some of his cultural needs and how will you address those? Notes: BP = blood pressure; P = pulse; RR = respiratory rate. ther. By semester s end the majority of students no longer felt cultural competence revolved solely around effective communication but involved being able to identify peoples needs and implement best practices in providing care and that assessment includes more than just the person, but vol. 31 no. 10 November/December 2013 Home Healthcare Nurse 585

5 the environment they live in. Most realized they were not culturally competent even those who had initially written that they were nor could they ever fully understand another individual outside of themselves, but that having many interactions in a multitude of settings helped promote competence. Research Question 3 Is there a difference between junior/senior students level of reflective writing using Hatton and Smith s (1995) criteria over one semester? Descriptive statistics were used to analyze reflective writing levels, using Hatton and Smith s (1995) framework and results suggested that seniors were at higher reflective writing levels than juniors both at midsemester and end of semester (see Table 1). Seniors started with higher levels of reflection overall and also improved their level of reflective writing of time as compared to juniors. Students commented that reviewing faculty journal feedback helped them acknowledge learning from previous interactions with diverse patients and older adults that they knew from other venues, and that they had incorporated learned methods to enhance care. Classroom Activities: Case Analyses and Simulation Debriefing Juniors During debriefing discussions, students revealed they had better patient understanding as they became more confident with their own values. Many admitted they had not previously perceived culture as encompassing so many variables and reported debriefing discussions were valuable in pointing this out, regardless of whether the patient was at home or in another setting. Seniors During debriefing sessions, seniors reported the importance of how cultural awareness affects care and that although meeting cultural needs was important, the diverse patients themselves were not that different from other people. Discussion Junior and senior nursing students enhanced the depth and breadth of cultural competence definitions in the care of older adults over time through reflective journaling and other activities. The two groups varied as to how they believed one could best increase the level of competency, and seniors had higher levels of reflective writing than juniors both at midsemester and end of semester. Common to both groups was use of identical debriefing guidelines after classroom activities, which may have contributed to richer end of semester cultural competence definitions. Conversely, many confounding variables may have contributed to the enhanced definitions such as other course work, clinical or study abroad experiences, knowing they were in a study, and being Table 1. Reflective Writing Levels for Junior and Seniors Journal 1: Mid Semester Descriptive writing (L1) (describes events but lacks critical thinking) Journal 2: End of Semester Junior n = 59 Senior n = 55 Junior n = 59 Senior n = 55 90% (n = 53) 22% (n = 12) 12% (n = 7) 7% (n = 4) Descriptive reflection (L2) (provides reasons for events based on learned alternate viewpoints) Dialogic reflection (L3) (demonstrates a conversation with self, using judgment, and role of self) Critical reflection (L4) (expresses extensive understanding of events) Source: Data from Hatton & Smith, % (n = 6) 43% (n = 24) 50% (n = 30) 22% (n = 12) 0 35% (n = 19) 38% (n = 22) 50% (n = 28) % (n = 11) 586 Home Healthcare Nurse

6 graded. It is interesting to compare first semester juniors to second semester seniors who have had more clinical rotations (including home care), summer internships, and experience with cultural content in other courses, which may explain seniors higher reflective writing levels. After reflecting and participating in simulations and debriefings, most seniors realized they would benefit from additional diverse patient interactions especially with older adults. Although both groups showed improvements in levels of reflective writing, seniors started out at and progressed to higher levels than juniors by semester s end. Juniors, having not had their home care course and clinical rotation, shared that having this experience with home care cases increased their awareness of the importance of building cultural competency. They realized that although patients may feel most comfortable receiving care in their homes, the nurse or nursing student may be feel more challenged if not aware of the patient/family cultural values. Juniors asked that class time be used to analyze additional culturally based case studies with time for interactive discussion and opportunities to receive feedback about patients receiving care in the home. Limitations Because students had other experiences taking place at the same time as the culturally based activities (case analyses and simulations), one cannot conclude that the classroom activities were solely responsible for the resulting enhancements in cultural competence definitions. Additionally, both groups were exposed to different activities, making it difficult to draw conclusions about the impact each activity had. Lack of a control group and use of a single study site also make conclusions difficult. Although this study did not use an instrument to measure cultural competency, the purpose was to promote reflection about cultural competency using various methods to keep the topic in the forefront of students awareness regardless of the type of care setting involved. Implications for Home Care Nearly 8.6 million people currently receive home care services in the United States (Joint Commission, 2011). Although the use of case studies to teach about the home care setting is not found readily in the literature, it seemed to be an effective model with this sample. Student nurses spend the majority of their clinical rotations in acute care settings, and thus have very limited exposure to patients in their homes (Mager & Campbell, 2013). Case studies are an inexpensive, convenient way to encourage students to think about more than just the physical aspect of care. Home care nurses must be able to incorporate holistic assessment skills that include consideration of a person s culture when providing quality care in the home. By exposing nursing students to the importance of culture in their nursing program, and by linking these skills to home care settings, we may be able to better prepare students for the workforce, especially given the large number of older adults living and receiving care at home. In addition, these methodologies may be beneficial to enhance cultural competency skills in practicing nurses in home care and community settings as well. Conclusion and Implications for the Future When a variety of classroom methods in this setting were used to promote student nurse reflection on cultural competency, students enhanced the depth and breadth of their cultural competency definitions and increased reflective writing levels using Hatton and Smith s (1995) framework. Use of qualitative surveys was an effective method to examine cultural competency definitions, whereas reflective writing, home care focused case study analysis, and/or simulation participation effectively promoted reflection and increased perceived culturally competent care of older adults. Future studies in this area are warranted and it may have been beneficial to follow students from junior through senior year to compare outcomes over time on the same group. Additionally using the same mode of classroom activity (either case study analysis or simulation) would be a stronger vehicle for comparison in future studies. Finally, use of both case study and/or simulation methodologies may be beneficial to enhance the cultural competency of professional nurses currently working in home care or community settings. Diana R. Mager, DNP, RN-BC, is an Assistant Professor at Fairfield University School of Nursing, Fairfield, Connecticut, and a Home Care Nurse at Visisting Nurse and Hospice of Fairfield Country, Fairfield, Connecticut. vol. 31 no. 10 November/December 2013 Home Healthcare Nurse 587

