Joan Engebretson

Cultural Competence in the Era of Evidence-Based Practice

Cultural competence has become an important concern for contemporary health care delivery, with ethical and legal implications. Numerous educational approaches have been developed to orient clinicians, and standards and position statements promoting cultural competence have been published by both the American Medical Association and the American Nurses Association. Although a number of health care regulatory agencies have developed standards or recommendations, clinical application to patient care has been challenging. These challenges include the abstract nature of the concept, essentializing culture to race or ethnicity, and the attempts to associate culture with health disparities. To make cultural competence relevant to clinical practice, we linked a cultural competency continuum that identifies the levels of cultural competency (cultural destructiveness, cultural incapacity, cultural blindness, cultural precompetence, and cultural proficiency) to well-established values in health care. This situates cultural competence and proficiency in alignment with patient-centered care. A model integrating the cultural competency continuum with the components of evidence-based care (i.e., best research practice, clinical expertise, and patients values and circumstances) is presented.

Facilitating risk reduction among homeless and street-involved youth

PurposeThe purposes of this evaluation project were to describe a group of homeless adolescents and street-involved youth who utilized a mobile unit that provided medical and mental healthcare services and to assess the efficacy of the services provided in reducing their health risk behaviors. Data sourcesThe records of 95 youth aged 15–25 years who used the medical mobile unit for an average of 14 months were examined and evaluated according to the national health indicators related to risk reduction. Current literature related to health risk behavior among homeless youth was reviewed, synthesized, and provided the background for this article. ConclusionsData were obtained from the records of mostly heterosexual youth with a mean age of 20.5 years. Approximately one third of the participants were high school graduates and most were without health insurance. Living situations were transient including friends, shelters, crash pads, or the streets. Abuse accounted for the majority leaving home. Psychiatric conditions and substance abuse were common. Medical conditions were related to transient living situations, substance abuse, and sexual activity. Success of the program was associated with sustained counseling, stabilizing youth on psychotropic medications, decreasing substance use, providing birth control and immunizations, and treating medical conditions. Implications for practiceHomeless youth are one of the most underserved vulnerable populations in the United States with limited access and utilization of appropriate healthcare services. Nurse practitioners often serve as care providers but are also in a position to effectively lobby to improve health care for homeless youth through professional organizations and community activism. Furthermore, when designing and evaluating healthcare services, multidisciplinary teams need to consider risk reduction for homeless youth in the context of their environment.

An ethnographic approach to interpreting a mental illness photovoice exhibit.

The aim of this study was to explore the use of photovoice as an innovative methodology for understanding aspects of the mental illness experience. Applied ethnographic methods were used to examine 15 photographs and accompanying narratives from a mental illness photovoice exhibit. Analysis occurred within and across cases, resulting in individual case studies and a thematic description of the narratives. Suffering, stigma, and loss of identity were found at the center of this rendering of mental illness experience. The findings suggest that a photovoice project offers a useful lens from which to examine experiences associated with living with mental illness.

Providing Mother’s Own Milk in the Context of the NICU A Paradoxical Experience

Background: Mothers of very preterm infants continue to face challenges related to providing their expressed breast milk in the neonatal intensive care unit (NICU). Objective: This qualitative study sought to understand the experience of mothers of hospitalized very preterm infants related to their daily pumping routine during the NICU stay. Methods: Fourteen women who were pumping breast milk for their hospitalized infants were interviewed. Sequential, semistructured, audiotaped individual interviews were conducted at 2 different time points: within 2 weeks following delivery when the mothers were pumping only, and 4 to 6 weeks once breastfeeding had been initiated. Results: The central themes found were: becoming a “mother–interrupted” and negotiating a paradoxical experience of separation and connection. Unique to these findings were the paradoxical view of the pump as both a wedge and a link to their infants, the intense dislike the mothers had for the tasks required to provide their expressed breast milk, and diversionary tactics used during pumping sessions. Conclusion: The complexity of thoughts, actions, and behaviors revealed in the mothers’ narrative accounts provides a guide to direct future breastfeeding interventions and management.

Ethical issues of incorporating spiritual care into clinical practice.

