CULTURALLY SENSITIVE, FAMILY-CENTERED CARE: UNIQUE NEEDS OF THE MILITARY FAMILIES SERVING ABROAD
AN OVERVIEW OF THE NAVAL MEDICAL SERVICES
The United States Navy (USN) currently has 328,267 active duty and 97,219 reserve members serving in various roles throughout the world.1 Navy Medicine, the healthcare division of the USN, operates 17 US Naval Hospitals (USNHs) worldwide, 2 of which are located in Japan. One is on mainland Japan in Yokosuka2 near Tokyo and the other is located on the southern island of Okinawa.3 USNH-Okinawa is the Navy Medicine's largest overseas military treatment facility providing direct patient care to over 47,000 personnel on Okinawa and nearly 189,000 in the Western Pacific region.4 The USNH-Okinawa has a level III, 12-bed neonatal intensive care unit (NICU).5 USNH-Yokosuka is the largest facility in mainland Japan providing a wide range of emergency, inpatient, and outpatient care for approximately 43,000 active duty members and their families. The geographic service area for USNH-Yokosuka and its branch clinics stretches from the northern tip of Japan, south to Iwo-Jima, and west to Diego Garcia, and essentially covers the entire Indo-Asia-Pacific region.6 USNH-Yokosuka does not offer specialized care for high-risk newborns or high-risk pregnancies, leaving a gap in neonatal care for this region. To meet the specialized needs of this population, USNH-Yokosuka has established a system to make high-risk services available through a joint partnership with civilian Japanese neonatal services in the region. The aim of this report is to highlight this collaborative partnership. In addition, the efforts of naval service leadership have been discussed to better understand the care of the high-risk newborns who require admission to the NICU and their families while serving our country overseas.
The Clinical Nurse Specialist for the Maternal and Infant Unit, Lieutenant Commander (LCDR) Michelle Westcott, RN, MSN, CNS, reports that USNH-Yokosuka provides routine prenatal, labor, delivery, and postpartum care. Highly skilled midwifery service provides quality care in partnership with the obstetrical team at Yokosuka Naval Medicine. The care of high-risk mothers and newborns, such as premature births, requires collaboration with the network of Japanese hospitals in the region that provide specialized NICU care. USNH-Yokosuka obstetrical team provides quality prenatal care by monitoring the suitability and safety of pregnant patients for delivery at USNH-Yokosuka. When problems are identified, arrangements for maternal transfers to USNH-Okinawa or back to the United States are made to achieve optimal patient outcomes. However, the dynamic nature of pregnancy and labor and delivery may prevent the opportunity to provide maternal transport to an appropriate military or US civilian facility.
The USNH-Yokosuka transport team is used to transport high-risk mothers or moderately ill infants to Japanese accepting facilities. However, in emergent cases when mothers cannot be transported or following the delivery of an extremely preterm infant(s), Japanese teams are requested to transport the infant/infants to the outlying Japanese facility. These high-risk infants remain in the Japanese NICUs until they are stable, and then they are transferred back to USNH Yokosuka for newborn screening and a short period of observation before discharge home with their families. Although USNH-Okinawa has a 12-bed, level III NICU with neonatology service,5 the 1000-mile distance between USNH-Yokosuka and Okinawa is neither practical for families nor realistic for transport of high-risk infants in urgent or emergent situations. LCDR Westcott reports that annual transport needs vary; however, upwards of 20 cases including high-risk infants and high-risk pregnant mothers are transferred from USNH-Yokosuka to surrounding Japanese hospitals. The bed availability determines transfer location while also facilitating closeness for infants and families. The collaboration between the US and Japanese hospitals is not without challenges, increasing stressors for families that could have potential long-term consequences.
CHALLENGES FOR THE NAVY FAMILIES AND ALSO FOR THE JAPANESE HEALTHCARE PROVIDERS
Navy families are far removed from their own family support system during the time they serve their nation from posts abroad. Naval support systems are in place; however, not having your own immediate family and close friends nearby during a prolonged hospitalization with an ill child is a highly stressful experience both psychologically and physically. Although the Japanese hospitals where their infants are transported to may be in the “region,” the distance can still require extended driving times—as much as an hour or more. Frequent travel off-base to the foreign hospital is not included in typical training for the anticipated “overseas” experience for Navy service members or their families.
