The context of Australian nursing practice
In line with other developed nations Australian nursing is a highly regulated profession, the stated purpose of which is to protect the public through order, consistency and control over practice standards (ANCI 2001). The nursing competencies endorsed by the Australian Nursing Council provide guidelines for accreditation of Australian registered and enrolled nurse education programs and are a benchmark for all nurses, including those with qualifications earned in other countries. ANCI (2001) defines competence as the combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a professional or occupational area. Through the process of tightening controls over knowledge acquisition, creation, development and application, key authorities, such as nurses’ registration boards, define and legitimize particular nursing beliefs and values (Kanitsaki 2003). These competencies pursue both conformity in nursing standards and a particular way of practising nursing. Very few would argue against the pursuit of conformity to nursing standards; however, the authors take issue with the imposition of particular approaches to nursing that are applied uncritically and which are, at times, antithetical to the health care needs and expectations of some cultural health populations (Kanitsaki 2003).
The ANCI competency standards clearly define the principles to achieve culturally competent nursing care, and require nurses to respect the values, customs, spiritual beliefs and practices of all individuals and groups; however, they are not sufficiently explained or developed to guide nursing practice. What the standards need to make clear is that the constituents of competence are found not in the nurse alone, but in the relationship that exists between the nurse, their colleagues, patients, and families, and with the situation itself (McMurray 2004).
There are two main concerns with current quality measures and nursing practice standards in Australia. The first concerns health consumers from different cultural backgrounds, and the second concerns nurses qualified overseas who work within the Australian health care system.
There is little debate on the merits of a competent nursing workforce, but the values and the particular focus of nursing competencies are not neutral. They are shaped by the cultural and social structures of Australia's political, legislative and moral frameworks within which nurses operate. This particular civic identity includes, among other things, the rule of law and the Constitution, parliamentary democracy, and equality under the law for all members of society (Grbich 1996). Thus, the definitions and requirements of nursing practice in Australia, as in all other nations, are socially framed and clearly socially specific. Uncritical adherence to a specific nursing approach will restrict health consumers’ access to other approaches that may be more compatible with their own world views. This is particularly the case for indigenous Australians (Grbich 1996, pp. 226–8; South-east Health 2000; NSW Health 2003).
At the same time, the necessity to conform to the Australian ‘way’ of nursing and the scant opportunities afforded to overseas qualified nurses to contribute to nursing care quality (NSW Health 2000), will force these nurses into restrictive moulds. This has the effect of both denying them the right to advance nursing practice (D’Cruz & Tham 1993); and reduces their capacity to provide culturally competent care. To remedy this situation Australian nurses must recognize that their knowledge and scope of practice remain limited when caring for persons from cultures different to their own (Omeri 2004).
These limitations are revealed most clearly in Australian nurses’ general approach to health consumers, for example, advocacy for patient/client self-determination. This is a fundamental principle enshrined in law and articulated within Australian nursing practice (Carberry 1998). This principle is not necessarily promoted within other cultures, particularly those in which family and/or community, rather than the individual, are the arbiters for health care decision-making (Kanitsaki 2003). Thus, achieving self-determination is not necessarily a desirable goal for some health consumers within these cultures, as there is a strongly held belief that the sick person should not be burdened by ‘bad’ news, or making health decisions (D’Cruz & Tham 1993). This single example of an Australian nursing principle, born out in practice, is exclusionary to the degree that alternative perspectives are held to be invalid, and therefore not acceptable, despite the potential for harm that might ensue in applying the principle of self-determination.
Achieving culturally competent, quality nursing practice
To what degree, then, is the goal of culturally competent nursing care possible, given the shaping influence of legitimized nursing practices? In Australia cultural competence is defined as a ‘congruent set of behaviours, attitudes and policies that come together in a system, agency or among professionals and enables these to work efficiently in cross-cultural settings’ (South-east Health 2000, p. 2). In any health setting the culturally competent nurse recognizes and understands the impact that their own cultural and professional beliefs have on workplace practices.
