Cultural diversity in the Information Age

The Information Age has seen many technological developments in medicine. Technology has not, however, replaced the essence of human caring. A cultural approach to medicine usually focuses on diversity among populations. Yet there is a counterpoint to this cultural approach that is unique to the Information Age-the widening of the cultural gap between nurses and physicians through the use of electronic records. Nursing interventions and outcomes are typically not documented in automated information systems, due to a lack of a nursing-specific language. This article explores the diversity of roles within a multi-disciplinary care team and focuses on the requirements of a language from the informatics perspective.     

Instructional bias--awareness and reduction in perioperative education

Through the use of instructional materials, perioperative educators provide education to staff members, physicians, patients, and family members. Although accrediting bodies and scholars have addressed the importance of diversity in patient assessment and nursing care, there has been little discussion regarding how instructional materials incorporate cultural, age, and gender diversity. This article defines bias and explores six forms of instructional bias. Suggestions are offered on ways to reduce or eliminate bias in instructional materials. AORN J 75 (April 2002) 808-816.     

Nursing Leadership Must Confront Implicit Bias as a Barrier to Diversity in Health Care Today

Implicit bias can prevent diversity and inclusion in organizations; however, attempts to mitigate its damage in health care have not always been successful. Nursing leadership struggles with integrating these topics into organizational nurse training programs. Implicit bias is common and can be activated unknowingly, despite a nurse’s best intention, and can result in health disparities and poor outcomes for patients. Nursing leadership must raise awareness of implicit bias and help all nurses, from novice to senior, recognize its existence as a barrier to diversity, and create a safe environment to bring concerns, identify triggers, and invest in education and training.     

Comparison of native versus nonnative English-speaking nurses on critical thinking assessments at entry and exit

Diversity of language among healthcare employees and nursing students is growing as diversity increases among the general population. Institutions have begun to develop systems to accommodate diversity and to assimilate workers. One barrier to nonnative English-speaking nurse hires may be posed by readiness for the licensure exam and the critical thinking assessments that are now an expected outcome of nursing programs, and act as a gatekeeper to graduation and to employment. To assist in preparing for high-stakes testing, the Assessment Technologies Institute Critical Thinking Assessment was developed in compliance with credentialing bodies' educational outcomes criteria. This pilot study of 209 nursing students was designed to reveal any possible language bias that might act as a barrier to nonnative English speakers. Nursing students were entered as whole classes to the study to control for selection bias. A sample representative of national nursing enrollment was obtained from 21 universities, with 192 (92%) native English-speaking students and 17 (8%) nonnative English speakers participating in the study. All students were given the Assessment Technologies Institute Critical Thinking Assessment at entry and exit to their nursing program. Average scores on entry were 66% for nonnative speakers and 72% for native speakers. At exit, the nonnative speakers had closed the gap in academic outcomes. They had an average score of 72% compared to 73% for native speakers. The study found that the slight differences between the native and nonnative speakers on 2 exit outcome measures-National Council licensure examination (NCLEX-RN) pass rates and Critical Thinking Assessment-were not statistically significant, demonstrating that nonnative English speakers achieved parity with native English-speaking peers on the Critical Thinking Assessment tool, which is often believed to be related to employment readiness.     

Ethical implications of implicit bias in nursing education

Nurses possess the responsibility of promoting equality and diversity by treating all patients, families, and colleagues with respect and dignity. This responsibility includes providing culturally informed care and practicing within the ethical principles of autonomy, justice, beneficence, veracity, and nonmaleficence. Implicit biases impact nursing education and subsequent interactions between student nurses and patients and hinder effective communication. Patients who have experienced implicit bias in health care may come to expect negative interactions in the future. Nurse educators hold the responsibility of preparing nursing students to deliver care to diverse populations by guiding them to recognize their responses to cultural differences. Awareness of students’ implicit biases is the first step in incorporating efforts to overcome them. A gap exists in nursing education which illustrates the lack of inclusion of implicit bias in the curriculum. The purpose of this paper is to examine the ethical implications of implicit bias in nursing education. Ethical principles are presented and discussed in the context of implicit bias and nursing education. Recommendations for incorporating strategies of identification and awareness of implicit bias into the nursing curriculum are discussed. The inclusion of the implications of implicit bias in the nursing curriculum provides opportunities for educators to direct students to develop plans to recognize the damaging effects of implicit bias and become aware of behaviors that become barriers to patient interactions. The results of this education include improved patient outcomes and the delivery of culturally appropriate care.     

