The United States faces a dual challenge: recognition of the extent of health disparities within the population and cultural disconnects associated with providing health-care to an increasingly multicultural and economically diverse community of patients. Foreign-born and individuals from cultural minority groups may experience exceptional healthcare needs throughout their entire lives and the challenges of healthcare provision for low-income populations is well established. Both issues underscore the importance of the research on cultural aspects of healthcare disparities.
We focus on one component within the health disparities puzzle—efforts by healthcare providers to minimize culturally influenced disparities, an area of healthcare practice where nurse practitioners (NPs) assume a prominent role. While findings discussed in this manuscript locate NPs within the broader context of interdisciplinary healthcare teams serving vulnerable communities, our main focus is on how NPs' approaches to negotiating cultural differences among their co-workers and patients were unique and distinctive compared to other healthcare professionals. We identify key themes associated with healthcare professionals' perspectives (especially NPs) on providing culturally competent care in primary care settings. Our findings show that NPs occupied a unique bridging position that contributed to competence in two radically different cultures: the healthcare culture within which they were embedded, and the cultures of the diverse patient communities they served.
There is a growing recognition that health is much more than a biological phenomenon, i.e., it also includes social, cultural, psychological, environmental, and behavioral experiences (House, 2002; Link & Phelan, 2005). The link between low socioeconomic status (SES), ethnicity, and health is obviously multifaceted; consequently, there is no single straightforward or uncomplicated way for researchers to tease out the relative contributions of each of those vulnerabilities to the cultural experiences of health.
Despite the obvious complexities, the literature is clear that those who are most vulnerable to chronic disabilities and poor health are from lower SES groups (Hayward, Miles, Crimmins, & Yang, 2000; Hayward & Gorman, 2004; Lantz, Lichtenstein, & Pollack, 2007), the economic strata in which minority groups are overrepresented. Several connections link poor health with low SES and minority group status. Some argue that lack of routine access to health-care associated with the United States's health insurance arrangements is one culprit (Kaiser Commission on Medicaid and the Uninsured, 2008). However, neither lack of health insurance nor low income alone explains health disparities. Regardless of insurance availability or higher levels of SES, minority individuals, on average, still suffer from poorer health and decreased levels of physical and psychosocial functioning (Angel, Frisco, Angel, & Chiriboga, 2003; Geronimus, Hicken, Keene, & Bound, 2006; Zuvekas & Taliaferro, 2003). For ethnic minorities, the disadvantages of being in a minority cultural position are often layered on top of economic disadvantages that persist over time. The purpose of our research is to explore how health professionals, particularly NPs, understand and enact practices that attempt to address the cultural component of health disparities by providing culturally competent care.
Cultural competence and culture brokering
Cultural competency is the term describing how healthcare providers consider and understand how social and cultural factors affect individuals' health and attitudes toward illness and disability (Berlin & Fowkes, 1983; Black & Purnell, 2003). There is not one universally agreed definition (Matteliano & Stone, 2010), but most healthcare providers agree that cultural competence occurs on many levels—from policy to clinical interactions (Sobo, 2009), and is a process rather than a one-time event (Campinha-Bacote, 2002). Cultural awareness—the ability to understand one's own culture and perspective alongside the stereotypes and misconceptions associated with other unknown or less known cultures and statuses—is a first step toward providing culturally competent care. Cultural sensitivity improves when providers recognize how their own culturally specific values and beliefs influence the patient/provider interaction. Advocates of culturally competent care regard improving providers' cultural sensitivity as an important step toward achieving culturally competent care (Benkert, Teplin, Schim, Doorenbos, & Bell, 2011; Sotnik & Jezewski, 2005).
Culturally competent healthcare providers not only understand how language, customs, values, and beliefs about illness influence patients' health behavior, but also account for other contextual considerations (such as SES and the environment) that impact access to health-care and the capacity of individuals to change health behaviors (Sotnik & Jezewski, 2005). While cultural attributes associated with minority status are an essential piece of the cultural competence puzzle, so too are cultural practices associated with differences in SES—these social locations are quite inextricably intertwined. Furthermore, culturally competent providers realize that each new patient encounter may require an adaptation in approach, continually striving to understand the patient and their context to become culturally proficient (Langer, 1999).
