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Culturally Competent Care of Women Newborns: Knowledge Attitude Skills
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C L ~ I C MISSUES
Culturally Competent Care of Women and Newborns: Knowledge, Attitude, and Skills Lynn Clark Callister, RN, PhD
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In a variety of health care settings throughout the United States and Canada, nurses are caring for women and newborns from culturally diverse backgrounds. In the technologically complex and bureaucratic world of health care delivery, cultural considerations in provision of care often are overlooked and neglected. The purpose of this article is to define ways in which culturally competent nursing care can be implemented. Nursing education and clinical practice guidelines are clear on the importance of gaining cultural competence. Providing culturally competent care includes understanding the dimensions of culture; moving beyond the biophysical to a more holistic approach; and seeking to increase knowledge, change attitudes, and hone clinical skills. Building on the strengths of women rather than utilizing a deficit model of health care is an essential part of providing culturally competent care. The achievement of both measurable and ”soft” outcomes related to the delivery of culturally competent care can make a critical difference in the heath and well-being of women and newborns. JOGNN, 30,
209-2 15; 2001 .
Keywords: Cultural competence-Culture and childbirth-Women‘s health Accepted: September 2000
Ours is a richly pluralistic society, evidenced by dramatic demographic changes. At the beginning of the 21st century, more than 25% of the population of the United States is culturally and ethnically diverse. The purpose of this article is to describe considerations related to the delivery of culturally competent care. In the last decade of the 1900s, the number of Caucasians living in the
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United States and Canada decreased from 83.9% to 82.6% of the total population (U.S. Bureau of Census, 1998). Similar changes are taking place in Canada. In 1996, 17% of the Canadian population were immigrants (Canadian Institute for Health Information, 1999). Currently, African Americans constitute 12.6% of the population in the United States. By 2050, the black population is expected to nearly double its present size. Hispanics show the highest increase in population growth. Within 5 years, this group is projected to become the largest emerging minority group. Asian AmericadPacific Islanders constitute 3.6% of the population, projected to be at 8.7% by 2050. Native Americans and Alaskan natives presently constitute 0.9% of the population of the United States (www.census.gov). By contrast, only 9% of registered nurses in the United States come from culturally diverse backgrounds (U.S. Department of Health and Human Services, Bureau of Health Professions, 1998). The notion of a “global village” is becoming more and more acknowledged as a truism, as refugees, immigrants, diplomatic and military personnel, and their dependents move around the world. According to Freedman (2000, p. 437), “One of the implications of globalization is that virtually no culture is untouched by others.” Diversity is a reality. In a variety of women’s health care settings throughout the United States, a nurse may care for a childbearing woman from Africa who has been ritually circumcised, an Orthodox Jewish family with special needs, an Arabic Muslim woman, or a Hispanic woman newly arrived from Central America who doesn’t speak English.
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Not all women and newborns enjoy the advantages of the developing world. Whereas women giving birth in developed countries focus on fetal well-being and the quality of their birth experience, those women living in the developing world face the harsh reality of high maternal and infant mortality rates. The United Nations estimates that 1 woman in 48 will not survive childbirth (Maine & McGinn, 2000). In Guatemala, lay midwives are educated in aseptic technique and taught by health professionals how to appropriately cut the umbilical cords of newborns. Working within the framework of traditional birthing practices and utilizing lay midwives who are well respected in their villages is proving effective in reducing infant mortality caused by tetanus. In the developing world, maternal conditions account for 3 of the 10 leading causes of disease burden (premature death and disability) in reproductive-aged women (Murray & Lopez, 1996). Outreach efforts by nurses as part of interdisciplinary teams can make significant contributions to the health of women and newborns. Extending beyond geographic borders, history, political systems, and cultural diversity, nurses seek to make important differences throughout the world. The World Health Organization now has a Women’s Health and Development Program dedicated to the promotion of women’s health and human rights. Participating in international exchanges in research, clinical practice, and education expands the perspectives of nurses globally (Locsin, 2000).
practice guidelines are clear on the importance of gaining cultural competence. Gaining linguistic skills is an important objective for all nurses to consider.
Framework for the Provision of Culturally Competent Care Providing culturally competent care includes (a) understanding the dimensions of culture; (b) moving beyond the biophysical to a more holistic approach; and (c) seeking to increase knowledge, change attitudes, and hone clinical skills (Callister, in press-a). Building on women’s strengths rather than a deficit model of health care is essential (see Table 1).
Understanding the Dimensions of Culture Although there are multiple definitions of culture, in essence culture may be considered an “invisible blueprint for living” (Jones, 1999, p. 395), the essence of one’s being. It is essential to recognize that the term culture goes beyond racial, ethnic, and linguistic differences (Andrews & Boyle, 1999; Castillo, 1996). There are many “cultures” that may be less visible, including women who have been ritually circumcised, women who are incarcerated, women who have experienced perinatal loss, childhood sexual abuse survivors, adolescent mothers, and others. The bio-Western model of health care delivery is a culture in and of itself.
Moving Beyond the Biophysical
Mandates for Culturally Competent Care According to the American Association of Colleges of Nursing (AACN) BSN Essentials document and the Pew Health Commission recommendations (1998), the development of cultural competence is a priority. Nursing graduates should have the knowledge and skills to “provide holistic care that addresses the needs of diverse populations” (American Association of Colleges of Nursing, 1998, p. 15). Opportunities should be provided in nursing education for clinical experiences caring for richly diverse patients, families, and peoples (Callister & Hobbins, 2000; Kelley & Fitzsimons, 2000; Mattson, 2000a; Ryan, Carlton, & Ali, 2000). Standards for the Joint Commission for Accreditation of Health Care Organizations mandate cultural and spiritual interventions as an essential part of the plan of health care. The objectives of Healthy People 2010 include two broad goals of (a) increasing the span of healthy life and (b) eliminating health disparities of not only racial and ethnic minorities but also women, people with disabilities, high-risk children and the vulnerable elderly, and those of low socioeconomic status (U.S. Department of Health and Human Services, Division of Public Health, 1999). Nursing education and 220 JOG”
Health assessment skills should include knowledge of biologic and physidogic variations among ethnic and racial groups, including disease risk such as diabetes and hypertension. It is essential that there be recognition that cultures are significant, unique, and reflect the life experiences of that particular woman within the framework of her sociocultural context. Culture is “dynamic and individually adaptive” (Nance, 1995, p. 249). Perceptions frame the meaning of life experiences, including the pivotal event of childbirth and the menopausal transition (Carolan, 2000; Nichols, 1996). Such works provide a forum for further discussion by nurses on providing care that moves beyond biophysical assessments to an understanding of TABLE 1
Providing Culturally Competent Care Understanding the dimensions of culture Moving to a holistic approach Seeking to increase knowledge, change attitudes, and hone clinical skills Building on women’s strengths
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the emotional and spiritual dimensions of women’s lives. These dimensions have a significant impact on women’s experiences of health and illness. Religious faith and a spiritual lifestyle are correlated with a higher quality of life emotionally, mentally, and physically (Burkhardt & Nagai-Jacobson, 1997; Rojas, 1996). An assessment of the importance of these dimensions may include the following questions: 1. Do her spiritual beliefs have a strong impact on how she defines life experience, health, illness, and death? 2. How meaningful is her faith? 3. What are her sources of strength and coping (Miller, 1995, p. 261)?