Surveying minorities with limited-English proficiency: does data collection method affect data quality among Asian Americans?

BACKGROUND: Little is known about how modes of survey administration affect response rates and data quality among populations with limited-English proficiency (LEP). Asian Americans are a rapidly growing minority group with large numbers of LEP immigrants. OBJECTIVE: We sought to compare the response rates and data quality of interviewer-administered telephone and self-administered mail surveys among LEP Asian Americans. DESIGN: This was a randomized, cross-sectional study using a 78-item survey about quality of medical care that was given to Vietnamese, Mandarin, or Cantonese Chinese patients in their native language. MEASURES: We examined response rates and missing data by mode of survey and language groups. To examine nonresponse bias, we compared the sociodemographic characteristics of respondents and nonrespondents. To assess response patterns, we compared the internal-consistency reliability coefficients across modes and language groups. RESULTS: We achieved an overall response rate of 67% (322 responses of 479 patients surveyed). A higher response rate was achieved by phone interviews (75%) as compared with mail surveys with telephone reminder calls (59%). There were no significant differences in response rates by language group. The mean number of missing item for the mail mode was 4.14 versus 1.67 for the phone mode (P< or =0.000). There were no significant differences in missing data among the language groups and no significant differences in scale reliability coefficients by modes or language groups. CONCLUSIONS: Telephone interviews and mail surveys with phone reminder calls are feasible options to survey LEP Chinese and Vietnamese Americans. These methods may be less costly and labor-intensive ways to include LEP minorities in research.     

Potential influence of nurses’ implicit racial bias on maternal mortality

Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.     

A survey of breast cancer detection methods in long-term care facilities

The majority of women residents in long-term care facilities are at high risk for the development of breast cancer. Routine breast cancer detection methods are indicated but not used for women in long-term care facilities on Long Island, New York. There appears to be an age-related bias concerning breast cancer detection of long-term care residents among health-care providers. There is no literature that addresses the need for breast cancer detection among residents in long-term care facilities.     

Nursing interpreters? Interpreting nurses?

Swiss hospitals are characterized by an increasing diversity, in the sense of personal and social differences such as including origin, gender language, skills, age, lifestyles and social status. Diversity is a challenge for hospitals. It is crucial to language barriers and migration and their clinical consequences. In spite of a trend towards interpreter services "going professional", interpreters are only reluctantly used. This is surprising. In this article we deal with three questions: What are clinical consequences of language barriers? How can language barriers be overcome? Should nurses act as interpreters? The literature available clearly shows that due to insufficient flow of information patients speaking a foreign language tend to receive inadequate care. Also, there is a consensus that patients' relatives acting as ad hoc interpreters are ill-equipped or unsuited to overcome language barriers. Conversely, professional interpreters improve most evidently the quality of care of patients speaking a foreign language. However in clinical everyday life the consistent use of interpreters is not always feasible. Thus, the setting-up of a pool of hospital-based ("internal"), trained bilingual health professionals appears to be an acceptable alternative.     

Undergraduate nursing students' experiences and attitudes towards working with patients with opioid use disorder in the clinical setting: A qualitative content analysis