According to Jezewski and Sotnik (2005), culture brokering manages some disconnects in clinical encounters that are associated with intervening conditions. These range from type of illness and/or disability, method of communication, age of the client, cultural background, perceptions of power or powerlessness, economics, bureaucracy, politics, network, and stigma, because all substantially influence health decisions both for clients and practitioners. Culture brokering is part of a process that involves compromise, negotiation, conflict reduction, and attention to intervening conditions that influence health outcomes (Jezewski & Sotnik, 2005). Healthcare providers who abandon counterproductive stereotyping behaviors change the power differential between the patient and provider by brokering gaps across different cultures (Ayonrinde 2003; Black & Purnell 2003; Sotnik & Jezewski 2005) achieving cultural competence. Such gaps are routinely presumed to exist between patients and providers; less studied, however, is the need for culture brokering within medical cultures. Here NPs occupy a niche, where their professional socialization not only equips them to bridge the traditional gap between medical and patient cultures, but also provides opportunities to close gaps within professional health cultures (i.e., between physicians and other healthcare professionals) associated with different kinds of professional socialization.
Healthcare professionals' culture stems from their medical background and training experiences and varies across professional categories. Yet, healthcare professionals tend to ignore their unique cultures and to view others (rather than themselves) as having a culture. Typically, most of what healthcare providers regard as “cultural” are patients who speak a different language, are from different social groups, or come from a different country (Sobo, 2009). However, healthcare providers have a system of shared values and beliefs that they learn as they don the cultural cloak of their professions and are socialized in its beliefs during their education and work experiences, whether they recognize it or not. There are many cultural subsets and a hierarchical ordering of health professions (Abbott, 1988; Clark, 1997; Lichtenstein, Alexander, McCarthy, & Wells, 2004; McMurray, 2011).
Within the domain of health professions, distinctive subsets include physicians, NPs, nurses, occupational and physical therapists, social workers, and other health professionals. Physicians, NP, nurses, and rehabilitation professionals develop specialties even within their professions (Nancarrow & Borthwick, 2005), each specialty with a culture of its own. Even when healthcare providers are culturally similar to their patients in other ways, such as gender or race/ethnic concordance, there is often a socioeconomic divide. Despite the multiplicity of cultures—professional and patient, majority and minority, rich and poor—in the healthcare environment, the intersections between medical cultures and culturally competent healthcare delivery are understudied. Focusing on NPs, given their unique bridging position in primary care, provides an opportunity to do so.
Cultural advantages of teamwork in primary care
Effective teamwork improves the efficiency of care and improves outcomes, especially in primary care (Gittell, Fairfield, Bierbaum, Head, Jackson, Kelly, et al., 2000; Rosenthal, 2008; Whitehead, 2007). Neighborhood community practices located in underserved areas, like the ones in this study, have patients with distinct economic, cultural, and social needs (Ayonrinde, 2003; Barr, 2008; Becker, Beyene, Newsom, & Rogers, 1998; Carrillo & Ananeh-Firempong, 2003). Interdisciplinary teams of healthcare professionals are better equipped than solo practitioners to provide the full range of health care to patients with complex health needs that require long-term management (Clark, 1997; Hall, 2005) and to enact cultural competence because of a broader pool of individuals with a range of cultural skills.
Among the team members practicing in such settings are physicians, NPs, nurses, rehabilitation therapists, and social workers. While nursing's main function historically was as physician helper (Hall, 2005), the profession has broadened its jurisdiction through increasingly specialized practice, to encompass roles once exclusively the domain of physicians. The nursing profession is now considered a collaborative team member among medical professionals (Hall, 2005; Martin, O'Brien, Heyworth, & Meyer, 2005; Philips, Green, Fryer, & Dovey, 2001), in some cases directly challenging physician authority (McMurray, 2011). When community practices try to meet the healthcare needs of diverse communities, NPs occupy a professional niche with the capacity to offer unique contributions within interdisciplinary healthcare teams. Among the team members, the professional socialization of NP creates the capacity of a bridging position that can both surmount some of the cultural barriers that separate the health professions and also close gaps in the provision of culturally competent health care for patients.
The principle investigator conducted interviews and observations at three primary healthcare facilities located in inner city neighborhoods in a mid-size city in the northeastern United States. Findings are reported using pseudonyms (both of field sites and the individuals within them) to maintain confidentiality of the participants in the research. Two of the field sites are private practices. The third site is affiliated with the city's largest not-for profit corporate hospital group. Each healthcare site is located in a different inner city neighborhood with racially and ethnically diverse low-income residents and distinctive patient bases.
Washington Family Medicine (Washington) serves an almost exclusively African–American clientele. Six attending physicians, 11 resident physicians, a Registered Nurse (RN), three Licensed Practical Nurses (LPNs), an office manager, a phlebotomist, a secretary, and four additional clerical staff make up the workforce at Washington Family Medicine. According to data provided by the practice, during 2008 Washington had 17,259 patient encounters with 14,542 office-only visits. The insurance payer mix was 67% Medicare/commercial insurance and 39% Medicaid (note: percentages do not total 100 because some elders are dual eligible).