How essential it is that cultural competency be characterized by sensitivity to the multiple dimensions of women’s lives.
Seeking to Increase Knowledge, Change Attitudes, and Hone Clinical Skills Cultural competence has been defined as “the ability to think, feel, and act in ways that acknowledge, respect, and build upon ethnic, cultural, and linguistic diversity” (Lynch & Hansen, 1998, p. 49). Cultural competence is a combination of knowledge, attitudes, and clinical skills. Health care encounters involve bringing together at least three worlds: the culture of the health care provider, the culture of the woman and her family, and the culture of the health care delivery system (Jones, 1998; Spector, 2000). Cultural competence is a dynamic process that occurs over time. It begins with an exploration of one’s own cultural beliefs and practices, as well as biases and stereotypical attitudes in order to gain a beginning understanding of others (Mattson, 2000b). It can be richly rewarding to gain a historical perspective of one’s cultural heritage by interviewing parents and grandparents. Personal writing, such as recording one’s own life history, and journaling may be effective strategies fostering introspection and self-assessment. Much information is available from a variety of written and electronic sources about cultures (see Table 2). However, gaining knowledge of “facts” about another culture is “not sufficient for understanding” (Bartol & Richardson, 1998, p. 7 5 ) . Clinical handbooks and other literature may provide lists or tables outlining the general characteristics of a specific culture (Lipson, Dibble, & Minarik, 1996; Shilling, 2000; Spector, 2000). However, it is essential not to draw stereotypical conclusions about an individual woman and her family based solely on such overviews. Accessing such information is only the beginning of cultural understanding because of the complexity of culture (Zhan, 1999). There often is considerable heterogeneity within cultural groups in spite of some commonalities that may exist, related to level of acculturation and assimilation, social MarchlApril2001
TABLE 2
Electronic Sources of Ctilttiral lizformation Canadian Statistics http://www.statcan.cdenglish/Pgdb/People/ Population/demoZla.htm National Maternal and Child Health Clearinghouse http://www.circol.com/mch Office of Research for Women’s Health http://www.4woman.gov http://www.aamc.org/research/adhocgp/women.html University of Indiana http://www.iun.indiana.edu/trannurs.htm University of Utah (Spanish) http://www.med.uta.edu/pated University of Washington http://www.son.washington.edu/ethnomed/emedhp.htm http://www.son.washington.edu/centers/cwhr/socio.asp World Health Organization http://www.lib.iun.indiana.edu/trannurs.htm http://[email protected] World Health Organization Women’s Health and Development Program http://www.who.int/frh-wh/index.htm
support, length of time living in the United States or Canada, generational ties, linguistic ability, and other factors (DePacheo & Hutti, 1998). Understanding can be increased through accessing literature. Books such as The Spirit Catches You and You Fall Down (Fadiman, 1997) documents the compelling story of a Hmong family and their encounter with the health care delivery system as their young daughter suffered seizures. The parents perceived that Lia was experiencing “the fleeing of her soul from her body and the soul had become lost,” and this book chronicles the frustration experienced through the cultural conflicts felt by caregivers and family alike. Him (1999) chronicles her experiences as a Cambodian refugee in When Broken Glass Floats, which should be helpful in increasing understanding of the terror such women have experienced. Fictional works that may serve to increase understanding include Black and Blue (Quindlen, 1998), about the “culture” of women experiencing domestic violence. Plain Truth chronicles the demise of a neonate born to an Amish adolescent woman (Picoult, 2000) and the complex cultural issues in which this tragedy is enmeshed. An encapsulated summary of such readings may be presented as part of clinical staff meetings so that cultural sensitivity can be increased. Cultural competence implies an increasing level of consciousness and sensitivity by “maintaining an open and inquiring attitude about cultural beliefs and behav-
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iors” (Bartol & Richardson, 1998, p. 7 5 ) .Appreciation and understanding of cultural differences begets individualized care. A cultural assessment includes learning about a woman’s beliefs, typical health care practices, habits, likes, dislikes, customs, and cultural rituals and practices (Mattson, 2 0 0 0 ~ )For . example, one of the most universal explanations of congenital anomalies has been prenatal maternal impressions and behaviors. A woman may feel guilt if she believes that reaching above her head, walking in a circle, or tying knots cause the umbilical cord to be knotted or twisted around the neck of the fetus, compromising the well-being of her child.
C u l t u r a l assessment includes learning about
nurse could feel palpable tension that filled the room. The nurse could not speak Chinese either, but she tried to convey a sense of caring, touching the woman, speaking softly, modeling supportive behavior for her husband, and helping her to relax as much as possible. The atmosphere in the room changed considerably with the calm competence and quiet demeanor of the nurse. Following the birth of a handsome son, the father thanked the nurse and conveyed to her how grateful he was that she spoke Chinese. She tactfully said, “Thank you, but I don’t speak Chinese.” He looked at her in amazement and said with conviction, “You spoke Chinese.” The language of the heart transcends verbal communication, as this nurse cared enough to make a difference in the quality of the birth experience of this family.
a woman’s beliefs and values, health related
Building on Women’s Strengths
behaviors, and cultural rituals and practices.
Health care should build on the incredible strengths of culturally diverse women rather than a model that assumes and emphasizes deficits (Downs, Bernstein, & Marchese, 1997; Fraktman, 1998). Building on women’s strengths is a more holistic approach to caring. In clinical practice and in more than a decade of interviewing women in North and Central America, Scandinavia, the Middle East, and China, I have been struck with the marvelous strength of women around the world (Callister, 1995, in press-b; Callister & Hobbins, 2000; Callister, Lauri, & Vehvilainen-Julkunen, 2000; Callister, Semenic, & Foster, 1999; Callister & Vega, 1998; Callister, Vehvilainen-Julkunen, & Lauri, 1996, 2001; Khalaf & Callister, 1997). There is a sense of hardiness of Finnish childbearing women who are in touch with their personal ability to give birth unmedicated. These women understand the meaning and place of momentary pain in one’s life. Mayan women demonstrate a stoic acceptance of devastating poverty and difficult life circumstances while desiring a better life for their children. This is manifest by their willingness to walk many miles on dirt roads in the remote highlands of Guatemala to a schoolyard clinic to have their children immunized. There is considerable maternal power and influence in Canadian Orthodox Jewish women within the framework of strong religious injunctions that guide their daily lives. Palestinian women living in refugee camps demonstrate a fierce motivation to fulfill their obligation to bear and rear children, especially male children, to continue the bloodline. As the lives of Orthodox Jewish women are guided by the Torah and the lives of women who are members of the Church of Jesus Christ of LatterDay Saints are guided by the Book of Mormon and the Bible, so these women’s lives are framed by the Holy Qur’an.