It is also rare for Navy families serving in Japan to have language proficiency in the native language of Japanese. The Japanese hospital's standard practice does not typically include readily available English written materials, putting English-speaking patients and families at a disadvantage. It is common to find only a handful of nursing staff who may speak some English, but rarely at a proficient level. Some of the physician staff members may speak near-proficient English; however, his or her availability at the bedside is limited.
A complex combination of barriers potentially creates further complications for Navy families, especially when the hospitalization is prolonged. Annual transports of up to 20 infants from USNH-Yokosuka to Japanese hospitals may not sound significant to readers whose practice carries out significant number of transports yearly; however, the impact of these transport cases, which originate from the Navy base, must be viewed in terms of the “total patient days of hospitalization,” and the day-to-day struggle and stress Navy families endure in a foreign culture. We must also consider the day-to-day efforts the Japanese care providers make attempting to meet both the medical needs of the infants and the support for the families. In the NICUs in North America, we strive to welcome NICU families who speak limited English or no English at all, who may not have lived in the United States for a long time, so that our care quality, both actual and perceived, is not negatively impacted. The NICU environment is often perceived as “foreign,” “unwelcoming,” or “intimidating” even in the absence of language or cultural barriers. Table 1 summarizes some of the barriers and challenges that present to Navy families as well as the challenges expressed by Japanese hospital healthcare providers when Navy families face crisis in the NICUs in Japan.
CURRENT EFFORTS BEING MADE
Navy leadership is aware of actual or potential obstacles that service members experience in the host country hospital. Currently, a bilingual Japanese civilian staff that has previous nursing experience is incorporated into the care team by USNH-Yokosuka to support the navy families who are hospitalized off-base. This member visits the Japanese NICUs once a week to serve as an interpreter, visit with, and encourage Navy families. On these visits, complex matters are discussed with the healthcare team to ensure accurate information is communicated to families while any special needs of the families can be relayed to the care providers.
To support this partnership, Naval Hospital leadership initiated a US–Japan Joint Nursing Symposium, inviting the local Japanese nursing community to an annual face-to-face meeting. The objective of this joint meeting is to nurture the cross-cultural professional relationship and to develop opportunities to improve the partnership in coordination of care, to optimize the experiences of patients and families. USNH-Yokosuka hosted the 4th Annual US–Japan Joint Nursing Symposium on February 12, 2018, at the Admiral Arleigh A. Burke Officer's Club on the Naval Base in Yokosuka, Japan. Nearly 100 nurses (Japanese, navy, air force, and civilian U.S. nurses working in USNH Yokosuka) representing numerous area hospitals where Navy service members or their families have received care or collaborated with in the past attended the event. The US–Japan joint participants were able to share healthcare challenges, and be inspired by the collaborative nursing spirit that ties them together in spite of the differences in culture or language. Invited speakers were from both the maternal–infant and the pediatric specialty care areas. The former Commanding Officer of USNH, Captain Rosemary C. Malone, MD, delivered her opening message with words of sincere gratitude to the Japanese hospital representatives for this innovative partnership. LCDR Westcott presented her sincere and heart-felt words of “thank you” by recognizing each hospital that was represented at this symposium.
Several Japanese presenters discussed the efforts as well as the immense sense of responsibility they felt as they cared for the Navy families and their infants. One presenter reported the efforts they have made to translate some of the materials into English, especially the initial admission consent forms. These materials will be used to facilitate communication with the Navy families at her institution. Japanese presenters also expressed the challenges they experienced when collecting maternal history or delivery information. It is not easy for the Japanese staff to review the history information sent with the patients from the Naval Hospital that is all written in English. One presenter stated that, in some emergency transports, all they know is “a baby is coming from the base” without a detailed history, making preparation a challenge.
