 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
Telephone:
416 928-0900
Toll Free in Ontario:
1 800 387-5526
Fax:
416 928-6507
Publications & Resources > Here for You
Publications and Resources
Corrections and document updates
Publications
Tools
Nursing and You
Volume 1, No. 5, Oct. 1999 - Multi-Cultural Care
EDITORIAL
To care for someone, I must know who I am.
To care for someone, I must know who the other is.
To care for someone, I must be able to bridge the gap between myself and
the other.
- Jean Watson.
In these few lines, nursing philosopher Jean Watson has captured the essence of delivering quality nursing care in a culturally diverse environment. Nurses need to take the time and effort to understand their own and their patient’s culture; only then will they be able to achieve the best outcome for everybody.
Recognizing that Ontario has some of the most ethnically diverse communities in the world, and that our nurses needed more support in providing appropriate care for those communities, the College of Nurses recently published A Guide to Nurses for Providing Culturally Sensitive Care, and sent it to all Ontario nurses.
The Guide outlines the basic concepts in learning about culturally sensitive care and putting them into practice. Together with stories of nurses facing these issues in their everyday practice, we hope they will provide you a better understanding of how important these concepts are to good nursing.
Everyone has an individual culture, which is influenced by many factors such as race, gender, religion, national origin, economic status, sexual orientation, and so on. And culture is dynamic. It changes and evolves over time as individuals change over time. A client’s values and beliefs are inevitably influenced by culture, and it is not up to that client to adapt personal values and beliefs to those of the caregiver, the nurse. Rather, it is the nurse, who has much of the power in her/his relationship with the client, whose responsibility it is to learn about the client’s culture and adapt her own practice to accommodate it.
This issue of Nursing and You shows how well nurses across Ontario are doing just that.
Mary MacLeod, RN
Council President, College of Nurses of Ontario
Margaret Risk, RN
Executive Director, College of Nurses of Ontario
What is the College of Nurses of Ontario?
The College of Nurses (CNO) is the regulatory body for nursing in this province. Established by, but at arm’s length from, the provincial government, CNO derives its revenues from annual membership fees; it receives no funding from the province. The College decides the criteria for becoming a nurse in Ontario, and the standards of practice to be met to maintain that designation and privilege. No one can practice as a nurse in Ontario, or use the titles "nurse", "registered nurse", or "registered practical nurse", without a valid certificate of registration from the College
How Nurses Regulate Themselves: Determining a Nurse' Fitness to Practise
The mission of the College of Nurses of Ontario is to protect the public’s right to quality nursing services. One of the ways we do this is to respond to public concerns by determining a nurse’s "fitness to practise", the capacity to do her or his job effectively and safely.
By "fitness to practise", we don’t mean whether a nurse has the skills, experience or educational preparation necessary to do the job. These matters are assessed when the nurse first applies to practise in Ontario, and are the responsibility of the College’s registration department.
Instead, the Fitness to Practise program is concerned with a nurse’s ongoing physical or mental ability to provide quality nursing care.
For instance, an employer, colleague or client may observe slurred speech, sloppy work habits, impaired judgement, wide mood swings or increased absenteeism. These are some of the warning signs of a chemical dependency, such as alcoholism or drug abuse, the most common cause of a nurse’s incapacity to practise effectively. In this case, the College will attempt to work with the nurse to establish a suitable treatment program, and the conditions under which the nurse can continue to practise (such as limiting access to certain medications, or reducing the extent of the nurse’s responsibilities). The College will monitor the nurse’s progress, and ensure the conditions are being met.
If the nurse is unwilling or unable to cooperate with the College, a closed hearing may be held, where both the nurse and the College may be represented by lawyers. Restrictions or even suspension of the nurse’s registration may be imposed. Any action taken by the College will have time limits, and specific targets for treatment of the health concerns.
As much as possible, the College’s Fitness to Practise program is meant to rehabilitate, with the ultimate objective being the nurse’s healthy return to work. Nevertheless, the protection of the public is the bottom line, as it is in everything the College undertakes.
Nursing in a Chinese Seniors' Community
As a Registered Practical Nurse (RPN) at the Yee Hong Centre for Geriatric Care in Scarborough, where the clients are almost exclusively of Chinese ancestry, Linda Cheung would seem to have a decided advantage over some of her colleagues. She is of Chinese descent herself, having been born and raised in Hong Kong, emigrating to Canada only five years ago.
Although many of her clients at the Yee Hong Centre are also from Hong Kong, Linda still cannot make assumptions about what to expect when she first meets a new patient. For one thing, the patient may be from mainland China; more immigrants from that country are arriving in Canada every year, and many are elderly. This changes things quite a bit.
For one thing, many of the mainland Chinese, particularly from Beijing or the north, speak Mandarin, while Linda’s first language is Cantonese. "I can usually make myself understood," she says, "but communication is certainly more difficult. And I also think the mainland Chinese people are more afraid of authority figures, like doctors or nurses. It is harder to get them to trust you."