Complex issues surround the delivery of health care as perceived by women. For example, a correlational study of Pap smear use intention among black and Hispanic women identified the need for more research focusing on differentiating beliefs in women who consistently have regular Pap smears and those who do not (Jennings-Dozier, 1999). Through understanding and sensitivity and listening to the voices of women, barriers can be eliminated and morbidity and mortality rates associated with cervical cancer in women of color can be decreased. Cultural conflicts may arise when traditional beliefs and practices conflict with standard nursing care protocols. Preservation of potentially helpful beliefdpractices or harmless or neutral beliefdpractices that respect the natural wisdom of the culture should be encouraged. Harmful beliefs/practices may be changed by focusing on a woman’s protective instincts toward her child or her motivation to be healthy to continue to care for her family. Balancing respect for cultural beliefs and practices while maintaining professional standards of care is an art. Developing the ability to communicate in ways that transcend language can be a meaningful experience for the nurse, the woman, and her family (Luckman, 1999). A labor and delivery nurse described being assigned to care for a Chinese primigravida who spoke no English. Her husband spoke little English, and from his perspective, birthing was woman’s work. When the nurse came on her shift and entered the birthing room, the unmedicated and fearful woman was experiencing the intensity of transition. The physician was present, frustrated by an inability to communicate with the couple, and the
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The one child policy in China influences the meaning of giving birth to a child to a young Chinese woman who balances a multiplicity of roles and has this one chance to become a mother. A primigravida plagued with painful flashbacks and nightmares associated with childhood sexual abuse triumphs over her fears. She describes a sense of control and exhilaration as she gives birth free from experiencing the devastating feelings of disassociation and numbness. Women have incredible strengths that should be celebrated. Building on the strengths of women rather than focusing on deficits is critical. For example, a perinatal advantage has been noted in less acculturated Mexican American women and their newborns despite being socioeconomically and educationally disadvantaged, uninsured, and having inadequate or no prenatal care. Adherence to a traditional Mexican cultural orientation seems to protect otherwise vulnerable childbearing women and their newborns from poor perinatal outcomes (Fuentes-Afflick, Hessol, & Perez-Stable, 1998). It has been postulated that maintenance of traditional dietary habits, a lower prevalence of smoking and alcohol use, extensive family support, and a spiritual or religious lifestyle may contribute to such positive outcomes. Health care delivery should build on these sociocultural strengths rather than insisting that women adopt harmful attitudes and behaviors as they become more acculturated and assimilated into mainstream society. Refugees and immigrants, as well as women who have experienced childhood sexual abuse, may show evidence of post-traumatic stress syndrome. These women should be respected as survivors of such trauma. They demonstrate a measure of their incredible resilience and strength as survivors. The biotechnological environment of women’s health care delivery may be foreign, frightening, and threatening to such women because of issues of control and personal boundaries. How can nurses build on their survival skills, acknowledging their strengths and empowering them to continue to succeed and master challenging life experiences? How can nurses create encounters with the health care delivery system that acknowledge the impact of such life experiences through the provision of truly individualized care? Spiritual beliefs and religious affiliation can be effective coping mechanisms and sources of support (Rehm, 1999). These represent strengths upon which health care can focus. How can nurses tap into this resource? How can nurses more fully acknowledge, respect, value, and celebrate spiritual and religious traditions? For example, a traditional healer may play an important role in an inclusive approach to health care. When a cherished child is born and then that life is cut short, how can nurses sensitively care for families in a way that is culturally supportive? How can nurses build on spiritual
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values and religious practices in the face of grief and loss? More research is needed on how to build on and incorporate women’s strengths in the delivery of health care. One example of an ongoing program built on the strengths of immigrant women is that provided by the University of California at San Francisco. Health information, cultural and language interpretation, referral services, health promotion workshops, and opportunities for value clarification are provided (Meleis, Omidian, & Lipson, 1993). Another model program building on the strengths of Hispanic women, De madres a madres, has the goal of “promoting mother to mother support for at risk pregnant Hispanic women through caring, sharing information, and developing a safety network for a healthier community” (McFarlane, 1996; McFarlane, Kelly, Rodriguez, & Fehir, 1994, p. 470). A Web-based health information and support site based at the University of Washington School of Nursing has been generated for Japanese women living in the United States (Oshio, 2000). The use of the Internet as a nursing intervention is an interesting and innovative strategy.
Outcomes of Culturally Competent Care The term cultural care has been coined, which implies a model of care that allows “individuals, organizations, and systems to work effectively with diverse racial, ethnic, religious, and social groups” (Spector, 2000, p. 11). Project Cultural Competence is a collaborative model with the primary goal of increasing cultural competence. This model includes a short-term cultural immersion program for Dallas health care providers in Cuernavaca, Mexico, and a nurse exchange program between Parkland Health and Hospital System and the Instituto Mexicana Seguro Social Hospital (Jones, 1998). This creative collaborative project is the beginning of what constitutes a lifelong process of gaining cultural competence. Measurable outcomes of providing culturally competent care have been identified by Willis (1999) (Table 3). In the highly technologically complex world of health care delivery, cultural considerations in the provision of care often are overlooked. But the achievement of the measurable as well as what is termed “soft” outcomes can make a critical difference in promoting the health and well-being of women and newborns.