AIMS AND OBJECTIVES The aim of this article was to analyse the scholarly discourse on the ethical issues of incorporating spirituality and religion into clinical practice. BACKGROUND Spirituality is an important aspect of health care, yet the secularisation of health care presents ethical concerns for many health providers. Health providers may have conflicting views regarding if and how to offer spiritual care in the clinical setting. DESIGN Discursive paper. RESULTS The discourse analysis uncovered four themes: ethical concerns of omission; ethical concerns of commission; conditions under which health providers prefer to offer spiritual care; and strategies to integrate spiritual care. Ethical concerns of omission of spiritual care include lack of beneficence for not offering holistic care. Ethical concerns of commission are coercion and overstepping ones competence in offering spiritual care. Conditions under which providers are more likely to offer spiritual care are if the patient has a terminal illness, and if the patient requests spiritual care. Strategies for appropriate spiritual care include listening, and remaining neutral and sensitive to spiritual issues. CONCLUSIONS Health providers must be aware of both the concerns of omission and commission. Aristotles golden mean, an element of virtue ethics, supports a more moderate approach that can be achieved by avoiding the imposition of ones own personal beliefs of a religious persuasion or beliefs of extreme secularisation, and focusing on the beneficence to the patient. Relevance to clinical practice.  Key components for health providers in addressing spiritual concerns are self-reflection, provision of individualised care, cultural competency and communication.

Hands-on: the persistent metaphor in nursing.

The metaphor “hands-on” has been used throughout the history of nursing, highlighting internal conflict and reflecting the centrality of patient care. Connection with the intent to heal suggests the deeper meaning of the metaphor. Nurses have struggled to maintain a holistic approach to patient care while reflecting larger social values. Some nurses have moved from holistic care of the client to a holistic use of self as healer. This unified approach of head, heart, and hands is exemplified in healers using touch therapies. Head and heart unite with the action of the hand with intent to heal.

Alternative and complementary healing: Implications for nursing

The current interest in alternative and complementary therapies is examined within the social context of technology, economics, and philosophical beliefs of a culture that is moving from the Industrial Age into the Information Age. A philosophical shift toward ecology, religion, and spirituality coincides with a shrinking global perspective resulting in increased accessibility to healing ideologies from other cultures. The community of alternative and complementary healers is responding to these social conditions by offering healing modalities congruent with public interests. Responses of the health care industry are discussed as are the similarities of alternative and complementary healing to nursing practice. Implications for nursing research, practice, and education are suggested.

A Multiparadigm Approach to Nursing

Nursing theory development has made good progress in differentiating the domain of nursing from medicine; many of these theories are categorized as holistic theories. Nursing classification systems are also being developed to organize extant nursing practice. The dissonance between the two has been one of the most difficult contemporary issues for the leadership of nursing. A framework is proposed that would account for these disparate approaches. This proposed framework for the domain of healing is in keeping with the metaparadigm of health and uses a multiple paradigm approach. Nursing interventions are discussed in relation to the framework. It invites a dialogue in keeping with the scholarship of holism. Practice and scholarship implications are discussed.

Factors influencing disclosure of abuse by women of Mexican descent.

PURPOSE The purpose of this study was to describe the factors that influence disclosure of abuse by women of Mexican descent. Few published studies describe the experiences of women of Mexican descent with a history of intimate partner abuse, specifically in terms of their process of disclosure of abuse. METHODS A qualitative research design was used to conduct this study in south Texas adjacent to the United States-Mexico border. Twenty-six key informants were recruited from two different sites. An open-ended approach with a semistructured interview guide was used to collect the narrative information from the 26 participants. RESULTS The findings illuminated that many factors hindered disclosure. Some of these factors included protecting their partners, avoidance of worrying their mothers, and fear of losing their children. CONCLUSIONS The study may help healthcare providers to understand the complexity of disclosure by women with a history of intimate partner abuse and may help explain why women do not readily disclose their abusive situations. CLINICAL RELEVANCE This study on the disclosure decision process of abuse by women of Mexican descent provides some understanding on the cultural or situational factors that hindered or encouraged disclosure; ultimately this knowledge can help healthcare providers and others to provide for the womans health, welfare, and safety.

Clinically Applied Medical Ethnography: Relevance to Cultural Competence in Patient Care

Medical anthropology provides an excellent resource for nursing research that is relevant to clinical nursing. By expanding the understanding of ethnographic research beyond ethnicity, nurses can conduct research that explores patients constructions and explanatory models of health and healing and how they make meaning out of chronic conditions and negotiate daily life. These findings can have applicability to culturally competent care at both the organizational or systems level, as well as in the patient/provider encounter. Individual patient care can be improved by applying ethnographic research findings to build provider expertise and then using a cultural negotiation process for individualized patient care.