Ardith Z. Doorenbos

Culturally Congruent Care Putting the Puzzle Together

This article presents the 3-D puzzle model of culturally congruent care, defines the levels and constructs employed by this model, presents some assumptions, and lays out some basic propositions as a foundation for further work. There are many extant frameworks and theories of culture and cultural competence in nursing and health care; the model presented here draws heavily from prior work and is an attempt to present a synthesis of concepts and processes in a new way. The ideas presented here build particularly on pioneering work in transcultural nursing by Leininger. Leiningers work specifically focuses on the use of qualitative methods to understand the ways in which culture influences nursing care from an emic, or insider, perspective. The 3-D puzzle model extends Leiningers work to include concrete articulations of constructs relevant to design and implementation of intervention strategies for teaching and measuring competency among nurses and other providers.

Cultural Diversity in Nursing Education: Perils, Pitfalls, and Pearls

Increasing diversity in the classroom challenges nursing educators to identify issues that complicate teaching (perils), analyze barriers for themselves and their students (pitfalls), and select new strategies for working with nontraditional students (pearls). This article identifies concerns arising from attitudes and values within nursing and common approaches to diversity education, and then discusses key issues in nursing education that relate to human nature, culture, faculty workload, and student demographics. Finally, some strategies are proposed for increasing the effectiveness of professional preparation with diverse students through a focus on culturally congruent education and development of faculty cultural competence.

A Three-Dimensional Model of Cultural Congruence: Framework for Intervention

ABSTRACT Culture provides the context for all health care and social service throughout the human life span. Improving end-of-life and palliative care and enhancing patient and family outcomes requires a nuanced understanding of cultural contexts for those who provide care and those who receive it. The authors of this article propose an emerging model of culturally congruent care that can guide intervention for social workers, mental health professionals, nurses, and other health care workers caring for a diverse population of patients, families, and communities.

Physical Functioning: Effect of Behavioral Intervention for Symptoms Among Individuals With Cancer

Background: Individuals with cancer receiving chemotherapy suffer deterioration in physical functioning due to symptoms arising from the cancer disease process and its treatment. Objectives: To determine if age, chronic health conditions (comorbidity), stage of cancer, depressive symptomatology, symptom limitations, sex, and site of cancer moderate the effects of cognitive behavioral intervention on physical function and to determine if symptom limitations mediate the effect of the intervention on physical functioning. Methods: Two hundred thirty-seven individuals with solid tumor cancer (118 experimental and 119 control group) participated in this 10-contact, 18-week randomized control trial. Cognitive behavioral theory guided the nurse-delivered problem-solving experimental intervention. The control group received conventional care. Interviews occurred at baseline and 10, 20, and 32 weeks. Results: Women with breast cancer had significantly better physical functioning than women with lung cancer. Chronic health conditions, symptom limitation, and depressive symptomatology at baseline were found to moderate the effect of intervention on physical function. Symptom limitation, however, was not found to mediate the effect of intervention on physical functioning. Discussion: The intervention was shown to affect physical function trajectories differently for individuals with different personal and health characteristics. Because poor physical functioning is strongly associated with mortality and poor quality of life, this information may be used by health professionals to target interventions to those who might be most responsive.

Cultural competence among hospice nurses

The purpose of this study was to examine variables associated with cultural competence among hospice nurses. In a cross-sectional descriptive design, a convenience sample of 107 hospice nurses from five different hospice agencies completed a survey that included the Cultural Competence Assessment instrument. Regression analysis revealed a significant association between higher education and cultural awareness and sensitivity, as well as an association between diversity training and self-reported cultural competence behaviors. Findings support the need for additional education and training for hospice nurses and provision of more resources targeted toward enhancing cultural competency.

A Problem Solving Intervention for Hospice Caregivers: A Pilot Study

The Problem Solving Intervention (PSI) is a structured, cognitive-behavioral intervention that provides people with problem-solving coping skills to help them face major negative life events and daily challenges. PSI has been applied to numerous settings but remains largely unexplored in the hospice setting. The aim of this pilot study was to demonstrate the feasibility of PSI targeting informal caregivers of hospice patients. We enrolled hospice caregivers who were receiving outpatient services from two hospice agencies. The intervention included three visits by a research team member. The agenda for each visit was informed by the problem-solving theoretical framework and was customized based on the most pressing problems identified by the caregivers. We enrolled 29 caregivers. Patients pain was the most frequently identified problem. On average, caregivers reported a higher quality of life and lower level of anxiety postintervention than at baseline. An examination of the caregiver reaction assessment showed an increase of positive esteem average and a decrease of the average value of lack of family support, impact on finances, impact on schedules, and on health. After completing the intervention, caregivers reported lower levels of anxiety, improved problem solving skills, and a reduced negative impact of caregiving. Furthermore, caregivers reported high levels of satisfaction with the intervention, perceiving it as a platform to articulate their challenges and develop a plan to address them. Findings demonstrate the value of problem solving as a psycho-educational intervention in the hospice setting and call for further research in this area.

Enhancing cultural competence among hospice staff.