7 Sheila Grossman, PhD, APRN, FNP-BC, FAAN is a Professor and the Family Nurse Practitioner Track Coordinator at Fairfield University School of Nursing, Fairfield, Connecticut. The authors and planners have disclosed that they have no financial relationships related to this article. Address for correspondence: Diana R. Mager, DNP, RN-BC, 1073 North Benson Rd, Fairfield, CT (dmager@fairfield.edu). DOI: /01.NHH b4 REFERENCES Averill, J. B. (2012). Priorities for action in a rural older adults study. Family & Community Health, 35(4), Davis, B. H., & Smith, M. K. (2013). Developing culturally diverse direct caregivers for care work with older adults: Challenges and potential strategies. Journal of Continuing Education in Nursing, 44(1), Dorrejo, X. M., & Wilson, P. (2012). Research on culturally tailored interventions aimed at improving chronic disease risk factors and management. Home Healthcare Nurse, 30(9), Grossman, S., Mager, D., Opheim, H., & Torbjornsen, A. (2010, June). Simulation technology impacts cultural competence of North American and Norwegian students. Clinical Simulation in Nursing Journal. doi: /j.ecns Hatton, N., & Smith, D. (1995). Reflection in teacher education: Towards definition and implementation. Teaching & Teacher Education, 11(1), Hines, D. (2012). Cultural competence: Assessment and education resources for home care and hospice clinicians. Home Healthcare Nurse, 30(1), Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Retrieved from Retooling-for-an-Aging-America-Building-the-Health- Care-Workforce.aspx Institute of Medicine Report Brief. (2010). The future of nursing focus on education. Retrieved from The Joint Commission. (2011). Home the best place for health care: A positioning statement from The Joint Commission on the state of the home care industry. Retrieved from assets/1/18/home_care_position_paper_4_5_11.pdf Kardong-Edgren, S., & Campinha-Bacote, J. (2008). Cultural competency of graduating U.S. bachelor of science nursing students. Contemporary Nurse, 28(1 2), Langley, M. E., & Brown, S. T. (2010). Perceptions of the use of reflective learning journals in online graduate nursing education. Nursing Education Perspectives, 31(1), Mager, D. R., & Campbell, S. H. (2013). Home care simulation for student nurses: Medication management in the home. Nurse Education Today, 33(11), doi: /j.nedt Mihalic, A. P., Morrow, J. B., Long, R. B., & Dobbie, A. E. (2010). A validated cultural competence curriculum for U.S. pediatric clerkships. Patient Education & Counseling, 79(1), Momeni, P., Jirwe, M., & Emami, A. (2008). Enabling nursing students to become culturally competent: A documentary analysis of curricula in all Swedish nursing programs. Scandinavian Journal of Caring Sciences, 22(4), Prosser, R., Korman, D., & Feinstein, R. A. (2012). An orthodox perspective of the Jewish end-of-life experience. Home Healthcare Nurse, 30(10), Reese, C., Cleary, J., Cato, M., & Boese, T. (2011). Advancing care excellence for seniors: Development of unfolding simulations focusing on intentional encounters with older adults. Clinical Simulation in Nursing, 7(6), e260-e261. Schuessler, J. B., Wilder, B., & Byrd, L. W. (2012). Reflective journaling and development of cultural humility in students. Nursing Education Perspectives, 33(2), Smith, S. J., & Barry, D. G. (2012). An innovative approach to preparing nursing students for care of the elderly in the home. Geriatric Nursing, 34(1), doi: /j.gerinurse Taylor-Haslip, V. (2010). Guided reflective journals depict a correlation to the academic success of nursing students. Teaching and Learning in Nursing, 5, Yeager, S. T., & Gotwals, B. (2010). Incorporating highfidelity simulation technology into community health nursing education. Clinical Simulation in Nursing, 6(2), e53-e59. Young, J. S. (2012). Online resources for culturally and linguistically appropriate services in home healthcare and hospice, part 2: Resources for Asian patients. Home Healthcare Nurse, 30(4), Young, J. S. (2013). Resources for Middle Eastern patients: Online resources for culturally and linguistically appropriate services in home healthcare and hospice, part 3. Home Healthcare Nurse, 31(1), For 26 additional continuing nursing education articles on cultural competence topics, go to nursingcenter.com/ce. 588 Home Healthcare Nurse