Cultural Humility and the Importance of Long-Term Relationships in International Partnerships
Jennifer Foster, CNM, PhD, School of Nursing, 1520 Clifton Road, Atlanta, GA 30322.
email@example.com The author and planners for this activity report no conflict of interest or relevant financial relationships. The article includes no discussion of off-label drug or devise use.
This article describes an education, leadership, and health professional interchange project in the Dominican Republic. It emphasizes the importance of long-term relationships and explores how over time, dialogue has led to cultural humility, self-reflection, and empowerment among nursing colleagues across national boundaries, despite differences in assumptions. The project is an example of a north–south collaboration encouraged by the World Health Organization to strengthen nursing and midwifery globally.
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After reading and studying this article, the reader will be able to:
- 1Define cultural humility.
- 2Explain why developing nursing partnerships is important to global maternal-newborn health.
- 3Name one of the expected results from the World Health Organization's objective to improve access to quality nursing and midwifery services.
Cultural competence/sensitivity is essential for nurses who work across borders within and outside their country of origin. Assessment of the achievement of cultural competence remains elusive, however, because the concept of culture is broad, fluid, and constantly changing. A more useful concept, therefore, is cultural humility, a lifelong process of self-reflection and self-critique (Tervalon & Murray-Garcia, 1998). Nurses who exhibit cultural humility develop respectful partnerships with each of their clients by means of client-centered interview techniques in which they explore differences and similarities between their own and each client's values, priorities, and goals (Hunt, 2005). Respectful partnerships are important not only with clients, but also with nursing colleagues around the world.
One avenue to cultural humility is through cultural immersion. Cultural immersion programs involve immersion in a foreign milieu; frequently, these programs for nursing students or professional nurses are located in settings where social and health disparities are manifested widely. These projects often serve to provide participants with a social justice orientation (Boutain, 2005).
The published record about the effects of cultural immersion experiences for nurses is generally positive. Specifically, there are documented reports of personal and professional meaning (Callister & Cox, 2006), interest in alternative paradigms of health care (Wallace, 2007), and the unraveling of ethnocentric perceptions held before student travel (Johanson, 2006).
The emphasis in immersion programs may be upon cultural learning for the traveling participants rather than the mutual and reciprocal learning that includes both the visitors and the visited. There are few documented accounts of the experiences of persons in the receiving culture in cultural immersion projects. This article describes a painful experience in which a well-meaning encounter between U.S. nursing students and nurses in a maternity ward in the Dominican Republic (DR) revealed unanticipated practice differences, which ultimately led to deep learning on both sides.
A Cross-Cultural Nursing Partnership in the DR
Project ADAMES (an acronym for ADelante, Asegurando Madres E Infantes Sanos [Working toward Healthy Mothers and Babies]) is a nonprofit, nongovernmental organization created in 2004 as a collaborative partnership between the maternity nurses in one public hospital in the DR and a team of certified nurse-midwives from the United States. The primary aim of Project ADAMES is to improve the quality of maternal and newborn care in this public hospital through the education and leadership development of maternity nurses, with the overarching goal of reducing maternal-newborn mortality. Project ADAMES creates relationships within health care systems that are characterized by mutual respect and dialogue (Proyecto ADAMES, 2005).
In the DR, registered nurses have a baccalaureate nursing degree. Auxiliary nurses have a high school diploma and 1 year of training in all areas of nursing. Although the nurses and auxiliaries are not licensed midwives (midwifery is not a recognized profession in the DR), they manage and attend the vaginal deliveries in many public hospitals. Operative deliveries are managed by physicians.
The initial raison d'être of Project ADAMES was to provide the maternity nursing staff in the hospital with a midwifery curriculum in agreement with internationally recognized standards (Fullerton, Severino, Brogan, & Thompson, 2003). This transpired in week-long, educational conferences staggered over 3 years. It is important to emphasize that this project came about as a direct result of a request made by the Director of Nursing in the Dominican hospital for consultation regarding the doubling of maternal deaths in a 6-month period in the hospital.
One arm of Project ADAMES is the Professional Interchange Program. Health care students and practitioners have the opportunity to participate as volunteers in Project ADAMES, and the program draws those who have a budding interest but little experience in international health. These interchange volunteers travel to the DR, stay with host families, take Spanish language lessons with a tutor, and volunteer in the hospital maternity ward or in the project's community outreach programs anywhere from 1 week to 2 months. Interchange volunteers have included not only undergraduate nursing students but also nurses, medical residents, pediatricians, obstetricians, and a perinatologist. Additionally, undergraduate liberal arts students have volunteered in various ways. Since 2003, over 65 interchange volunteers have participated in Project ADAMES. Along with interest and enthusiasm in improving global maternal-newborn health, these volunteers may bring resources of the latest evidence-based knowledge, material equipment of donated medical supplies, and an orientation to family-centered care.