Centro de Asistencia Médica (Centro) serves a dominantly Hispanic community and a smaller subpopulation of refugees. Centro's practice includes six attending physicians, six residents, four NPs, four RNs, two LPNs, two certified medical assistants, five medical assistants, five translator/receptionists, two file clerks, a social worker, a part-time physical therapist, a facilitated insurance enroller, and a part-time podiatrist. Centro reported 30,542 patient visits in 2008. Twenty-one percent of Centro's patients were covered by a local commercial health maintenance organization (HMO), followed by 28% Medicaid, 19% commercial insurance, 14% Medicare, 2% self-pay/charity, 1% no fault/workers compensation, and approximately 15% self-pay or uncompensated care.
Good Samaritan Family Practice (Good Samaritan) is considered a single field site, but offers services at two locations. Good Samaritan's main clinic operates in a very diverse transitional neighborhood serving elderly Italian residents who have aged in place, a more recent influx of Hispanic residents and African Americans, plus a sizeable refugee population. The smaller Good Samaritan satellite site serves an almost exclusively African–American neighborhood. Good Samaritan's staff includes three physicians, two NPs, four nurses, and several supportive office staff. The medical director at the satellite site is a NP. Good Samaritan provided services for 6151 patients with 24,000 patient visits in 2008. Medicaid covered 63% of patients, 18% by Medicare, 19% had private insurance, and 10% of patients were uninsured (note: percentages do not total 100 because some elders are dual eligible).
Data consist of intensive interviews and field observations of individuals working at three different health practice organizations. Sites were selected purposively to ensure a range of practice types and patient bases with unique cultural needs. Interviews with individuals within the sites also used purposive sampling to cover a range of perspectives from individuals in different professional positions.
Because professional socialization and practice characteristics are contextually complex, and this was an exploratory study, a qualitative approach to data collection and analysis was most appropriate (Guba & Lincoln, 1994). Data validity was enhanced by direct access to the environment, sustained interactions with research participants, and rich and varied contextual observations at each field site (Altheide & Johnson, 1994; Babbie, 2004), cross-validated both with respondents and other experts in the field. Data are from field notes, observations, and transcripts of over 50 intensive formal interviews with health professionals and office staff in the three healthcare field sites. Thirteen physicians were interviewed and 13 other healthcare providers (NPs, nurses, a social worker, and a physical therapist) and 15 office and support staff were also interviewed.
Nine additional interviews with administrators, social workers, healthcare providers at refugee centers, and professors in nursing and medical schools who teach cultural competency in their curricula, provide additional context for the research. The University's Social and Behavioral Sciences Institutional Review Board (SSIRB) approved the project.
We used grounded theory techniques, first organizing the data under broad topical or thematic headings. Transcripts were read and reread, identifying broad conceptual categories that guided data organization and descriptive code words developed for recurring concepts. Analytic choices determined where these more refined concepts fit or overlapped within the overarching categories initially developed. The last analytic step was to compare across conceptual categories using axial coding. The initial process of creating concepts (open-coding) transitioned to examining the relationship between the concepts within the categories and subcategories that were created (Strauss & Corbin, 1998).
Common themes among healthcare providers
Reoccurring themes in the data reflected common ways providers (regardless of professional status) talked about providing culturally competent care in their practices. These themes included going beyond the call of duty, having altruistic motivations, probing for root causes, and advocating for patients.
Many healthcare providers went beyond the call of duty. For example, one NP drew the sun and the moon on prescription bottles to help an illiterate mother and daughter take medications at the right time of day. She also created a Spanish/English handout chart on medication management that patients can refer to for dosages in their native language [Centro, NP 2]. In a similar vein, the African physician at Centro calls her patients some evenings. She checks in with her patients after hours because she can relate to young mothers and the problems they face [Centro, Physician 4].
Many practitioners, not just NPs, expressed altruistic motivations as the impetus behind their practice with underserved populations. NPs, in particular, identified their work as a vocation—their work expressed their values and altruism that had inspired them to serve culturally diverse and underserved patient populations.
I think especially among the NPs and I would say the physician staff too … You are really called as a vocation to do this and not as an occupation … if you were there for the paycheck you would just not do it there is a lot of easier jobs around … you know but the thing is, it is a call to serve your community … it is a vocation … because I have worked in hospitals for years but I always have known I was going to do something like this you know[NP 2].
… My philosophy is I can live my religion by doing the best I can as a mother, a wife, as a NP so I can live my religion as being … Treating everyone as best I can and give him or her the best care but that is not for a paycheck or in some way a mission[NP 1].
Personal characteristics, including religious motivations, are part of the complex motivations for providers' choice of practice settings. Although NPs recognized that they could earn more in other settings, all said they were motivated by a vocational sense of responsibility to try to provide quality health care in underserved communities.