BackgroundWith the US facing an opioid epidemic, undergraduate nursing students are increasingly encountering patients with opioid use disorder in the clinical setting. Yet, nursing curriculums have not adapted to meet this need. Previous research indicates students are exposed to negative messages that might influence their views about patients with opioid use disorder.ObjectivesThe purpose of this study was to examine nursing students' experiences encountering patients with opioid use disorder in the clinical setting, their attitudes about their encounters, and their perceptions of their educational preparedness to care for this population.MethodPurposive sampling was used to identify participants. Semi-structured interviews were conducted until saturation. Krippendorff's method for qualitative content analysis was used to cluster units within the data to identify emergent themes.ParticipantsEleven senior nursing students from a public university in New England participated.ResultsAnalysis revealed six themes, including: navigating ethical dilemmas, gaining comfort with time and experience, avoiding the “elephant in the room,” learning from real-world scenarios, witnessing discriminatory care, and recognizing bias and stigma.ConclusionsStudents were most likely to experience bias and internal conflict in maternity clinical rotations. Education should include practical communication strategies to reduce avoidance behaviors among nursing students as well as techniques to manage difficult situations and reduce moral distress. Nurses must be mindful of their power to influence students and should model non-judgmental language and behavior. Students ultimately expressed a desire to provide informed and empathetic care.     

Primary Mental Health Care Information and Services for St. John's Visible Minority Immigrants: Gaps and Opportunities

This article draws on an environmental scan and interviews with visible minority immigrants in a small urban Atlantic community to report on gaps and opportunities for improving access to information about primary mental health care services and barriers to utilization of these services. Information about services was limited and did not specifically address the complex health-related concerns of immigrants with diverse religious and cultural backgrounds. Accessing information about mental health care services was challenging for some visible minority immigrants because of physical and financial constraints and limited computer and language literacy. The major barriers to the utilization of primary mental health care services were lack of information, language and literacy issues, a mistrust of primary mental health care services, the stigma associated with mental illness, long wait times, lack of finances, and religious and cultural differences and insensitivity. A list of nine recommendations, which may be of interest to mental health decision-makers and service providers in small urban centers with limited ethno-cultural diversity, is provided.     

Impact of Language Barrier on Acute Care Medical Professionals Is Dependent Upon Role

Communication with patients is essential to providing quality medical care. The study was conducted to evaluate the effects of language barriers on health care professionals. It is hypothesized that these language barriers are commonly perceived by health care professionals and they are a source of workplace stress in acute care environments. We designed and distributed a survey tool of staff experiences and attitudes regarding the English-Spanish language barrier among patients in an acute care surgical environment of a tertiary medical center. Responses were anonymous, stratified by professional role and comparisons made using paired t tests. Sixty-one nurses and 36 physicians responded to the survey. Overall, 95% of nurses reported that the language barrier was an impediment to quality care, whereas 88% of physicians responded similarly (P = .0004). More nurses than physicians report experiencing stress (97% vs. 78%) and the degree of stress appears to be greater for nurses (P < .0001). The basis of stress was unique between the two groups. This study demonstrates that acute care hospital medical professionals perceive language barriers as an impediment to quality care delivery and as a source of workplace stress. Nurse and physician perceptions differ; therefore, strategies to address these language barriers should be specific to those professional roles. These barriers create a void in health care quality and safety that has effects on health care professionals.     

Intraspecific DNA variation in nuclear genes of the mosquito Aedes aegypti

Single nucleotide polymorphisms (SNPs) are an abundant source of genetic variation among individual organisms. To assess the usefulness of SNPs for genome analysis in the yellow fever mosquito, Aedes aegypti, we sequenced 25 nuclear genes in each of three strains and analysed nucleotide diversity. The average frequency of nucleotide variation was 12 SNPs per kilobase, indicating that nucleotide variation in Ae. aegypti is similar to that in other organisms, including Drosophila and the malaria vector Anopheles gambiae. Transition polymorphisms outnumbered transversion polymorphisms, at a ratio of about 2:1. We examined codon usage and confirmed that mutational bias favours G and C ending codons. Codon bias was most pronounced in highly expressed genes. Nucleotide diversity estimates indicated that substitution rates are positively correlated in coding and non-coding regions. Nucleotide diversity varied from one gene to another. The unequal distribution of SNPs among Ae. aegypti nuclear genes suggests that single base variations are non-neutral and are subject to selective constraints. Our analysis showed that ubiquitously expressed genes have lower polymorphism rates and are likely under strong purifying selection, whereas tissue specific genes and genes with a putative role in parasite defence exhibit higher levels of polymorphism that may be associated with diversifying selection.     