For some participants in the Professional Interchange Program, the trip to the DR is their first experience outside of the United States. For others, it is their first exposure to a public hospital in a low-resource area in a developing country. What they first encounter is the uneven provision of both running water and electricity, insufficient supplies, and systems of care organized by multiple tasks divided among few. The volunteers see themselves as helpers providing service to poor childbearing women in an under-resourced hospital in the DR. They bring donations of medical supplies that are clean and in good condition but that might be discarded in the United States. The nurses also bring stories of well-stocked birthing units, unrationed disposable equipment, and sufficient clean sheets required to keep a woman dry during birth.
Participant Observation and Nursing Practice Exchange
Some of the participants in Project ADAMES have been involved since the project's inception, so they have been participant observers of the interchange experiences over time. Participant observation is a method well known by, but not limited to, anthropologists; it is a way to get to know and garner a deep understanding of the tacit knowledge of cultural others (Spradley, 1980).
For the midwives who have returned frequently, the lived experience of shouldering responsibility for maternal-newborn well-being, in the context of profound material constraints, has fostered self-reflection. For example, one night a mother almost bled to death during delivery from a vaginal laceration that the nurses could not visualize well enough to repair. In this case, there was sufficient oxytocin and blood for transfusions. Yet the enormity of the nurses' responsibility and their isolation in the face of near disaster, functioning without the abundant resources of personnel in U.S. hospitals, evoked a more profound realization among the U.S. midwives about the devastation that such deprivation in working conditions can have on provider morale.
The term used to describe diminished working morale among nurses is compassion fatigue. Compassion fatigue is acknowledged among nurses in many settings in the developing world to be the result of deprivation in working conditions (Kingma, 2006). Barbara Sabo has defined compassion fatigue as a consequence of caring for suffering people within a work environment that triggers “frustration, powerlessness and an inability to achieve work goals” (Sabo, 2006, p. 138). Compassion fatigue can then lead to a distancing toward the people one cares for, the social production of indifference (Scheper-Hughes, 1992).
Stillbirth in the DR
The experience of the Dominican nurses with U.S. nursing students also provided moments of self-reflection. The following ethnographic vignette describes an incident in which the differences in cultural orientation to stillbirth between U.S. and Dominican nurses was painfully played out but ultimately contributed to self-reflection.
During a period when a group of volunteer nursing students were visiting the DR, a 19-year-old single mother of three boys, who arrived alone at the hospital late in the evening, quickly delivered a stillborn girl. She was placed on the postpartum ward with the other mothers and their infants. In the morning, two U.S. nursing students in the Project ADAMES program arrived on the ward. They found the mother sobbing uncontrollably. Distraught, the students came to me, their faculty preceptor, requesting a psychosocial intervention to allow the mother to see her deceased infant, a common practice in the United States (Hughes, Turton, Hopper, & Evans, 2002).
This intervention involves asking the parent(s) if they wish to see their stillborn infant, dressed and wrapped in baby clothes, presenting the infant to the mother, pointing out the normal features of the infant, and allowing the family time in private to hold, examine, and if desired, name the infant. This intervention can include the nurse taking a photograph of the mother and infant, if the family wishes, as remembrance to mark the infant as a person.
Both students had explained this practice to the mother who said she wished to participate. The Dominican nursing staff was puzzled by the proposed activity, but given the passionate momentum of their visiting guests agreed to it.
The students had brought baby blankets and infant caps from the United States as part of their collection of donated medical supplies. I took one of each, went down to the delivery area, picked up the lifeless baby girl out of the brown cardboard box sitting on a chair in the now empty delivery room, and swaddled her. The students found a functional wheelchair, and they wheeled the mother from the crowded postpartum ward to an empty labor bed, one of the few beds that had curtains to pull around it. This was to be a private grieving space and the place to take the photograph.
Having never seen such practice, two of the Dominican nurses and a handful of Dominican nursing students gathered around outside the curtain, peeking through a gap in the opening. Throughout, the mother wept, wiping her face with a donated infant nightshirt.
“You are making her unhappy,” one of the nurses said, alarmed, “You are making her sad.” The U.S. students wanted to maintain an atmosphere of silence and calm, and as they saw the practice was upsetting to the nurses, after the mother had had a few moments with the baby, they wheeled her back to the postpartum ward. I took the baby back to the delivery room, took the blanket and cap off her, and placed her back in the brown cardboard box.