Providers who regarded their care as culturally competent reported that they were good at finding novel or unconventional ways to intervene for many patients who lacked social and monetary resources. For example, they probed until they got to the “real” reason when compliance with treatment was a problem. The focus on root causes demonstrates that providers often regarded their culturally distinctive patients as different from an idealized “average” patient—whether the reason for difference was some obvious cultural distinction, such as the race or language of the patient, or poverty. As such, providers often reported needing further investigation to understand problems arising in the clinical encounter. Providers also advocated for patients by finding specialists willing to work around insurance and cultural barriers to provide needed specialty care.
NPs' contributions to culturally competent care
While the foregoing indicates that many health professionals, regardless of specialization, shared common themes associated with their individual commitment to offer culturally competent care to their patients, NPs were distinctive in several important ways that can likely be attributed to unique components of their professional socialization in their medical specialty (Benkert, Templin, Schim, Doorenbos, & Bell, 2011; McMurray, 2011; Nancarrow & Borthwick, 2005). Themes that surfaced from interviews with NPs included using a holistic approach, developing partnerships with patients, enacting personalismo/established niches, adherence to professional standards, and culture brokering.
A common theme in cultural competence among providers more generally, but echoed especially by NPs, was using a holistic approach to practice, taking into account how various nonmedical problems beyond the clinical encounter affect patient health.
Non-compliance or non-adherence is a problem but it is at least for nurses and NPs it is easy for us to figure out what the problem is because we will look at everything else to see why you didn't do it. I will ask if I give you medicine: “does your insurance cover it, do you have money for the co-pay, do you know are you going to be able to get to the drug store to get this because it is really important that you start it today” … [NP 3].
Her experience and training as a NP helped this NP move beyond an exclusive focus on the health problem her patient manifested to understand the contextual circumstances that could interfere with a patient's ability to fully comply with recommendations. Using a holistic approach in providing culturally competent treatment also includes having the background knowledge to address diet and lifestyle issues by using clinical interactions as teaching opportunities, something most members of healthcare teams mentioned as an essential component of culturally competent practice (Carrillo, Perez, Salas-Lopez, Natale-Pereira, & Byron, 2011).
I try to be very straightforward with my patients with the diabetes, and high cholesterol and high blood pressure and that kind of stuff and I explain what you can do and there are some herbals that are good for things like that and I explain to them about what they need to go for and butters that have flaxseed oil and oatmeal that have flaxseed oil added to it and if you can get that naturally into your diet wonderful, all the better but you also need not to eat the fried plantains every night and the fired pork, once in awhile is ok but not every Sunday … you know every week[NP 2].
Understanding cultural considerations that are closely linked with diet and using an approach that negotiates with patients is more culturally competent and, according to NPs, more successful, than merely providing a list of dos and don'ts that might negate any compromise.
The holistic approach that NPs advocate in the practices studied demonstrates the need for cultural competence not only in patient interactions, but within the culture of healthcare professional teamwork, too. Several NP said establishing partnerships rather than hierarchical relationships with fellow professionals and patients both were a critical part of their approach to enacting culturally competent care. In the patient/provider encounter, it sometimes meant that NPs had to adjust their clinical practice to address patient issues, like multiple health problems and high no-show rates. While it was less routinized than a hierarchically ordered clinical event, it made sense to the NPs to prioritize the patient's needs and take care of the most urgent problems during the visit, given the realities of the clinical context.
Yeah, trying to address specifically what is important to them but not letting go of two things they want and two things you think are important. You know they may have come in with a sore toe but their blood pressure is so out of control and I have seen it with some providers for an urgent visit and they haven't had their diabetes monitored and they just tell them to come back. Where I will try to address what I can and I will try to address that blood pressure … if the diabetes has not been checked in a year check a blood sugar and if it is 300 so you … I try and do what I can in the time frame that you have[NP 1].
The give and take that the NP describes is indicative of efforts to address the patient's immediate concerns while simultaneously addressing impending medical concerns through negotiation and partnership, implemented despite institutional requirements for productivity. Another NP approached patient care similarly:
I encourage my patients to bring a list, we may only get to three issues on it but bring your list … and it's hard because when you are a part of [hospital name] well you got to make numbers, you got to see so many people … [NP 2].
There are so many needs with underserved populations that it is difficult to untangle social and medical needs; NPs were unanimous in seeing them as interrelated. In fact, the NPs we studied said they took that into account and practiced differently than they would in other settings where patients' health needs were not so often based on crisis.