Promoting stigma self-awareness in nursing students through brief unconventional clinical experiences

Background: Literature reflects nursing student bias toward stigmatized groups. This article describes nursing students’ clinical experiences at a human immunodeficiency virus (HIV) community clinic, a state maximum-security carceral facility, and an HIV service-learning university campus project. Approach: Brief and unconventional experiences focused on linking cultural diversity concepts to stigma self-awareness in clinical settings and improving patient-centered care. The faculty implemented current recommendations to promote awareness of bias and stigmatizing behavior. Students’ experiences were first-person, participatory, and interactive. Students completed reflections and clinical evaluations focusing on thoughts, feelings, and awareness of bias, thereby bridging the gap of stigmatized populations and nursing practice. Conclusion: Associate degree nursing students participated in clinical learning environments with stigmatized populations. Students rated the clinical learning experiences as positive and meaningful in addressing stigma and bias. The brief clinical experiences align with the current National League for Nursing best practices to reduce stigma and promote bias awareness.     

Clinical review: International comparisons in critical care - lessons learned

ABSTRACT: Critical care medicine is a global specialty and epidemiologic research among countries provides important data on availability of critical care resources, best practices, and alternative options for delivery of care. Understanding the diversity across healthcare systems allows us to explore that rich variability and understand better the nature of delivery systems and their impact on outcomes. However, because the delivery of ICU services is complex (for example, interplay of bed availability, cultural norms and population case-mix), the diversity among countries also creates challenges when interpreting and applying data. This complexity has profound influences on reported outcomes, often obscuring true differences. Future research should emphasize determination of resource data worldwide in order to understand current practices in different countries; this will permit rational pandemic and disaster planning, allow comparisons of in-ICU processes of care, and facilitate addition of pre- and post-ICU patient data to better interpret outcomes.     

Addressing diversity in clinical nursing education: support for preceptors

Nursing preceptors are challenged by a broad set of teaching–learning diversity issues that are related to their role as clinical teachers of senior nursing students in clinical settings. A lack of awareness and understanding of these diversity issues may contribute to preceptor-student miscommunication and conflict. Ultimately, these factors can impact on the extent to which the educational objectives are achieved. Most of the health sciences literature focuses on diversity and patient care, and unfortunately, the literature that does address diversity and learning primarily examines the influence of culture and language in classroom education. Few resources are available to guide preceptors as they engage in “real life” real-time clinical learning encounters. To assist preceptors with their teaching strategies and skills, a diversity and learning workshop was developed to support preceptors in their critical role as both clinical teachers and role models. A diversity and learning framework is suggested and applied to the set of teaching–learning diversity issues.     

Time to disable the labels that disable: the power of words in nursing and health care with women, children, and families

Nursing is grounded in communication with others, yet rarely are the words critiqued. Despite an ethical call to honor diversity, promote empowerment, and to do no harm, some of the language used in health care reflects historical prejudices, reductionism, and/or the overarching authority of medical or moral models. This article exposes some of the "harsh words" nurses sometimes unconsciously use, and it suggests alternatives. Influenced by an ethic of social justice and the ethic of relationship with others, an attempt will be made to explore nursing language with women and children. Implications for nursing philosophy and practice will be discussed.     

Eliminating cultural bias in nursing examinations

Nursing program's enrollment reflects greater numbers of students for whom English is a second language. According to the National League for Nursing, approximately 32% of nursing students are from minority groups (National League of Nursing, 2012). The language diversity within the nursing student body provides challenges for the nursing faculty when developing nursing examinations. This article will discuss the need for nursing faculty to be mindful of the language used when creating nursing examinations that may lead to confusion for culturally diverse students. Focus should be placed on developing examinations that test discipline-specific concepts that do not rely on a student's familiarity with “colloquiums” and “expressions” to be successful. This article will provide recommendations for the development of testing committees composed of nursing faculty who are culturally sensitive and aware of cultural bias that may be present in nursing examinations. Case study exemplars and examples of culturally biased questions will be provided, and recommendations will be made to develop culturally neutral, discipline-specific examination.