Linda first emigrated to Canada in 1994, three years before Hong Kong reverted to Chinese rule. Trained in Hong Kong as a nurse, she found she needed to upgrade her education in Canada before being registered here; in the meantime, she found employment at Yee Hong as a Health Care Aide (an unregulated health care provider). Linda has now been an RPN for almost three years, and is continuing her education, having recently completed a Gerontology course at Centennial College in Scarborough.
In addition to working at Yee Hong, Linda also worked part time at a downtown Toronto nursing home, and this provided an excellent on-the-job education in culturally sensitive care.
"There were so many different kinds of people there," she recalls, "from so many different parts of the world. They all had different attitudes to me as a nurse, and to what I was trying to do. I had to keep this in mind as I worked."
Eventually Linda gave up her downtown job to be closer to home and family in Scarborough, and she now works full time at Yee Hong, where she is a supervising nurse on one of the floors of the 150-bed nursing home.
"The Chinese seniors have great expectations of the nurse," she says. "They are to be accorded respect because of their age. Also, the nursing home is very strange to them. In Chinese tradition, the old people are taken care of in the family. But now, with everyone having to work, their children can’t do that. So they bring their parents here, and the elders feel that no one loves them or respects them. The nurse tries to give back what they think they’ve lost."
As for incorporating traditional Chinese medicine in the program of care at Yee Hong, one difficulty is to find doctors or nurses who have the knowledge or experience to use it. "In time," says Linda, "we will come to know more about these treatments, and the clients will become more comfortable with the modern ones. We’ll learn from the elders, and they’ll learn from us. Yee Hong is very young."
Nurses and patients learning from each other. That exchange is at the very core of culturally sensitive care.
Adjusting to Canadaian Nursing: the Experience of a Somali Nurse
Abdiqani Qasim is definitely a nursing success story. The coronary intensive care nurse at Toronto General Hospital was recently awarded the annual Lichtblau Scholarship, given to enable the unit’s nurses to pursue further studies. Abdiqani will be taking a Master’s degree at D’Youville College in Buffalo to become a Family Nurse Practitioner, commuting two days a week while maintaining his hospital job to support a young family.
It’s hard to believe that only 10 years ago, Abdiqani was labouring in a friend’s furniture factory, having almost given up on his nursing career. But persistence and many long hours of hard work and study have led to his current position, with even better prospects for the future.
Abdiqani was born into a poor family in the town of Kismayo in southern Somalia. Determined to help his family, he took a two-year diploma in nursing offered by the Ministry of Health. He was given a post in a military hospital just before his country’s war with Ethiopia broke out. After the war, he moved to a general hospital, then to a health unit for Somali refugees fleeing from Ethiopia.
While in Holland on a course, he met his future wife, and they began to consider not returning to Somalia, where conditions were steadily worsening. They visited Abdiqani’s cousin in Toronto, and decided to stay in Canada. But when he first tried to register with the College of Nurses of Ontario, he was turned down.
"The College had not much knowledge of Somali education and working conditions," he recalls. "It was very difficult getting information." So to make ends meet, Abdiqani went to work in the furniture factory. Then he received word that the College had acquired more information on Somali nursing, and he decided to try again.
"This time, they said I was qualified to write the national exam to become an RPN (Registered Practical Nurse)," he says. "I passed. At last, I was back into nursing. But I still was not satisfied."
First Abdiqani went to Toronto’s Seneca College to get a diploma as a Registered Nurse, then to Centennial College in Scarborough for a certificate in critical care. This began his career in the CICU (coronary intensive care unit). Still thirsty for more knowledge and credentials, he received his B.Sc. in nursing at Toronto’s Ryerson University. Throughout, he continued to work as many hours as possible; even now, he works as a replacement nurse for a Toronto agency, in addition to his full time job in the CICU.
"It has taken a long time to get here," he says, "but it has been worth every hour. The struggles have made me more confident in myself. I will continue learning my whole life; I will always go where there is a challenge."
In 1994, Abdiqani founded the Somali Canadian Nursing Association, dedicated to helping other Somali nurses become registered and start working in Canada. As an advocate for his fellow Somalis, Abdiqani, now a Canadian citizen, has been very helpful to the College of Nurses in updating its information on nursing training in Somalia.
How does nursing differ in the two countries? "Obviously, the technology, the ideas are more advanced in Canada," he says. "And there was not the protection in Somalia for the patient. At the same time, nurses there were more independent, more hands-on. It’s nice to have both, that’s why I want to become a nurse practitioner."
A dedicated student, Abdiqani also enjoys the teaching aspect of nursing. "It’s wonderful," he says, "to share your ideas and your skills with patients and especially with other nurses. Nurses need to share, to cooperate more with each other. That’s how you grow."