I went down the hall to give the blanket to the mother. She asked if the baby could be buried, wrapped in that blanket. “No,” said the Dominican nurse, “We put all the dead babies together naked in the incinerator.” One of the students left the room, went down the hall outside the delivery room, and leaning against the wall, wept. One of the Dominican nurses walked by and saw the student's face. She looked alarmed at her grief. “Why are you crying?” the nurse said. “Because this is so sad,” the student answered. The nurse paused, with a look of disbelief. “Oh, mi amor,” she lamented, “You have seen nothing!”
I began to think this had all been a terrible mistake, an example of American interventionism, another doomed example of a well-intentioned but misguided adventure in development. When the nursing supervisor came by, I explained our activities and asked for her reactions. “It's true,” she said, “you have helped this mother psychologically, perhaps. But this is such a detail!” In discussion afterwards, one of the Dominican nurses noted how the frequent prevalence of stillbirth had made them numb. “You are right,” she reflected, “It is sad.”
This ethnographic vignette is one example of many experiences in which the nurses involved in Project ADAMES learn from each other, despite the markedly contrasting environments in which they usually work. The U.S. nurses, encountering the resource deprivation and low staffing the Dominican nurses face, have a deeper understanding how the environment can make the Dominican nurses numb to the psychological needs of individual women and their families experiencing the death of their infants. The Dominican nurses, viewing the attention and care the U.S. nursing students, wished to provide the one individual facing tragic loss have a deeper understanding of how engagement with the woman facing loss can help her feel nurtured during a difficult experience. They witnessed the nursing students making space to acknowledge the essential sorrow of the situation. The U.S. midwives, having experienced the working environment, realized how vulnerable all health providers can be to compassion fatigue under difficult working conditions.
In 2007, for the first time, three Dominican nurses traveled to the United States for a reciprocal cultural immersion experience with U.S. health care personnel as part of Project ADAMES. The Dominican nurses saw firsthand but in reverse the disparity in resources for maternity care between a tertiary care hospital in the United States and the public tertiary care hospital in the DR. The Dominican nurses were especially aware of the abundance of simple resources like bed linen, towels, and regular running water, resources that nurses in the United States take for granted. The Dominican nurses stated how much they wished they could provide these things to the women they cared for. For previous Professional Interchange Program participants who revisited the Dominican nurses during their time in the United States, the disparity in resources was mutually acknowledged.
As Project ADAMES continues, both U.S. midwives and Dominican nurses continue to contribute to the dialogue with one another to share successes and to acknowledge the place of grief and openness to vulnerability of personal suffering. Paul Farmer has written, “the suffering of the world's poor intrudes only rarely into the consciousness of the affluent, even when our affluence may be shown to have direct relation to their suffering” (Farmer, 2003, p. 31). It has been possible to achieve deeper levels of dialogue because of the trust and relationship that has been built between the nurses over time and an openness to change among both groups that goes beyond what it familiar.
Results of the Partnership
One successful outcome of the partnership in Project ADAMES is that the Dominican nurses articulated their own vision for the care of mothers and babies, which is posted on the Project ADAMES website as a guiding message (Proyecto ADAMES, 2005). The knowledge that their vision is viewable as a globally public statement has been a source of pride for the Dominican nurses; they appreciate public acknowledgment of the strides they are making to improve the quality of care in their setting.
Other concrete steps to improve maternal-newborn care have been documented as a result of the partnership. These include skills development, such as auscultation of fetal hearts and avoidance of unnecessary episiotomies. These steps also include knowledge development, such as calculation of gestational age and clinical history taking. Also attitude changes, such as more satisfaction with their jobs and feeling closer to the women under their care, are part of the documented changes as a result of the partnership (Foster, Regueira, Burgos, & Sanchez, 2005).
The proactive stance of the nurses to address the problem of maternal mortality helped to shape a highly participatory program. The successes, documented in initial outcomes in knowledge, attitudes, and skills among the all nurses (auxiliary and licensed), have been the building blocks for specific improvements in the quality of care (Foster et al., 2005). When the project began in 2003, there were 32 nurses assigned to the maternity ward, which includes a triage ward as well as labor, delivery, and postpartum, and most were auxiliary nurses. Since that time, many have pursued further education to become licensed nurses.
The present focus of Project ADAMES is the development of leadership skills among the staff maternity nurses in the hospital. The formation of a nursing committee to provide follow-up and support for quality improvements on the maternity unit, initiated by the Dominican nurses, is one outcome of these leadership meetings. One of their initiatives has been to train hospital volunteers as doulas to provide free doula services to women in labor. Doulas provide continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact, and explanations about progress during labor, and their presence has been shown to reduce the length of labor and the incidence of operative delivery (Klaus & Kennell, 1997). This program has been functioning well for over 1 year at the time of this writing (Foster & Heath, 2007).