A culturally competent nurse recognizes that cultural differences occur across all levels of diversity, both primary (age, gender, language, physical ability and sexual preference) and secondary (socio-economic background, geographical location, education and religion) (Polaschek 1998). This nurse will recognize the essential humanity in all persons whatever their cultural background (Zoucha & Husted 2000) and therefore will need to learn how to interact effectively with people in providing quality care, despite different social backgrounds, cultures, religions, and lifestyle preferences.
For a nursing service to be culturally competent it should reflect and respond to the needs of all its consumers, and therefore, be ‘accessible, appropriate, effective, efficient, adaptable and acceptable to them all’ (South-east Health 2000, p. 3). Indeed, Australian health services are expected to adapt as far as possible to changing social, cultural and consumer-focused values (NSW Health 2003). Given the wide range of cultural diversity occurring internationally, these goals can only be achieved through culturally sensitive administration, policies and procedures, training and professional development, workplace standards, and the inclusion of health consumers’ voices in all these domains (Leininger 1991). This is particularly relevant as nurses worldwide face the challenges of dynamic political, and economic climates.
Focus of the paper
Omeri (2004, p. 26) reminds us that governments hold health care providers accountable for delivering services that are appropriate for consumers from culturally and linguistically diverse backgrounds, with the aim of reducing racial and ethnic, as well as social health disparities. A fictitious clinical exemplar is employed to identify issues of cultural competence in Australian nursing practice, to facilitate an understanding of what constitutes culturally competent, quality nursing care, and to consider the contribution that nurses qualified overseas can make in this regard.
Fictitious clinical exemplar
Mrs Sunnie Kim, 76, was admitted to Southbank Hospital via ambulance, accompanied by her son. Her admission was triggered by a fall in the bathroom where she lay for six hours until found by her family. She presented with a fractured neck of femur and paralysis to the right side, was unable to stand and had slurred speech. A diagnosis of left sided cerebral vascular accident (CVA) was made and the fracture repaired on the day after admission. One week later she was transferred from the orthopaedic ward to the rehabilitation unit, where she shared a four-bed room with three males.
Mrs Kim's social history
Mrs Kim arrived in Australia 2 years ago under auspices of the Family Stream of Australia's Migration Program, is a widow and lives with her son, daughter-in-law, and two grandchildren aged 8 and 10 years. She is eligible for Government health cover, but not for the aged pension. The family live in the eastern suburbs of Sydney, which has a small and scattered Korean population. Her son and daughter-in-law run a family owned grocery business and work long hours, including weekends. As Mrs Kim has no English skills, and there are no Korean community programmes in her neighbourhood, she has become house bound.
Admission to the rehabilitation unit
Mrs Kim does not communicate easily with the hospital interpreter, and there is no access to other Korean speaking staff. Her family has not been able to speak with a social worker or the supervising doctor, as they can only to visit at night. Staff feel her reluctance to mobilize and engage in other activities of daily living is related to her misunderstanding of rehabilitation, and the nursing role. She does not buzz the nurses when she needs to toilet, and will not eat and drink, even though the dietician has ordered Asian-style foods. Her family brings cooked food for her everyday after work but it is difficult for staff to re-heat these meals. She refuses to take medications with water or juice, and is becoming dehydrated.
These issues are not resolved during the three weeks allocated for Mrs Kim's rehabilitation, despite a number of attempts by the translator to explain the situation to her. The family expect that Mrs Kim will continue to be cared for in hospital until she is fully recovered, able to mobilize and take responsibility for most activities of daily living and are surprised when told she is ready for discharge. A family conference is convened with the assistance of the translator to discuss her discharge. Mrs Kim's treating doctor informs them that Mrs Kim will have to be discharged to a residential aged care service because she needs assistance with toileting, personal care and mobilization. While this goes against their cultural belief, the family feel they have no other option and reluctantly agree to this decision. Mrs Kim's family feel very uncomfortable about their inability to provide care for her at home and are afraid that the staff and translator will make this known to others.
They have no experience with the Australian aged care system, and are not able to communicate fluently in English, yet they are asked personally to find a residential aged care facility for Mrs Kim. As they are unable to locate a preferred facility, the hospital discharge planner arranges a transfer for Mrs Kim 24 h later to the first available aged care service near to their home.