Conclusion The provision of culturally competent care requires a commitment by the individual nurse to develop, refine, and use specific skills in the care of women and newborns. These skills include
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TABLE 3
Measurable Outcomes of Providing Culturally CornfietentCare Evidence of increased self-reliance, a sense of control, and enhanced feelings of self-worth Adoption of behaviors supportive of health and wellness, including self-care measures A sense of shared power with health care providers whom women view as culturally sensitive consultants who promote their health and well-being Appropriate use of health care services during child bearing and across the life span Higher levels of positive coping strategies in the woman and her family
Gaining an understanding of the complex dimensions of culture Moving beyond the biophysical to a holistic approach to care Seeking increased knowledge about cultural beliefs and practices unique to specific groups and individuals Changing one’s own ethnocentric attitudes Performing cultural assessments Developing communication and linguistic skills Demonstrating genuine interest in and appreciation for cultural differences Using culturally appropriate teaching techniques Accommodating cultural beliefs and practices in the context of care delivery Demonstrating respect for the sociocultural diversity of women, their newborns, and their families REFERENCES American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care. Philadelphia: Lippincott. Bartol, G. M., & Richardson, L. (1998). Using literature to create cultural competence. Image: The Journal of Nursing Scholarship, 30(l),75-79. Burkhardt, M. A., & Nagai-Jacobson, M. G. (1997). Spirituality and healing. In B. M. Dossey (Ed.), Core curriculum for holistic nursing (pp. 42-51). Gaithersburg, MD: Aspen. Callister, L. C. (1995). Cultural meanings of childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 327-331. Callister, L. C. (In press-a). Cultural competence in perinatal nursing practice. In K. R. Simpson & P. Creehan (Eds.), Perinatal nursing practice. Philadelphia: Lippincott. Callister, L. C. (In press-b). Perinatal nursing care of Mormon women and their infants. In M. L. Moore (Ed.), Peri-
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natal nursing in a multi-cultural society. White Plains, NY: March of Dimes. Callister, L. C., & Hobbins, D. (2000). Enter to learn, go forth to serve: Service learning in nursing education. Journal of Professional Nursing, 26(3), 177-183. Callister, L. C., Lauri, S., & Vehvilainen-Julkunen, K. (2000). A description of birth in Finland. MCN: The American Journal of Maternal Child Nursing, 25(3), 146-150. Callister, L. C., Semenic, S., & Foster, J. C. (1999). Culturalkpiritual meanings of childbirth: Orthodox Jewish and Mormon women. Journal of Holistic Nursing, 17(3),280-295. Callister, L. C., & Vega, R. (1998). Giving birth: Guatemalan women’s voices. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27(3), 289-295. Callister, L. C., Vehvilainen-Julkunen, K., & Lauri, S. (1996). Cultural perceptions of childbirth: A cross-cultural comparison of childbearing women. Journal of Holistic Nursing, 1(l),66-78. Callister, L. C., Vehvilainen-Julkunen, K., & Lauri, S. (2001). Giving birth: Perceptions of Finnish childbearing women. MCN: The American Journal of Maternal Child Nursing, 26(1), 28-32. Canadian Institute for Health Information. (1999). Statistical report on the health of Canadians. Montreal, Canada: Author. Carolan, M. (2000). Menopause: Irish women’s voices. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29(4), 397-404. Castillo, H. M. (1996). Cultural diversity: Implications for nursing. In S. Torres (Ed.), Hispanic voices (pp. 1-12). New York: National League for Nursing Press. DePacheo, M. R., & Hutti, M. H. (1998). Cultural beliefs and health care practices of childbearing Puerto Rican American women and Mexican American women. Mother Baby Journal, 3(l),14-22. Downs, K., Bernstein, J., & Marchese, T. (1997). Providing culturally competent primary care for immigrant and refugee women. Journal of Nurse Midwifery, 42(6), 499-508. Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Staus and Giroux. Fraktman, M. G. (1998). Immigrant mothers. In C. G. Coll, J. L. Surrey, & K. Weingarten (Eds.), Mothering against odds (pp. 85-107). New York: Guilford. Freedman, L. P. (2000). Human rights and women’s health. In M. B. Goldman & M. C. Hatch (Eds.), Women and health (pp. 428-438). San Diego, CA: Academic Press. Fuentes-Afflick, E., Hessol., N. A., & Perez-Stable, E. J. (1998). Maternal birthplace, ethnicity, and low birthweight in California. Archives of Pediatric and Adolescent Medicine, 2.52, 1105-1112. Him, C. (1999). When broken glass floats. New York: W. W. Norton. Jennings-Dozier, K. (1999). Predicting intentions to obtain a Pap smear among African American and Latina women: Testing the theory of planned behavior. Nursing Research, 48(4), 198-205. Jones, F. C. (1999). Cultural influences. In M. E. Broome & J. A. Rollins (Eds.), Core curriculum for the nursing
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care of children and their families (pp. 393-409). Pitman, NY: Janetti. Jones, M. E. (1998).Developing a culturally competent work force: An opportunity for collaboration. Journal of Professional Nursing, 14(5),280-287. Kelley, M. L., & Fitzsimons, V. M. (2000). Understanding cultural diversity: Culture, curriculum, and community in nursing. Sudbury, MA: Jones & Bartlett. Khalaf, I., & Callister, L. C. (1997). Cultural meanings of childbirth: Muslim women living in Jordan. Journal of Holistic Nursing, 25(4), 373-388. Lipson, J., Dibble, S., & Minarik, P. (Eds.). (1996). Culture and nursing care: A pocket guide. San Francisco: University of California at San Francisco Nursing Press. Locsin, R. C. (2000). Building bridges: Affirming culture in health and nursing. Holistzc Nursing Practice, 15( l),14. Luckman, J. (1999).Transcultural communication in nursing. Albany, NY: Delmar. Lynch, E. W., & Hansen, K. J. (1998).Developing cross-cultural competence. Baltimore: Paul H. Brookes. Maine, D., & McGinn, T. (2000). Maternal mortality and morbidity. In M. B. Goldman & M. C. Hatch (Eds.), Women and health (pp. 395-403). San Diego, CA: Academic Press. Mattson, S. (2000a). Core curriculum for maternal newborn nursing. Philadelphia: Saunders. Mattson, S. (2000b). Striving for cultural competence. A W H O N N Lifelines, 4(3), 48-52. Mattson, S. ( 2 0 0 0 ~ Working ). toward cultural competence: Making the first steps through cultural assessment. A W H O N N Lifelines, 4(4), 41-43. McFarlane, J. (1996).De Madres a Madres: An access model for primary care. American Journal of Public Health, 86(6), 879-890. McFarlane, J., Kelly, E., Rodriguez, R., & Fehir, J. (1994). De madres a madres: Women building community coalitions for health. Health Care for Women International, 15,465-476. Meleis, A. I., Omidian, P. A., & Lipson, J. G. (1993).Women’s health status in the United States: An immigrant women’s project. In B. J. McElmurry, K. F. Norr, & R. S. Parker (Eds.), Women’s health and development: A global challenge (pp. 163-181). Sudbury, MA: Jones & Bartlett. Miller, M. A. (1995). Culture, spirituality, and women’s health. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 257-263. Murray, C.J.L., & Lopez, A. D. (1996). The global burden of disease. Cambridge, MA: Harvard University Press. Nance, T. A. (1995). Inter-cultural communication: Finding common ground. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 249-255.