… This is a hard place to be because … [patients are]very crisis oriented, so they don't often address their health care and they don't come for health promotion things and wellness events often, they are here for crisis so if you don't change the way you practice and go ahead and grab those things while they are here … take them and catch them up on their immunizations and say ok you are here for your cough but you are not up on you mammogram and lets screen for diabetes … and all these other things and let's come back for a visit so we can go over that stuff, you have to really adjust your practice in order to see this, I think because I have adjusted my practice to screen for things I think I find things earlier because I do that but if I waited for people to come in for their physical it would not happen as much[NP 3].
Providers viewed patient education as paramount to reaching patient compliance. The NPs especially emphasized the need for patients to learn about and to begin to take responsibility for their own health.
You know I think that I acknowledge my patients' abilities even with minimal education to preserve and maintain their own health and I don't lecture … it is not like I will say you have to do this, this, and this … I will work with you but you have to do your part. I am not your mother and I am not here to tell you what to do. I am here to guide you and give you good advice to help you live a healthy life but you are the one that has to decide whether to quit drinking or you are going to quit smoking[NP 2].
Encouraging patients to become self-efficacious is a building block toward achieving personal responsibility toward health-care. This is a push/pull situation and NPs gave many examples of holding patients responsible, but also understanding when circumstances influenced noncompliance. For example, all of the NPs mentioned examples of treating patients who arrived late, despite risking outrage from the office staff, and some providers who took a more rigid and mechanistic approach to scheduling.
There are some providers that are willing to see late and I'm one of those and there are some providers that feel that if you allow them to be late they will always be late and you are training them that way, you know … [NP 1].
The NP linked such patient behavior to her personal challenges of getting all of her children to medical appointments on time. Another NP saw a patient late, despite protests from the office staff. He said he watched the late patient he had just treated push her child in a stroller through the snow [Good Samaritan, NP 5]. Using their personal experiences to inform their professional roles and empathy were motivating factors for many NPs to be inconvenienced by patient behavior. This provider/patient connection, a hallmark of emphasis in NP training, provided a bridging opportunity for NPs in dealing with their patients.
Personality traits including warmth, empathy, and willingness to share personal information about themselves came across frequently during NP interviews. While physicians in the practices were certainly personable, professional socialization in medical training and residencies often emphasizes depersonalization and clinical distance as part of physician identity (White, 2002). This is in contrast with the more holistic emphasis in nursing and NP professional socialization, where personal connections with patients are part of the repertoire of skills that can be used during clinical encounters. For example, a non-Hispanic NP at Centro said: “I think my Spanish patients like me because I share a lot of myself and my family”[NP 3]. Many Hispanic cultures view casual conversation as an important prelude to business, referred to as personalismo (Thompson & Blasquez, 2006). This NP adapted personalismo to the healthcare setting, fostering rapport among culturally dissimilar patients. These strategies include openness in exchange and willingness to learn important patient cultural practices. By doing this, ethnically nonconcordant providers developed partnerships with patients who were culturally different. Such processes were not limited to Spanish-speaking patient populations.
NPs also discussed their ability to develop niches by establishing rapport with different cultural groups, and some of the limitations they faced when trying to do so.
… they really trust you that you are going to take care of that and you are not going to tell everyone about their problems and they are worried about that person and they are telling you about them. That works great for the Spanish speaking patients, and even the AA patients, I will say to them if you are my mom or my sister I would do this for you and this is what I would recommend for you and they appreciate that and if I tell them not to worry I think they believe that … they know I really care about them, I don't have very many Asian patients and I have only a few … I feel like they don't trust this whole system very well (laughs) I don't know why if it is because I am not comfortable with them or if it is a cultural thing[NP 3].
In contrast to the comfort she felt with Hispanic patients, Asian patients were a more challenging cultural group for this particular NP. Some NPs admit discomfort with socialized norms within certain cultural groups. A provider may relate well to Hispanic and African–American patients, but struggle with patients of other cultural groups.
I don't have very many Arab patients … I know they like [another NP] a lot … she has so many Arab patients and they love her … and I don't know if it is because I like to look at people and you have to look at the husband and talk to the husband and not ask him certain things if the wife … so even about the kids you are asking the father and I will be asking Mom … and it is hard for me not to ask Mom and that I have to ask the Dad … It is really hard[NP 3].
Establishing rapport with Arab [Muslim] or Asian patients was a breach filled by another NP on the team. In such instances, the team approach is invaluable as different providers develop niches in their capacities to work well with particular cultural groups.
Recognizing limitations in the ideal of delivery of culturally competent care by individual practitioners and realizing that some issues are difficult or impossible to resolve quickly are recurring themes expressed among NPs. Providers emphasized the extra time it took to develop the quality of patient/practitioner relationships in order to manage the disconnects associated with patient cultural realities—and even then, some cultural issues and medical problems seemed difficult or impossible to fully resolve.