Wakako Eklund, DNP, NNP-BC, a NANN and NANNP member, was invited to present at this event. Her presentation, titled, “Our collaborative team of 29 NNPs and 10 Neonatologists!” described the common neonatal practices in the United States as Dr. Eklund practices in Nashville, Tennessee. She shared how a large geographic area is covered by the partnership of neonatologists and neonatal nurse practitioners in collaboration with area hospitals and their staff. She discussed the challenges in caring for non-English-speaking families whose infants are admitted to NICUs in the region. She also described that her Nashville practice has transported numerous infants from a military base in the region when higher level of NICU care was required and of the challenges that families face off-base. These challenges aligned with the collaborative practice between USNH-Yokosuka and area Japanese hospitals. Her message included the value of culturally sensitive and family-centered care, emphasizing how families' stress can be minimized by providing family support with various strategies especially when families do not speak English. She shared her own experience of caring for Japanese families with premature infants in the United States, and how intensely families seek someone of their own language/culture when in crisis for comfort or reassurance. This, she shared, is necessary for non-English-speaking families to feel confident in the care their infants are receiving, and to feel secure in an incredibly insecure moment in their lives.
Navy nurses asked what more they can do to prepare the Navy families before they go to the Japanese hospitals, and they also expressed their observations of how the healthcare culture appeared to differ significantly between the United States and Japan. Dr. Eklund was able to visit with the nurse who makes the weekly visits to the NICU to meet with Navy families who are being cared for in the Japanese facilities. She learned from Japanese NICU nurses about the difficulty they experience as they take care of Navy families in a manner satisfying to both the Navy families and to the care providers. Not being able to fully engage with families in deep discussions with the simple verbal communication is challenging, and they shared concerns about not being able to adequately understand the families' feelings while the families were not adequately able to express their needs to the caregivers, thus potentially adding unnecessary stressors for all.
Cristal Grogan, a former Navy wife who underwent an emergency cesarean section to deliver her son at 29 weeks' gestation while her husband was stationed in Spain, offers the following reflection based on her lived experience in a “foreign NICU.” Cristal is an active member of the “Premie Parent Alliance (PPA),”7 which is a dynamic network of former NICU parents, with the mission to advocate for the needs of NICU families by closely collaborating with the members of the neonatal, pediatric, and perinatal organizations. PPA is actively engaging in neonatal initiatives at the local, state, national, and also at an international front.
My son had a complicated course in the NICU. But I truly believe that so much of the trauma we experienced as parents, and the PTSD [posttraumatic stress disorder] that I may always live with, could have been minimized by the simple ability to “speak” or “communicate intelligently” back and forth with the care team. The biggest stressor and the distress experienced as a result was mainly centered around the communication barrier, specifically the lack of access to interpreters. We had so many questions and we sensed that we were viewed as a burden to the NICU staff because of our lack of knowledge to speak the host-country's language, Spanish. Because of not being able to fully understand how my son's condition was improving, progressing, or regressing in concrete terms, I always feared the worst, traumatizing myself every day. My difficulty during those days negatively impacted my ability to bond with my dear son for well over a year post-discharge. It affected my mental health and my overall ability to care for my son, including breast feeding or to create special memories/moments with him during the early phase of his life. Today, it is known that PTSD is a reality to many NICU families even when there is no cultural or language barriers, and I understood later that my condition was far worse for a reason that was explainable.
While we provide culturally sensitive care in the United States to non-English-speaking families from other cultural backgrounds, we must also remember some of our men and women who are serving abroad and experiencing culturally stressful hospitalization experiences. Dr. Eklund has contacted some of the Japanese hospital leadership to inquire how she could support such efforts as document translation, creation of English educational materials, or to participate in any future joint initiatives to facilitate any efforts using her language and neonatal expertise. She considers it an honor to have been a part of the 4th US–Japan Joint Nursing Symposium and to take part in any future efforts by keeping in touch with those NICU members in Japan where the Navy babies and their families are being cared for. She sensed a highly motivated collaborative spirit between the US Navy nurses and the Japanese nurses in attendance and is confident that the continued joint partnership between USNH-Yokosuka and the Japanese healthcare community in the region will continue to offer positive changes to the experiences of Navy families and their infants.