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Nichols, F. H. (1996). The meaning of the childbirth experience: A review of the literature. Journal of Perinatal Education, 5(4), 71-77. Oshio, S. (2000, April). Web-based health information and support for Japanese women living in the United States. Podium presentation, Western Institute of Nursing Assembly: Communicating Nursing Research Conference, Denver, CO. Pew Health Professions Commission. (1998). Recreating health professional practice for a new century. San Francisco: The Center for Health Professions. Picoult, J. (2000). Plain truth. New York: G. P. Putnam’s Sons. Quindlen, A. (1998). Black and blue. New York: Random House. Rehm, R. S. (1999). Religious faith in Mexican American Families. Image: The Journal of Nursing Scholarship, 32(1),33-38. Rojas, D. Z. (1996). Spiritual well being and its influence on the holistic health of Hispanic women. In S. Torres (Ed.), Hispanic voices (pp. 213-229). New York: National League for Nursing. Ryan, M., Carlton, K. H., & Ali, N. (2000). Transcultural nursing concepts and experiences in nursing curricula. Journal of Transcultural Nursing, 1 1 (4),300-307. Shilling, T. (2000). Cultural perspectives on childbearing. In F. H. Nichols & S. S. Humenick (Eds.), Childbirth education: Practice, research, and theory (pp. 138-154). Philadelphia: W. B. Saunders. Spector, R. E. (2000). Cultural diversity in health and illness. Upper Saddle River, NJ: Prentice Hall. U.S. Bureau of Census. (1998). Resident population of the United States: Estimates by sex, race, and Hispanic origin. Washington, DC: Government Printing Office. U.S. Department of Health and Human Services, Bureau of Health Professions. (1998). Selected facts about minority registered nwses. Rockville, MD: Government Printing Office. U.S. Department of Health and Human Services, Division of Public Health. (1999). Healthy people 2020. Rockville, MD: Government Printing Office. Willis, W. 0. (1999). Culturally competent nursing care during the perinatal period. Journal of Perinatal and Neonatal Nursing, 23(3), 45-59. Zhan, L. (1999).Asian voices: Asian and Asian-American health educators speak out. Sudbury, MA: Jones & Bartlett.
Lynn Clark Callister is an associate professor, Brigbam Young University College of Nursing, Provo, UT. Address for correspondence: Lynn Clark Callister, RN,PhD, Brigbarn Young University College of Nursing, 136 Kimball Tower,Provo, UT 84602-5544.E-mail: [email protected].
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C L ~ I C MISSUES
Culturally Competent Care of Women and Newborns: Knowledge, Attitude, and Skills Lynn Clark Callister, RN, PhD
=
In a variety of health care settings throughout the United States and Canada, nurses are caring for women and newborns from culturally diverse backgrounds. In the technologically complex and bureaucratic world of health care delivery, cultural considerations in provision of care often are overlooked and neglected. The purpose of this article is to define ways in which culturally competent nursing care can be implemented. Nursing education and clinical practice guidelines are clear on the importance of gaining cultural competence. Providing culturally competent care includes understanding the dimensions of culture; moving beyond the biophysical to a more holistic approach; and seeking to increase knowledge, change attitudes, and hone clinical skills. Building on the strengths of women rather than utilizing a deficit model of health care is an essential part of providing culturally competent care. The achievement of both measurable and ”soft” outcomes related to the delivery of culturally competent care can make a critical difference in the heath and well-being of women and newborns. JOGNN, 30,
209-2 15; 2001 .
Keywords: Cultural competence-Culture and childbirth-Women‘s health Accepted: September 2000
Ours is a richly pluralistic society, evidenced by dramatic demographic changes. At the beginning of the 21st century, more than 25% of the population of the United States is culturally and ethnically diverse. The purpose of this article is to describe considerations related to the delivery of culturally competent care. In the last decade of the 1900s, the number of Caucasians living in the
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United States and Canada decreased from 83.9% to 82.6% of the total population (U.S. Bureau of Census, 1998). Similar changes are taking place in Canada. In 1996, 17% of the Canadian population were immigrants (Canadian Institute for Health Information, 1999). Currently, African Americans constitute 12.6% of the population in the United States. By 2050, the black population is expected to nearly double its present size. Hispanics show the highest increase in population growth. Within 5 years, this group is projected to become the largest emerging minority group. Asian AmericadPacific Islanders constitute 3.6% of the population, projected to be at 8.7% by 2050. Native Americans and Alaskan natives presently constitute 0.9% of the population of the United States (www.census.gov). By contrast, only 9% of registered nurses in the United States come from culturally diverse backgrounds (U.S. Department of Health and Human Services, Bureau of Health Professions, 1998). The notion of a “global village” is becoming more and more acknowledged as a truism, as refugees, immigrants, diplomatic and military personnel, and their dependents move around the world. According to Freedman (2000, p. 437), “One of the implications of globalization is that virtually no culture is untouched by others.” Diversity is a reality. In a variety of women’s health care settings throughout the United States, a nurse may care for a childbearing woman from Africa who has been ritually circumcised, an Orthodox Jewish family with special needs, an Arabic Muslim woman, or a Hispanic woman newly arrived from Central America who doesn’t speak English.
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Not all women and newborns enjoy the advantages of the developing world. Whereas women giving birth in developed countries focus on fetal well-being and the quality of their birth experience, those women living in the developing world face the harsh reality of high maternal and infant mortality rates. The United Nations estimates that 1 woman in 48 will not survive childbirth (Maine & McGinn, 2000). In Guatemala, lay midwives are educated in aseptic technique and taught by health professionals how to appropriately cut the umbilical cords of newborns. Working within the framework of traditional birthing practices and utilizing lay midwives who are well respected in their villages is proving effective in reducing infant mortality caused by tetanus. In the developing world, maternal conditions account for 3 of the 10 leading causes of disease burden (premature death and disability) in reproductive-aged women (Murray & Lopez, 1996). Outreach efforts by nurses as part of interdisciplinary teams can make significant contributions to the health of women and newborns. Extending beyond geographic borders, history, political systems, and cultural diversity, nurses seek to make important differences throughout the world. The World Health Organization now has a Women’s Health and Development Program dedicated to the promotion of women’s health and human rights. Participating in international exchanges in research, clinical practice, and education expands the perspectives of nurses globally (Locsin, 2000).
practice guidelines are clear on the importance of gaining cultural competence. Gaining linguistic skills is an important objective for all nurses to consider.
Framework for the Provision of Culturally Competent Care Providing culturally competent care includes (a) understanding the dimensions of culture; (b) moving beyond the biophysical to a more holistic approach; and (c) seeking to increase knowledge, change attitudes, and hone clinical skills (Callister, in press-a). Building on women’s strengths rather than a deficit model of health care is essential (see Table 1).
Understanding the Dimensions of Culture Although there are multiple definitions of culture, in essence culture may be considered an “invisible blueprint for living” (Jones, 1999, p. 395), the essence of one’s being. It is essential to recognize that the term culture goes beyond racial, ethnic, and linguistic differences (Andrews & Boyle, 1999; Castillo, 1996). There are many “cultures” that may be less visible, including women who have been ritually circumcised, women who are incarcerated, women who have experienced perinatal loss, childhood sexual abuse survivors, adolescent mothers, and others. The bio-Western model of health care delivery is a culture in and of itself.