Transfer to the residential aged care service
Mrs Kim is admitted to Medlow Aged Care Service, accompanied by her daughter-in-law. She is allocated to a room shared by a person with dementia. The hospital discharge report outlines her medical history, medication regime and a brief summary of her rehabilitation progress to date. Residential care staff are not provided with her social background or documented history of the problems faced in the rehabilitation unit. Mrs Kim's daughter-in-law is provided with written information on the financial requirements and care provision available to Mrs Kim, however, she finds it difficult to understand the written material. She feels embarrassed and does not explain this to staff.
The family find Mrs Kim upset when they visit her each evening as a male nurse has been attending her personal care, she is being addressed by her first name ‘Sunnie’ and she has been placed in the sitting room at times with male residents. The family feel unable to discuss these issues with staff. On the third day following admission Mrs Kim is agitated, confused and crying, incontinent of urine and confined to bed with bedrails. They notice an untouched food tray containing the meal that they brought in for her the previous evening. Mrs Kim's son is very upset about his mother's condition and increasing distress caused by the other resident who is constantly calling out for the nurse. He seeks out a nurse to discuss his concerns about his mother's well-being. However, the nurse he approaches is employed only one evening a week, so knows little about Mrs Kim's history. She asks the registered nurse (RN) in charge to speak with Mrs Kim's son. The RN is from Hong Kong, has recently returned after a period of leave and to date, and has had no involvement in Mrs Kim's care. However, recognizing Mrs Kim's family's distress, she arranges an immediate meeting with her son and daughter-in-law.
During the meeting with Mrs Kim's son and daughter-in-law, the RN listens carefully to them and takes notes after clarifying the issues they raise. She learns that Mrs Kim and her family have been concerned by the language barrier and cultural differences. The RN asks the daughter-in-law if she would like to assist Mrs Kim to bathe, toilet, change her clothing and bedding and take her for a walk. She gladly accepts this opportunity, while the RN explains to Mrs Kim's son the scope of service delivery available at Medlow Aged Care Service. The RN assures the family that she will talk to other staff and try to resolve the issues raised. The RN also mentions briefly her experience as a nurse from a different country working in Australia, which helps them to feel that she understands them and will address their concerns. As the family find the RN very attentive to their concerns they feel that she is trustworthy.
Implications for nursing practice
There is nothing particularly remarkable about the nursing care needs of Mrs Kim. The health issues she faces are very similar to those facing all health consumers. However, she has been disadvantaged by not having many of these needs met because of language barriers and a lack of cultural awareness that fostered misunderstanding and neglect of her cultural values, beliefs and expectations. Like all other health consumers, she and her family expect to receive quality services, staffed by caring, knowledgeable nurses who are responsive to basic human rights and cultural differences. Therefore, when caring for persons whose culture is different from the mainstream, nurses need to adopt flexible approaches that draw heavily on consultation with family and translators who are acceptable to the family, to prevent problems arising and to find solutions to difficulties encountered.
All health consumers and nurses will enter the caring relationship with predetermined values, expectations and interpretations. Nurses must recognize that despite their cultural background, each health consumer is unique, thus, assessment of their expectations and needs requires an inclusive and comprehensive approach. They also need to remember that many of the ‘rules’ that guide nursing practice are hidden from health consumers like Mrs Kim and this can set up dissonance between them.
For example, Mrs Kim and her family may have felt that calling Mrs Kim by her first name and using a direct questioning approach via the interpreter was intrusive and rude, whereas for the nurse direct questioning through an interpreter may be the best way to get information. Similarly, the nurse may expect to receive direct answers via the interpreter to avoid confusion, and Mrs Kim's family may feel vague answers are preferable to avoid embarrassment in the presence of the interpreter, who may be regarded as a person with superior social standing. For Korean people maintaining a desirable social status and reputation is of the utmost importance. Achieving honour, being self sufficient and resourceful, and being accepted by others is a critical element in gaining this desirable social status (Kim et al. 2002).