Documentation and practice.
Documentation standards and professional expectations for nurses and NPs compared to physicians are an area of professional culture that NPs negotiate.
Yeah and the documentation is important too, some of the doctors write real quick and they are done and I don't get away with that because as a NP you are held to a tighter standard … that we adhere … I mean that is why we are sued so little is because we document well.
That and listening skills and acknowledging patients, they don't feel short changed and that they are treated poorly. [NP 2].
Not only does the NP differentiate her skill set developed on the nursing side of professional culture from physicians' professional socializations, she also recognizes that the professional culture of health-care held her to more stringent standards for documentation than physician counterparts. The more stringent guidelines required of NPs is a byproduct of their socialized experience as health professionals and serve as markers of the NP position in a hierarchical healthcare culture. Although the roles of specialized healthcare professionals have flourished and physician authority has been challenged by changes in the social organization of health-care and the rise of managed care (Light, 2000), the medical profession continues to maintain physician dominance in health-care (Abbott, 1988; Light, 2000; McMurray, 2011; Nancarrow & Borthwick, 2005).
Professional dominance may be accompanied by a presumed confidence among seasoned physicians, while NPs may adhere to stricter standards of care because of their status in the hierarchy. Practice differences in the treatment of high blood pressure provide an example of how this may play out. An older physician at one practice treated African–American patients with dangerously high blood pressures from his office instead of hospitalizing them.
… when I was in practice [years ago] if I had a blood pressure of 180/110 I was sending them to the emergency room, here I see 220/110 you know, I see 170/100, I say give them something and send them home, I would not have thought to do that but it's, it's just the order of magnitude higher and the difficulty treatment of the high blood pressure[physician 4].
Why this physician changed his treatment methods was not clear. The group he described—African–American patients—has more serious outcomes associated with high blood pressure than the general population. His less aggressive approach could be because experience has taught him that patients usually do not often follow medical regimens or recognition that he cannot address the social and environmental factors that compound the problem. However, other providers disagreed with such an idiosyncratic approach. NPs at Centro and Good Samaritan said they would always manage patients with uncontrolled blood pressure aggressively; exceptions based on a propensity for high blood pressure among a particular cultural population were not acceptable.
Understanding the reasons for noncompliance and advocating for patients with other health professionals—bridging professional cultural gaps—was another role for NPs whose brokering skills were practiced both within the context of their health practices with other health professionals and to bridge the gaps between healthcare staff and patients.
I have this guy who has diabetes and in dialysis and one of our LPNs works in dialysis part time and she goes: “oh he is so non-compliant” I said, “I don't know who you are talking about, this guy does everything I ask him to, he learned English, he does every last thing” and she goes … “he didn't show up for whatever appointments”[there was a mix up between two hospitals and he returned to the site that he thought he was supposed to go to] … you guys are busy thinking he is non-compliant but he did everything he knew to do and it is not his fault. I mean he speaks some English and he is trying hard to learn and um … he can't read English and he has had a couple of strokes and his eyesight is different and changed and so I said you did not explain it to him in a way he could understand it and so that is not his fault … so here you guys are thinking he is non-compliant[NP 3].
According to this NP, holistic practice requires understanding circumstances that affect compliance, then taking time to make sure that language and disabling factors are understood before labeling a patient “non-compliant,” thinking of ways NPs can broker information from patient and clinical sides of the encounter to the benefit the patient. Practitioners discussed the need for patience, time, and careful listening as components of culturally competent care. These characteristics may be familiar attributes cultivated among family physicians, and NPs, nurses, and other health professionals who practice in family practice settings, although not always in equal measure across professional categories.
Several themes were identified among health providers including going beyond the call of duty, altruistic motivations, probing for root causes, and advocating for patients. NPs, however, showed propensities in several areas that were unique to their profession. Themes that resonated among NPs that appear to be associated with their professional socialization included using a holistic approach to patient care, establishing partnerships with patients, using personalismo/established niches to bridge cultural gaps, adherence to professional standards, and culture-brokering within health care teams and across clinical encounters. In both field sites where NPs worked, NPs were distinctive in managing differences across professional cultures within healthcare teams and using tools from professional nursing socialization to bridge cultural gaps with patients. In those two sites, NPs played a critical role in bridging both professional and patient cultural divides. In the third field site (Washington) there were no NPs at the time of observation and interview. In some instances, staff who were racially concordant with the patient population served as culture brokers between physicians and patients; however, at Washington the approach to healthcare provision was somewhat more hierarchical. Although NPs were an essential component of culturally competent provision in two very diverse practices, their absence did not necessarily signal culturally incompetent care at the third—non-NP practice that was characterized by a nearly monocultural patient group and a racially concordant office staff who helped bridge professional and patient gaps.