A critical component in making hospice and palliative care services accessible and acceptable to diverse communities is preparation of all providers to enhance cultural competence. This article reports a study designed to test an educational intervention aimed at expanding cultural awareness, sensitivity, and competence with a multi-disciplinary and multilevel team of hospice workers. The purpose of this quasi-experimental, longitudinal, crossover design was to test the effects of an educational intervention for multidisciplinary hospice providers. Findings demonstrated that even with a modest face-to-face intervention, cultural competence scores were significantly greater after the educational intervention for participants in both groups. Although the intervention proved successful at enhancing cultural competence scores among diverse types of hospice workers, limitations and logistic insights gained from this pilot suggest the need for examination of alternative methods of program delivery.

Physician, patient, and contextual factors affecting treatment decisions in older adults with cancer and models of decision making: a literature review.

PURPOSE/OBJECTIVES To review physician, patient, and contextual factors that affect treatment decision making in older adults diagnosed with cancer, and to relate those factors to theoretical models of decision making. DATA SOURCES PubMed (1966 to April 2010), PsycINFO (1967 to April 2010) and CINAHL® (1982 to April 2010) databases were searched to access relevant medical, psychological, and nursing literature. DATA SYNTHESIS Physician factors in treatment decisions included physicians personal beliefs and values, medical expertise, practice type, perception of lowered life expectancy, medical factors, power, and communication style. Patient factors included personal beliefs and values, ethnicity, decisional control preferences, previous health-related experience, perception of the decision-making process, and personal factors. Contextual factors included availability of caregiver, insurance, financial status, and geographical barrier. CONCLUSIONS A diverse group of factors were identified, which are likely to form a unique framework to understand clinical decision making and plan future investigations in older adult patient populations. Using longitudinal and prospective designs to examine the real-time interplay of patient, physician, and contextual factors will enable a better understanding of how those divergent factors influence actual treatment decisions. IMPLICATIONS FOR NURSING Oncology nurses can advocate autonomous (patient-driven), shared, or family-controlled treatment decisions, depending on an older patients decisional role preference. Nurses can support patient autonomy during treatment decision making by coaching patients to engage in discussion of various evidence-based treatment options and a comprehensive discussion of the probability of success for each option with specialist providers. Oncology nurses may be able to promote treatment decisions that are consistent with a patients personal preferences and values, with strong consideration of the patients personal contexts.

A Noninferiority Trial of a Problem-Solving Intervention for Hospice Caregivers: In Person versus Videophone

PURPOSE OF THE STUDY Problem-solving therapy (PST) has been found effective when delivered to informal caregivers of patients with various conditions. In hospice, however, its translation to practice is impeded by the increased resources needed for its delivery. The study purpose was to compare the effectiveness of a PST intervention delivered face-to-face with one delivered via videophone to hospice primary caregivers. DESIGN AND METHODS The study design was a randomized noninferiority trial with two groups, Group 1 in which caregivers received PST face-to-face, and Group 2 in which caregivers received PST via videophone. Family hospice caregivers were recruited from two urban hospice agencies and received the PST intervention (in three visits for Group 1 or three video-calls in Group 2) in an approximate period of 20 days after hospice admission. Standard caregiver demographic data were collected. Psychometric instruments administered to caregivers at baseline and at study completion included the CQLI-R (Caregiver Quality of Life Index-Revised), the STAI (State-Trait Anxiety Inventory), and the PSI (Problem-Solving Inventory). RESULTS One hundred twenty-six caregivers were recruited in the study; 77 were randomly assigned to Group 1 and 49 to Group 2. PST delivered via video was not inferior to face-to-face delivery. The observed changes in scores were similar for each group. Caregiver quality of life improved and state anxiety decreased under both conditions. CONCLUSIONS The delivery of PST via videophone was not inferior to face-to-face. Audiovisual feedback captured by technology may be sufficient, providing a solution to the geographic barriers that often inhibit the delivery of these types of interventions to older adults in hospice.

Nursing interventions to promote dignified dying in four countries

PURPOSE/OBJECTIVES To describe nursing interventions to promote dignified dying as identified by nurses in four countries. DESIGN Cross-sectional survey design. SETTING Hospitals and clinics in Ethiopia, India, Kenya, and the United States. SAMPLE A convenience sample of 560 nurses who cared for dying patients in Ethiopia (n = 14), India (n = 229), Kenya (n = 36), and the United States (n = 281). METHODS Nurses who agreed to participate completed the International Classification for Nursing Practice Dignified Dying Survey. Responses to an open-ended survey question about the interventions nurses use to promote dignified dying were analyzed qualitatively. MAIN RESEARCH VARIABLES Nursing interventions. FINDINGS The Dignity-Conserving Care Model provided a framework to analyze nursing interventions used to promote dignified dying. Although some variation was found in the interventions used, nurses from all four countries identified interventions representing each of the three major categories of the model: illness-related concerns, a dignity-conserving repertoire, and a social-dignity inventory. CONCLUSIONS Nurses identified the holistic nature of the dying experience and the multiple interventions needed to promote dignity for dying patients and their family members. Palliative care is an area of practice that crosses healthcare settings, specialties, countries, and cultures. IMPLICATIONS FOR NURSING This study begins to identify specific interventions for future research and applies the Dignity-Conserving Care Model to further understand dignified dying from an international nursing perspective.