Moving Beyond the Biophysical
Mandates for Culturally Competent Care According to the American Association of Colleges of Nursing (AACN) BSN Essentials document and the Pew Health Commission recommendations (1998), the development of cultural competence is a priority. Nursing graduates should have the knowledge and skills to “provide holistic care that addresses the needs of diverse populations” (American Association of Colleges of Nursing, 1998, p. 15). Opportunities should be provided in nursing education for clinical experiences caring for richly diverse patients, families, and peoples (Callister & Hobbins, 2000; Kelley & Fitzsimons, 2000; Mattson, 2000a; Ryan, Carlton, & Ali, 2000). Standards for the Joint Commission for Accreditation of Health Care Organizations mandate cultural and spiritual interventions as an essential part of the plan of health care. The objectives of Healthy People 2010 include two broad goals of (a) increasing the span of healthy life and (b) eliminating health disparities of not only racial and ethnic minorities but also women, people with disabilities, high-risk children and the vulnerable elderly, and those of low socioeconomic status (U.S. Department of Health and Human Services, Division of Public Health, 1999). Nursing education and 220 JOG”
Health assessment skills should include knowledge of biologic and physidogic variations among ethnic and racial groups, including disease risk such as diabetes and hypertension. It is essential that there be recognition that cultures are significant, unique, and reflect the life experiences of that particular woman within the framework of her sociocultural context. Culture is “dynamic and individually adaptive” (Nance, 1995, p. 249). Perceptions frame the meaning of life experiences, including the pivotal event of childbirth and the menopausal transition (Carolan, 2000; Nichols, 1996). Such works provide a forum for further discussion by nurses on providing care that moves beyond biophysical assessments to an understanding of TABLE 1
Providing Culturally Competent Care Understanding the dimensions of culture Moving to a holistic approach Seeking to increase knowledge, change attitudes, and hone clinical skills Building on women’s strengths
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the emotional and spiritual dimensions of women’s lives. These dimensions have a significant impact on women’s experiences of health and illness. Religious faith and a spiritual lifestyle are correlated with a higher quality of life emotionally, mentally, and physically (Burkhardt & Nagai-Jacobson, 1997; Rojas, 1996). An assessment of the importance of these dimensions may include the following questions: 1. Do her spiritual beliefs have a strong impact on how she defines life experience, health, illness, and death? 2. How meaningful is her faith? 3. What are her sources of strength and coping (Miller, 1995, p. 261)?
How essential it is that cultural competency be characterized by sensitivity to the multiple dimensions of women’s lives.
Seeking to Increase Knowledge, Change Attitudes, and Hone Clinical Skills Cultural competence has been defined as “the ability to think, feel, and act in ways that acknowledge, respect, and build upon ethnic, cultural, and linguistic diversity” (Lynch & Hansen, 1998, p. 49). Cultural competence is a combination of knowledge, attitudes, and clinical skills. Health care encounters involve bringing together at least three worlds: the culture of the health care provider, the culture of the woman and her family, and the culture of the health care delivery system (Jones, 1998; Spector, 2000). Cultural competence is a dynamic process that occurs over time. It begins with an exploration of one’s own cultural beliefs and practices, as well as biases and stereotypical attitudes in order to gain a beginning understanding of others (Mattson, 2000b). It can be richly rewarding to gain a historical perspective of one’s cultural heritage by interviewing parents and grandparents. Personal writing, such as recording one’s own life history, and journaling may be effective strategies fostering introspection and self-assessment. Much information is available from a variety of written and electronic sources about cultures (see Table 2). However, gaining knowledge of “facts” about another culture is “not sufficient for understanding” (Bartol & Richardson, 1998, p. 7 5 ) . Clinical handbooks and other literature may provide lists or tables outlining the general characteristics of a specific culture (Lipson, Dibble, & Minarik, 1996; Shilling, 2000; Spector, 2000). However, it is essential not to draw stereotypical conclusions about an individual woman and her family based solely on such overviews. Accessing such information is only the beginning of cultural understanding because of the complexity of culture (Zhan, 1999). There often is considerable heterogeneity within cultural groups in spite of some commonalities that may exist, related to level of acculturation and assimilation, social MarchlApril2001
TABLE 2
Electronic Sources of Ctilttiral lizformation Canadian Statistics http://www.statcan.cdenglish/Pgdb/People/ Population/demoZla.htm National Maternal and Child Health Clearinghouse http://www.circol.com/mch Office of Research for Women’s Health http://www.4woman.gov http://www.aamc.org/research/adhocgp/women.html University of Indiana http://www.iun.indiana.edu/trannurs.htm University of Utah (Spanish) http://www.med.uta.edu/pated University of Washington http://www.son.washington.edu/ethnomed/emedhp.htm http://www.son.washington.edu/centers/cwhr/socio.asp World Health Organization http://www.lib.iun.indiana.edu/trannurs.htm http://[email protected] World Health Organization Women’s Health and Development Program http://www.who.int/frh-wh/index.htm
support, length of time living in the United States or Canada, generational ties, linguistic ability, and other factors (DePacheo & Hutti, 1998). Understanding can be increased through accessing literature. Books such as The Spirit Catches You and You Fall Down (Fadiman, 1997) documents the compelling story of a Hmong family and their encounter with the health care delivery system as their young daughter suffered seizures. The parents perceived that Lia was experiencing “the fleeing of her soul from her body and the soul had become lost,” and this book chronicles the frustration experienced through the cultural conflicts felt by caregivers and family alike. Him (1999) chronicles her experiences as a Cambodian refugee in When Broken Glass Floats, which should be helpful in increasing understanding of the terror such women have experienced. Fictional works that may serve to increase understanding include Black and Blue (Quindlen, 1998), about the “culture” of women experiencing domestic violence. Plain Truth chronicles the demise of a neonate born to an Amish adolescent woman (Picoult, 2000) and the complex cultural issues in which this tragedy is enmeshed. An encapsulated summary of such readings may be presented as part of clinical staff meetings so that cultural sensitivity can be increased. Cultural competence implies an increasing level of consciousness and sensitivity by “maintaining an open and inquiring attitude about cultural beliefs and behav-
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iors” (Bartol & Richardson, 1998, p. 7 5 ) .Appreciation and understanding of cultural differences begets individualized care. A cultural assessment includes learning about a woman’s beliefs, typical health care practices, habits, likes, dislikes, customs, and cultural rituals and practices (Mattson, 2 0 0 0 ~ )For . example, one of the most universal explanations of congenital anomalies has been prenatal maternal impressions and behaviors. A woman may feel guilt if she believes that reaching above her head, walking in a circle, or tying knots cause the umbilical cord to be knotted or twisted around the neck of the fetus, compromising the well-being of her child.
C u l t u r a l assessment includes learning about
nurse could feel palpable tension that filled the room. The nurse could not speak Chinese either, but she tried to convey a sense of caring, touching the woman, speaking softly, modeling supportive behavior for her husband, and helping her to relax as much as possible. The atmosphere in the room changed considerably with the calm competence and quiet demeanor of the nurse. Following the birth of a handsome son, the father thanked the nurse and conveyed to her how grateful he was that she spoke Chinese. She tactfully said, “Thank you, but I don’t speak Chinese.” He looked at her in amazement and said with conviction, “You spoke Chinese.” The language of the heart transcends verbal communication, as this nurse cared enough to make a difference in the quality of the birth experience of this family.
a woman’s beliefs and values, health related
Building on Women’s Strengths
behaviors, and cultural rituals and practices.