Another issue for Mrs Kim and her family is the perception of what constitutes her state of illness and the signs of illness that are culturally prescribed. Nurses need to understand that signs or symptoms of illness may not be as significant for Mrs Kim as the social context within which these occur and the way they are perceived and understood. As an older Korean woman, Mrs Kim is likely to consider that the force of nature itself must be kept in natural balance, or harmony, to achieve and maintain good health. In this world-view health occurs in the context of the total environment and imbalances will cause illness. As well, the way that Mrs Kim expressed her health problems, mental issues in particular, are culturally bound. She is likely to have been raised not to disclose her emotional difficulties (e.g. feelings of depression, distress and irritability) because this may indicate that she is immature (Kim et al. 2002).
Therefore, to identify the expectations and care needs of culturally diverse patients, nurses must consider her or his own cultural value systems and biases and identify the potential for misunderstanding and misrepresentation of behaviours that are culturally bound. A critical element to be addressed in nursing practice is the lack of openness and acceptance of other cultures. Culturally competent care requires nurses to be more accepting of difference and to recognize that there are complex issues to address when cultural misunderstanding occurs.
In order to develop a therapeutic plan of care for a culturally diverse health population nurses need to understand each patient's unique patterns of thinking, feeling and behaving. This understanding provides a blueprint for contextualizing health expectations, behaviours and reactions. Madeleine Leininger's (1991) ‘Acculturation Health Care Assessment Tool’ is highly recommended as a template for undertaking a comprehensive approach to assessment for persons of all cultures. Boxs 1–3 present checklists that guide nurses in providing culturally competent, quality care.
Box 1 Nurses to provide relevant information to patients and family members to facilitate consumer awareness
Characteristics of the particular care services (e.g. hospital or residential aged care) and exchange ideas about what it means to be admitted to these services in Australia compared with the consumer's country of origin.
Reason for admission and treatments/care services that will be provided.
Scope and purpose of nursing in the present health context, and also the role of the different members of the health team.
Processes involved when undertaking nursing and other health assessments.
Patient/resident mix and discuss the nature and manifestations of dementia and what this means for those with the condition.
Safety systems and staff as well as patient/resident responsibilities.
Financial arrangements for care services and possible options of extra care that can assist a speedy recovery and improve quality of life.
Box 2 Obtain and verify information to facilitate staff understanding about
Health consumer's understanding of the reason for admission, treatments prescribed, and care processes.
Health consumer and family expectations of services.
Health consumer's views/requirements for personal space, personal contact, privacy, comfort measures, personal care habits, communication processes, clothing preferences, complementary medicine use, eye contact when communicating, decision-making processes, gender appropriate care provision.
Culturally appropriate accommodation requirements, e.g. sharing with opposite gender and patients/residents who have dementia or disturbed behaviours.
Family relationships and lifestyle patterns.
Daily rituals and habits, for example religious practices, that are important and ways in which these can be upheld in the health service.
Health beliefs, rules and usual health behaviours, including diet, food preparation and presentation, exercise patterns and personal care.
Interpreter services to identify topics of discussion or practices that are taboo for the health consumer and their family, such as personal hygiene, illness or treatment.
Culturally appropriate greetings and farewells for staff, behaviours that denote respect, and the consumer's preferred use of their name.
Health consumer's ability to read their own language.
Box 3 Utilize existing resources to encourage effective team work, including
Knowledge, skills and cultural sensitivity that overseas qualified nurses can contribute to needs assessment, care planning and service evaluation for health consumers with cultures similar to their own.
Translation services to develop/access a ‘key phrase’ booklet/poster if the health consumer is able to read their own language, or if not literate, develop a pictorial chart to assist the consumer identify particular needs such as food, fluids, toileting, pain relief, and levels of comfort or distress, such as a pain.
Culturally sympathetic social workers able to follow through during the hospital stay and the transfer to the residential aged care service.
Accessing community-based resources such as culturally specific Aged Care Packages, Home & Community Care Services, residential aged care services that have appropriate staff, and community volunteer centres and networks.
Willingness of families to pay for extra services, like physiotherapy and occupational therapy.
Cultural awareness-raising for all staff.
Staff education and opportunities for debriefing where they can reflect on their perceptions, assumptions and concerns, and communication difficulties.