The leadership within Project ADAMES has observed over time that Dominican nurses are more empowered, and the U.S. nurses more humble. Jonsdottir, Litchfield, and Pharris (2004) have called for an understanding of nursing practice as a process of professional partnership, with relationship at its core. The U.S. midwives have asked the Dominican nurses what it is about the Project ADAMES partnership that has inspired them. Their answer has been unequivocally clear: What inspires us is your caring and interest in us. More than any concrete didactic content or clinical expertise, the Dominican nurses have felt that the commitment to them to improve care for mothers and babies has helped foster their own commitment. This has been a huge source of pride for the U.S. nurses.
Cultural humility is an essential orientation to the continued success of Project ADAMES activities. As a small, grassroots organization, Project ADAMES has limited scope; nevertheless, it is one contribution toward the achievement of two of the widely publicized goals of the United Nations (UN) and the World Health Organization (WHO).
At the Millennium Summit in 2000 and reaffirmed in 2005, the UN prioritized eight Millennium Goals, two of which pertain to reducing the disparities in maternal-newborn survival among the world's most vulnerable populations (UN, 2005). Millennium Development Goals 4 and 5 pertain directly to the work of ADAMES. By 2015, Goal 4 aims to reduce the under-5 child mortality ratio by two thirds. “About 40% of all deaths to children under 5 years of age, and nearly two thirds of all infant deaths (between birth and 12 months) occur during the neonatal period (the first month of life)” (Bale, Stoll, & Lucas, 2003, p. 9). Goal 5 aims to reduce the maternal mortality ratio by three fourths by 2015 (UN).
The WHO has concluded that an essential step in achieving these goals is to strengthen the training of skilled birth attendants. A skilled attendant is defined by the WHO as, “people with midwifery skills (e.g., doctors, midwives, nurses) who trained to proficiency in the skills necessary to manage normal deliveries and diagnose and refer obstetric complications” (WHO, 1999, p. 31). Physicians and nurses (including auxiliary nurses) at the hospital in the DR where Project ADAMES is engaged qualify as “skilled birth attendants,” and achievement of the UN Millennium Development Goals are important to them. The nurses' initial invitation to the U.S. midwives to help them assess and improve their clinical proficiency skills is evidence of their motivation. The invitation began as a 3-day consultation but evolved into the much more enduring project of educational and leadership conferences as well as the professional interchange program. Also, the U.S. midwives and Dominican nurses in Project ADAMES will collaborate in a community-based participatory research project supported by the U.S. National Institute of Nursing Research between 2008 and 2010.
Project ADAMES is focused on “how”: how to engage skilled attendants, a process that is articulated within the framework for perinatal health reform as laid out by the WHO/Pan American Health Organization Latin American Centre for Perinatology. This framework endeavors to, “ensure that care is woman and family centered … that focuses care not only on the physical dimension but also on emotional, social and cultural aspects … and that involves women in the process of care” (Belizan, Cafferata, Belizan, Tomasso, & Chalmers, 2005, p. 215). This framework is congruent with the midwifery model of care, yet, only 7 of 22 countries in Latin America have midwifery schools (Belizan et al.), and the DR is not one of them. Professionally trained midwives in Project ADAMES endeavor to model the midwifery model of care for nurses not previously exposed to the model.
The midwifery model of care is particularly important to demonstrate in the DR because as a study by Miller et al. (2003) has illuminated, the maternal mortality ratio in the country has been relatively high, despite the near universality of institutionalized deliveries (97%). The Miller study demonstrated that the lack of quality of care was one explanatory factor and that lack of institutional accountability left nurses not trained in midwifery skills to handle many births.
Also, as with many nations in the developing world, the DR has insufficient numbers of registered nurses to meet the needs of its population. Nurse migration to developed nations is one contributory factor (Kingma, 2006). According to the Spanish Foundation for the Development of Nursing, the DR has 3 nurses per 10,000 inhabitants in comparison, for example, to Spain, which has 45 per 10,000 inhabitants (Fundación para el Desarrollo de la Enfermería, n.d.).
The WHO, stating the strategic directions for strengthening nursing and midwifery services, has noted several key result areas from their stated objectives (WHO, 2002). Key result area 3 pertains to practice and health system improvement. One of the expected results from the objective to improve access to quality nursing and midwifery services is to identify, adapt, and disseminate innovative approaches to bridge the gap between health systems and the needs of the community. Another is to develop educational capacity through twinning of nursing and midwifery schools and North–South collaboration (WHO).