Health care should build on the incredible strengths of culturally diverse women rather than a model that assumes and emphasizes deficits (Downs, Bernstein, & Marchese, 1997; Fraktman, 1998). Building on women’s strengths is a more holistic approach to caring. In clinical practice and in more than a decade of interviewing women in North and Central America, Scandinavia, the Middle East, and China, I have been struck with the marvelous strength of women around the world (Callister, 1995, in press-b; Callister & Hobbins, 2000; Callister, Lauri, & Vehvilainen-Julkunen, 2000; Callister, Semenic, & Foster, 1999; Callister & Vega, 1998; Callister, Vehvilainen-Julkunen, & Lauri, 1996, 2001; Khalaf & Callister, 1997). There is a sense of hardiness of Finnish childbearing women who are in touch with their personal ability to give birth unmedicated. These women understand the meaning and place of momentary pain in one’s life. Mayan women demonstrate a stoic acceptance of devastating poverty and difficult life circumstances while desiring a better life for their children. This is manifest by their willingness to walk many miles on dirt roads in the remote highlands of Guatemala to a schoolyard clinic to have their children immunized. There is considerable maternal power and influence in Canadian Orthodox Jewish women within the framework of strong religious injunctions that guide their daily lives. Palestinian women living in refugee camps demonstrate a fierce motivation to fulfill their obligation to bear and rear children, especially male children, to continue the bloodline. As the lives of Orthodox Jewish women are guided by the Torah and the lives of women who are members of the Church of Jesus Christ of LatterDay Saints are guided by the Book of Mormon and the Bible, so these women’s lives are framed by the Holy Qur’an.
Complex issues surround the delivery of health care as perceived by women. For example, a correlational study of Pap smear use intention among black and Hispanic women identified the need for more research focusing on differentiating beliefs in women who consistently have regular Pap smears and those who do not (Jennings-Dozier, 1999). Through understanding and sensitivity and listening to the voices of women, barriers can be eliminated and morbidity and mortality rates associated with cervical cancer in women of color can be decreased. Cultural conflicts may arise when traditional beliefs and practices conflict with standard nursing care protocols. Preservation of potentially helpful beliefdpractices or harmless or neutral beliefdpractices that respect the natural wisdom of the culture should be encouraged. Harmful beliefs/practices may be changed by focusing on a woman’s protective instincts toward her child or her motivation to be healthy to continue to care for her family. Balancing respect for cultural beliefs and practices while maintaining professional standards of care is an art. Developing the ability to communicate in ways that transcend language can be a meaningful experience for the nurse, the woman, and her family (Luckman, 1999). A labor and delivery nurse described being assigned to care for a Chinese primigravida who spoke no English. Her husband spoke little English, and from his perspective, birthing was woman’s work. When the nurse came on her shift and entered the birthing room, the unmedicated and fearful woman was experiencing the intensity of transition. The physician was present, frustrated by an inability to communicate with the couple, and the
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The one child policy in China influences the meaning of giving birth to a child to a young Chinese woman who balances a multiplicity of roles and has this one chance to become a mother. A primigravida plagued with painful flashbacks and nightmares associated with childhood sexual abuse triumphs over her fears. She describes a sense of control and exhilaration as she gives birth free from experiencing the devastating feelings of disassociation and numbness. Women have incredible strengths that should be celebrated. Building on the strengths of women rather than focusing on deficits is critical. For example, a perinatal advantage has been noted in less acculturated Mexican American women and their newborns despite being socioeconomically and educationally disadvantaged, uninsured, and having inadequate or no prenatal care. Adherence to a traditional Mexican cultural orientation seems to protect otherwise vulnerable childbearing women and their newborns from poor perinatal outcomes (Fuentes-Afflick, Hessol, & Perez-Stable, 1998). It has been postulated that maintenance of traditional dietary habits, a lower prevalence of smoking and alcohol use, extensive family support, and a spiritual or religious lifestyle may contribute to such positive outcomes. Health care delivery should build on these sociocultural strengths rather than insisting that women adopt harmful attitudes and behaviors as they become more acculturated and assimilated into mainstream society. Refugees and immigrants, as well as women who have experienced childhood sexual abuse, may show evidence of post-traumatic stress syndrome. These women should be respected as survivors of such trauma. They demonstrate a measure of their incredible resilience and strength as survivors. The biotechnological environment of women’s health care delivery may be foreign, frightening, and threatening to such women because of issues of control and personal boundaries. How can nurses build on their survival skills, acknowledging their strengths and empowering them to continue to succeed and master challenging life experiences? How can nurses create encounters with the health care delivery system that acknowledge the impact of such life experiences through the provision of truly individualized care? Spiritual beliefs and religious affiliation can be effective coping mechanisms and sources of support (Rehm, 1999). These represent strengths upon which health care can focus. How can nurses tap into this resource? How can nurses more fully acknowledge, respect, value, and celebrate spiritual and religious traditions? For example, a traditional healer may play an important role in an inclusive approach to health care. When a cherished child is born and then that life is cut short, how can nurses sensitively care for families in a way that is culturally supportive? How can nurses build on spiritual
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values and religious practices in the face of grief and loss? More research is needed on how to build on and incorporate women’s strengths in the delivery of health care. One example of an ongoing program built on the strengths of immigrant women is that provided by the University of California at San Francisco. Health information, cultural and language interpretation, referral services, health promotion workshops, and opportunities for value clarification are provided (Meleis, Omidian, & Lipson, 1993). Another model program building on the strengths of Hispanic women, De madres a madres, has the goal of “promoting mother to mother support for at risk pregnant Hispanic women through caring, sharing information, and developing a safety network for a healthier community” (McFarlane, 1996; McFarlane, Kelly, Rodriguez, & Fehir, 1994, p. 470). A Web-based health information and support site based at the University of Washington School of Nursing has been generated for Japanese women living in the United States (Oshio, 2000). The use of the Internet as a nursing intervention is an interesting and innovative strategy.
Outcomes of Culturally Competent Care The term cultural care has been coined, which implies a model of care that allows “individuals, organizations, and systems to work effectively with diverse racial, ethnic, religious, and social groups” (Spector, 2000, p. 11). Project Cultural Competence is a collaborative model with the primary goal of increasing cultural competence. This model includes a short-term cultural immersion program for Dallas health care providers in Cuernavaca, Mexico, and a nurse exchange program between Parkland Health and Hospital System and the Instituto Mexicana Seguro Social Hospital (Jones, 1998). This creative collaborative project is the beginning of what constitutes a lifelong process of gaining cultural competence. Measurable outcomes of providing culturally competent care have been identified by Willis (1999) (Table 3). In the highly technologically complex world of health care delivery, cultural considerations in the provision of care often are overlooked. But the achievement of the measurable as well as what is termed “soft” outcomes can make a critical difference in promoting the health and well-being of women and newborns.