Power differentials may be less intimidating when health professionals are perceived as (more) concordant with their patients. For example, patients report higher levels of satisfaction from office visits with same ethnic providers and accord concordant physicians more respect (Malat, 2001). Ethnic or shared language in some cases and gender in others helps establish good relationships between providers and patients. Patients may perceive NPs as more similar to them in social status than physicians, which could contribute to greater sense of concordance, but perfect concordance is impossible. To remedy this situation, providers established rapport and trust using other shared characteristics or because they have learned other interactional strategies that enable them to pursue cultural competence (Benkert, Peters, Clark, & Keves-Foster, 2008). These strategies include openness in exchange and willingness to learn important patient cultural practices. By doing this, nonconcordant providers have established rapport with patients who are culturally different, a type of culture brokering. In terms of race/ethnicity and SES, NPs in our study were culturally different from the patient populations they served. Skills acquired during professional socialization were tools they used to bridge the several cultural gaps they confronted in their practices.
Providers who were adept at culture brokering did not consider or portray themselves as experts about the culture of the communities they served. Rather, they acknowledged their lack of skill in certain areas, the need to advocate while overcoming prejudices and stereotypes, and the continual journey they faced to find ways to negotiate the cultural gap. What was different about the NPs approach compared to the other health professionals? NPs seemed especially adept at addressing underlying contextual constraints whether cultural or SES or health literacy. Many NPs showed their ability to act as culture brokers by addressing the contextual constraints arising from culture, SES, or past traumatic experiences in very real ways. NPs seemed especially adept at using techniques (such as personalismo and niche development) to overcome cultural differences, while patients seemed to identify with them and become close in ways that helped establish trust and a therapeutic relationship.
Their holistic approach reached beyond the medical needs of their patients and addressed family issues, nutrition, lifestyle, cultural and financial constraints, and disability from chronic conditions (Martin, O'Brien, Heyworth, & Meyer, 2005; Robinson, Callister, Berry, & Dearing, 2008; Tyler & Horner, 2008). The NPs, when necessary, adjusted their practices to take into account characteristics of their patient population and organized visits to maximize attention to important patient needs even when faced with noncompliance and lack of preventative visits. Sick visits were used as an opportunity to address chronic health problems and many times NPs would see patients who arrived late. Nevertheless, NPs stressed the need for patients to be educated and become more responsible for their own health, to advocate for themselves. NPs saw great value in patients progressing to make their own decisions, treating informed patients as partners in care. Socialization of NPs probably explains this difference from physicians, who were more normatively directive (Nancarrow & Borthwick, 2005). While the physician remains at the top of the health professional hierarchy and expect compliance, NPs, as first nurses and then in their advanced degrees, seem to expect more cooperation–a subtle but important difference. NPs have had to learn to bridge the cultural gaps within the interdisciplinary team to effectively enact their professional roles (McMurray, 2011). In fact, the very skills that NPs have developed to function within the system of their workplace are reflected in the way they can bridge gaps and negotiate with their patients. While providers with traditional training may accept the traditional hierarchical positions expected with their patients, NPs seem to approach their relationships with their patients as partnerships (Alexander, 2004; Martin, O'Brien, Heyworth, & Meyer, 2005; Tyler & Horner, 2008). The NP acts as a culture broker within the organizational hierarchy with health professionals, as well as outside it with patients.
Many practitioners at Centro and Good Samaritan worried about their capacity to provide culturally competent care for Muslim patients, a growing part of their patient load. However, some providers established relationships of trust with Muslim patients and managed to deal with gender relation issues that arose with little fuss, and particular NPs seemed to manage this particularly deftly. The availability and functioning of a team of health providers added an important component to providing culturally competent care. The development of niches or cultural specialties within the healthcare teams seemed to occur most often among the NPs at Centro, the site with four NPs. NPs at this location had developed a supportive network with each other, allowing their talents to be used most effectively and which minimized the impact of shortcomings of single or particular members. This camaraderie seemed most apparent at this location because it had the highest number of NPs working together. In addition, many NPs had self-selected to work with diverse groups. These on-the-job socialization experiences helped them to fine tune their practice over the years, enabling them to establish trust and provide culturally competent care (Benkert, Templin, Schim, Doorenbos, & Bell, 2011).
Personal characteristics and professional socialization experiences influence health professionals' propensity and proficiency for culturally competent care. Concordance (ethnic, gender, age, language) between providers and patients helped providers in different roles in the three clinics to develop rapport and build trusting relationships with their culturally diverse patients. When professionals did not match the cultural characteristics that distinguished their patients, insights gleaned from personal and professional socialization experiences helped them develop trustful and sustained relationships with their patients over time (Benkert, Templin, Schim, Doorenbos, & Bell, 2011).