The focus upon improvement of care for women and their families at the institution level as well as in educational partnerships is an indirect but ultimately more sustainable way to serve women globally and to address health disparities. Of the many health disparities that exist between high-resource and low-resource countries, the greatest disparity is the difference in rates of maternal death (Tsu, 2004).
For U.S. midwives, the idea of accompaniment or being “with woman” is at the core of professional identity. Accompaniment of the nurses who manage deliveries in difficult environments is another way to be a midwife. The training of skilled birth attendants, whatever their formal degree or licensure may be, requires dialogue, advocacy, and promotion of cultural humility by all parties. Long-term partnership is a big commitment and requires much more effort than episodic immersion experiences in diverse cultures. The fruit of good partnerships is the trust that deepens the connections with each other; and it is these connections between nurses working on behalf of women and their families, despite the challenges, that sustain the motivation to improve the quality of care.
The author thanks all the participants of Project ADAMES in the DR for their efforts to improve maternal-newborn care.
- a.a lifelong process of self-reflection and self-critique.
- b.an essential part of the Dominican culture.
- c.best eliminated by learning culturally competent techniques.
- 2An effective way to prepare nurses to advocate for the reduction of social inequities is to
- a.participate in a cultural immersion program where health disparities exist.
- b.study abroad for a semester.
- c.take a course in public policy.
- 3Compassion fatigue is caused by
- a.ignorance of the International Council of Nurses Code of Ethics.
- b.inability to achieve work goals in a frustrating work environment.
- c.sleep deprivation from prolonged schedule changes and few vacation benefits.
- 4The greatest disparity in global health is
- a.child mortality under 5.
- b.infant mortality.
- c.maternal mortality.
- 5The United Nations Millennium Development Goal 5 strives to
- a.eliminate disparities in health by 2010.
- b.reduce the infant mortality ratio globally by 9/10 by 2015.
- c.reduce the maternal mortality ratio globally by 3/4 by 2015.
- 6Of all the children under 5 who die annually
- a.12% die because of congenital malformations.
- b.40% are newborns, mostly within 24 hours after birth.
- c.90% suffer from respiratory infections.
- 7According to the World health Organization, a skilled birth attendant is
- a.a midwife who is certified by the International Confederation of Midwives.
- b.a physician who is board certified in obstetrics.
- c.nurses, midwives, and physicians who can manage normal deliveries and diagnose and refer obstetric complications.
- 8The Pan American Health Organization Latin American Centre for Perinatology has a framework to guide care that
- a.is very congruent with the midwifery model of care.
- b.recommends all women be delivered by obstetricians.
- c.recommends at least one fetal ultrasound per pregnancy.
- 9One reason why developing countries have insufficient nurses to meet the needs of their populations is
- a.there are few applicants to nursing schools.
- b.nurse migration to developed countries is common.
- c.there are very few nursing schools.
- 10It is important to demonstrate the midwifery model of care in the Dominican Republic because
- a.as a Hispanic country, there is no historical tradition of midwifery.
- b.the maternal mortality rate in the country has been relatively high despite the high rate of hospital birth.
- c.there are very few doctors in the country.
- 11The World Health Organization has noted strategic directions to strengthen nursing and midwifery services. One recommendation for nursing schools is to
- a.convene to develop one standardized curriculum.
- b.develop educational capacity through twinning of nursing and midwifery schools.
- c.require English so that teleconferencing can take place between nursing schools.
- 12Jonsdottir, Litchfield and Pharris have described nursing practice as
- a.a process of professional partnership with relationship at its core.
- b.promoting or restoring health, preventing illness, and alleviating suffering.
- c.the assessment of human response to illness with interventions to improve health.
- 13One outcome of the partnership in Project ADAMES between midwives and nurses from the United States and the Dominican Republic is
- a.the Dominican nurses have become licensed midwives in their country.
- b.the Dominican nurses have begun to study English on their days off.
- c.the Dominican nurses have trained hospital volunteers as doulas to provide free doula services to women in labor.
- 14The Dominican nurses believe their practice has improved as a result of the Project ADAMES partnership because
- a.their US partners care about them and their commitment to mothers and newborns.
- b.they have learned new skills they never were taught before.
- b.they have new knowledge about evidence based nursing and medical care.
- 15This article advocates an approach to training in cultural understanding that
- a.develops trusted international partnerships that are ongoing.
- b.promotes participation in cultural immersion experiences.
- c.teaches one to care for patients with diverse values, beliefs and behaviors.