Conclusion The provision of culturally competent care requires a commitment by the individual nurse to develop, refine, and use specific skills in the care of women and newborns. These skills include
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TABLE 3
Measurable Outcomes of Providing Culturally CornfietentCare Evidence of increased self-reliance, a sense of control, and enhanced feelings of self-worth Adoption of behaviors supportive of health and wellness, including self-care measures A sense of shared power with health care providers whom women view as culturally sensitive consultants who promote their health and well-being Appropriate use of health care services during child bearing and across the life span Higher levels of positive coping strategies in the woman and her family
Gaining an understanding of the complex dimensions of culture Moving beyond the biophysical to a holistic approach to care Seeking increased knowledge about cultural beliefs and practices unique to specific groups and individuals Changing one’s own ethnocentric attitudes Performing cultural assessments Developing communication and linguistic skills Demonstrating genuine interest in and appreciation for cultural differences Using culturally appropriate teaching techniques Accommodating cultural beliefs and practices in the context of care delivery Demonstrating respect for the sociocultural diversity of women, their newborns, and their families REFERENCES American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care. Philadelphia: Lippincott. Bartol, G. M., & Richardson, L. (1998). Using literature to create cultural competence. Image: The Journal of Nursing Scholarship, 30(l),75-79. Burkhardt, M. A., & Nagai-Jacobson, M. G. (1997). Spirituality and healing. In B. M. Dossey (Ed.), Core curriculum for holistic nursing (pp. 42-51). Gaithersburg, MD: Aspen. Callister, L. C. (1995). Cultural meanings of childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 327-331. Callister, L. C. (In press-a). Cultural competence in perinatal nursing practice. In K. R. Simpson & P. Creehan (Eds.), Perinatal nursing practice. Philadelphia: Lippincott. Callister, L. C. (In press-b). Perinatal nursing care of Mormon women and their infants. In M. L. Moore (Ed.), Peri-
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care of children and their families (pp. 393-409). Pitman, NY: Janetti. Jones, M. E. (1998).Developing a culturally competent work force: An opportunity for collaboration. Journal of Professional Nursing, 14(5),280-287. Kelley, M. L., & Fitzsimons, V. M. (2000). Understanding cultural diversity: Culture, curriculum, and community in nursing. Sudbury, MA: Jones & Bartlett. Khalaf, I., & Callister, L. C. (1997). Cultural meanings of childbirth: Muslim women living in Jordan. Journal of Holistic Nursing, 25(4), 373-388. Lipson, J., Dibble, S., & Minarik, P. (Eds.). (1996). Culture and nursing care: A pocket guide. San Francisco: University of California at San Francisco Nursing Press. Locsin, R. C. (2000). Building bridges: Affirming culture in health and nursing. Holistzc Nursing Practice, 15( l),14. Luckman, J. (1999).Transcultural communication in nursing. Albany, NY: Delmar. Lynch, E. W., & Hansen, K. J. (1998).Developing cross-cultural competence. Baltimore: Paul H. Brookes. Maine, D., & McGinn, T. (2000). Maternal mortality and morbidity. In M. B. Goldman & M. C. Hatch (Eds.), Women and health (pp. 395-403). San Diego, CA: Academic Press. Mattson, S. (2000a). Core curriculum for maternal newborn nursing. Philadelphia: Saunders. Mattson, S. (2000b). Striving for cultural competence. A W H O N N Lifelines, 4(3), 48-52. Mattson, S. ( 2 0 0 0 ~ Working ). toward cultural competence: Making the first steps through cultural assessment. A W H O N N Lifelines, 4(4), 41-43. McFarlane, J. (1996).De Madres a Madres: An access model for primary care. American Journal of Public Health, 86(6), 879-890. McFarlane, J., Kelly, E., Rodriguez, R., & Fehir, J. (1994). De madres a madres: Women building community coalitions for health. Health Care for Women International, 15,465-476. Meleis, A. I., Omidian, P. A., & Lipson, J. G. (1993).Women’s health status in the United States: An immigrant women’s project. In B. J. McElmurry, K. F. Norr, & R. S. Parker (Eds.), Women’s health and development: A global challenge (pp. 163-181). Sudbury, MA: Jones & Bartlett. Miller, M. A. (1995). Culture, spirituality, and women’s health. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 257-263. Murray, C.J.L., & Lopez, A. D. (1996). The global burden of disease. Cambridge, MA: Harvard University Press. Nance, T. A. (1995). Inter-cultural communication: Finding common ground. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 249-255.
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Nichols, F. H. (1996). The meaning of the childbirth experience: A review of the literature. Journal of Perinatal Education, 5(4), 71-77. Oshio, S. (2000, April). Web-based health information and support for Japanese women living in the United States. Podium presentation, Western Institute of Nursing Assembly: Communicating Nursing Research Conference, Denver, CO. Pew Health Professions Commission. (1998). Recreating health professional practice for a new century. San Francisco: The Center for Health Professions. Picoult, J. (2000). Plain truth. New York: G. P. Putnam’s Sons. Quindlen, A. (1998). Black and blue. New York: Random House. Rehm, R. S. (1999). Religious faith in Mexican American Families. Image: The Journal of Nursing Scholarship, 32(1),33-38. Rojas, D. Z. (1996). Spiritual well being and its influence on the holistic health of Hispanic women. In S. Torres (Ed.), Hispanic voices (pp. 213-229). New York: National League for Nursing. Ryan, M., Carlton, K. H., & Ali, N. (2000). Transcultural nursing concepts and experiences in nursing curricula. Journal of Transcultural Nursing, 1 1 (4),300-307. Shilling, T. (2000). Cultural perspectives on childbearing. In F. H. Nichols & S. S. Humenick (Eds.), Childbirth education: Practice, research, and theory (pp. 138-154). Philadelphia: W. B. Saunders. Spector, R. E. (2000). Cultural diversity in health and illness. Upper Saddle River, NJ: Prentice Hall. U.S. Bureau of Census. (1998). Resident population of the United States: Estimates by sex, race, and Hispanic origin. Washington, DC: Government Printing Office. U.S. Department of Health and Human Services, Bureau of Health Professions. (1998). Selected facts about minority registered nwses. Rockville, MD: Government Printing Office. U.S. Department of Health and Human Services, Division of Public Health. (1999). Healthy people 2020. Rockville, MD: Government Printing Office. Willis, W. 0. (1999). Culturally competent nursing care during the perinatal period. Journal of Perinatal and Neonatal Nursing, 23(3), 45-59. Zhan, L. (1999).Asian voices: Asian and Asian-American health educators speak out. Sudbury, MA: Jones & Bartlett.
Lynn Clark Callister is an associate professor, Brigbam Young University College of Nursing, Provo, UT. Address for correspondence: Lynn Clark Callister, RN,PhD, Brigbarn Young University College of Nursing, 136 Kimball Tower,Provo, UT 84602-5544.E-mail: [email protected].
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