Many physicians, NPs, and other professional staff described their work at the practice sites as a calling or a vocation, providing health-care for underserved groups for altruistic reasons not exclusively motivated by profit or gain. In many ways, the service-driven orientation toward professional roles in these three settings seemed closer to the professional ideals taught in classrooms than experiences in many more mainstream practices. Shared values and beliefs in the importance of providing culturally competent health-care for the underserved were common themes in the interview data from the healthcare providers of all professional backgrounds.
Among the professionals studied, NPs were particularly adept at developing trustful relationships by learning more about patients, their family members, and the cultural and socioeconomic needs of the community, using strategies from their culture brokering toolkits, core components of their professional training, to go beyond the call of duty. NPs also emphasized the importance of the patients' eventual transition to self-initiated health behaviors. Our data show that while some health professionals were satisfied to have their patients trust them with decision-making processes (especially when they followed medical advice) other healthcare professionals, especially NPs, wanted patients to be less passive and more proactive. One plausible explanation for this apparent difference in approach to patient responsibility could be that the professional socialization of NPs differs from other health professionals (e.g., physicians and nurses). Providers with traditional training may take professional dominance for granted in patient (and professional) relationships; NPs seem to approach both sets of relationships as partnerships (Alexander, 2004; McMurray, 2011; Robinson, Callister, Berry, & Dearing, 2008). Emerging professional specialties, like NP, are different enough in their approaches in enacting culturally competent care that they may influence a cultural sea change in their professional settings as well (Benkert, Templin, Schim, Doorenbos, & Bell, 2011). Distinctions in professional socialization have wide-ranging ramifications, both for interactions between culturally diverse patients, and providers, and also within professional workplaces themselves, ultimately affecting the ways in which professionals of all specializations enact culturally competent care. This area in particular, i.e., the cultural differences within the healthcare workplace, is an area ripe for further study.
When individual professionals in this study could not meet patients' needs because of communication problems or because they failed to fully understand a patient's customs and culture, resources available from other members of healthcare teams could sometimes compensate. For example, NPs developed niches and specialties within their particular practices, and could bridge gaps in culturally sensitive services left by other providers on their teams. When that happened, NPs who had developed niche specialties were especially well suited to interpret customs and behaviors among specific groups and negotiate a plan of action for patient care up and down the hierarchy of the professions. These acts of negotiation, not only with patients but among other health professionals, were common among NPs and represented an important contribution to the overall efficiency of the practice. NPs increasing importance in primary care underscores the importance of their bridging role within the traditional medical professional hierarchies that sometimes undermine optimal care. NPs' unique niches in healthcare interprofessional teams helped optimize the talents and skills of all providers, filling gaps in ways that accommodated the cultures of the professions and the cultural diversity of their patient bases—representing a sum greater than the individual parts.
It was interesting to note that one site, Washington, did not use NPs as part of their healthcare team. NPs at Centro and Good Samaritan had developed autonomous roles and worked in partnerships with physicians. In fact, a NP was the medical director at Good Samaritan's satellite practice. NPs at Centro had an internally supportive network amongst themselves, reinforcing their continued socialization experiences leading to effective and culturally competent health-care. Nursing socialization, as in other professions, continues beyond the classroom and can provide opportunities for effective collaboration and improved health-care (Price, 2009). This leads us to question the apparent reluctance of physicians at the third site to employ NPs in their practice and points to the need for further research on the costs and benefits of NPs' roles as vital members of primary healthcare teams. Optimizing culturally competent care for underserved communities requires team members to respect each discipline's distinctive contributions to patient care. Providers may need to be willing to realign their traditional beliefs and concepts regarding autonomy and jurisdictions for the good of the community (Purden, 2005). This ideal for interdisciplinary healthcare teams likely demands rethinking the curriculum in several healthcare professions to lay the groundwork for knowledge and respect for other disciplinary contributions within the context of interdisciplinary healthcare teams (McCallin, 2001).
Limitations and future directions
Our work suggests future avenues for additional research about the holistic experience, the delivery of culturally competent care, and the important role NPs play in healthcare settings geared to meeting the needs of culturally distinct and vulnerable populations. Future research should be designed to build on this exploratory research to investigate the processes that enable and hinder NPs in pursuing their unique capacities to optimize culturally competent care by incorporating other providers, office staff, and especially patients in the research design. Extended observations of patient and provider encounters and the day-to-day routines of interprofessional clinical teams would better define when cultural competence is enacted within the entire milieu of the health setting, or at the very least assist researchers in identifying circumstances leading to culturally incompetent behaviors.
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