Assessing a Foreign-Trained Nurse
One of the important roles of the College of Nurses is to assess the education and experience of those who apply for registration. That assessment, together with the national exam that all nurses must pass to begin practice, ensures they are qualified to meet the high standards of practice for nurses in Ontario. Assessment presents a significant challenge when the applicant is not from North America, for although the College has comprehensive files on nursing programs all over the world, it is difficult to keep those files complete and current. Organizations like Abdiqani Qasim’s Somali Canadian Nursing association are invaluable in this regard.
Nurses in the News: A Parish Nurse Helping on the Street
Catherine Lofsky is a parish nurse. She is one of a growing number of parish nurses in Canada, women or men who for the most part act as home care nurses, visiting members of a congregation and ministering to their spirits as well as their minds and bodies.
But Catherine is a parish nurse with a difference. Instead of working for a single church or denomination, she works for the Oshawa Community Ministry Centre (also called Gate 3:16), sponsored by a wide variety of churches and individuals. Instead of working in the comfort of parishioners’ homes, she works out of a storefront in downtown Oshawa, catering to the homeless and the destitute.
"We need Catherine here," says Valieree Brecht, executive director of Gate 3:16 and a former nurse. "When you’re talking street people, you’re talking just about every kind of health problem. It’s hard to tackle that with volunteers."
Gate 3:16, a Christian drop-in centre, sees about 60 to 100 people a day, operating largely as a referral service for other community agencies, but itself offering a number of programs: lunches, counselling, life skills courses, and Catherine’s nursing service. Catherine is part-time care provider and part-time teacher; educating street people about good health takes a lot of her time. But as a parish nurse, she also pays particular attention to the spirit.
"Parish nurses treat the soul as well as the body and mind," she says. "It’s what makes us good nurses. And it’s surprising how spiritual street people are. When Gate 3:16 was threatened with being shut down a few months ago, the street people themselves got together with the whole community to save us. The clients say the spiritual aspect of the place is part of what makes it so special and so important."
Catherine, a former nurse educator at Oshawa General Hospital, first read about parish nursing in a magazine several years ago. She then enrolled part-time in a three-year program jointly offered by Interchurch Health Ministries and Emmanuel College at the University of Toronto. She is a nurse first and foremost, and must abide by the same high standards of practice as all Ontario nurses. For her, faith is just a natural part of the healing process, much as it is for the First Nation people on Manitoulin Island (see Diary, page 4).
"We’re much like a family at Gate 3:16, one that I wish I could spend more time with." says Catherine. "I’m fortunate to have found a place like this that uses my skills."
Developing and Interpreting Standards: The Role of CNO's Practice Consultants
One of the chief responsibilities of the College of Nurses of Ontario (CNO), in accordance with its mission "to provide leadership to the nursing profession in self-regulation", is to develop standards which will guide nurses in their practice. These are comprehensive documents to which nurses can refer in their day-to-day work. Standards may be quite broad, such as those dealing with ethics or nurse-client relationships, or focussed on specific aspects of practice, such as footcare, transporting clients, or giving telephone advice.
Who develops these standards? And who helps nurses with interpreting them, as thorny problems inevitably arise in individual practice situations? The answer to both questions is the same: CNO’s core team of about 10 practice consultants, veteran nurses who are called upon to fill a variety of roles in carrying out the College’s mandate.
"Ideally, a CNO practice consultant has many years in the trenches, and a wide variety of practice experience," says Denise Dietrich, a Registered Practical Nurse (RPN) with 23 years in acute care, visiting care and independent practice as a rehabilitation nurse. Denise also has a B.A. in sociology and numerous specialized certificates in addition to her RPN. "You have to have practised enough years and in enough places to be able to respond spontaneously and creatively to a nurse’s concerns. No answer can apply to every situation."
The consultants take a lead role in developing new standards or revising outdated ones; the latter is more frequently the case, as standards have to be dynamic to remain relevant to changing conditions in the workplace. As an important part of the process, the consultants draw on the advice of practising nurses, bringing many perspectives together in standards which can apply to everyone. The standards are then officially adopted by CNO’s governing Council.
Once in place, the standards are expected to be adhered to by each and every nurse across the province. But nurses have inquiring minds, and the consultants must be ready, on the phone or with groups of nurses in a workshop setting, to interpret the new standards strongly and consistently.
"Many nurses don’t have clinical educators in their workplace," says Denise, "to help them to apply a standard in a particular situation. For example, if I do this, is it quality care or unethical? If I assign a health care aide to provide this aspect of care, are there any risks to the client? They need the answer, and they need it now. For many nurses, we are their prime resource."
The College also relies on the consultants to keep in touch with working nurses, to see if the standards are doing their job, and are current and realistic for today’s nurse. The consultants must also respond to nursing employers when they wonder what the standards mean for them.
Beyond the standards, however, CNO’s resident nurses "consult" to other College departments and its statutory committees. In the Complaints and Investigations area, they interpret standards, and help customize learning plans for nurses who want to do better. They help develop policies on such matters as patient abuse, or submissions to groups like the recent Nursing Task Force. They participate in nursing education (Denise, for example, sits on the advisory committee for Humber College’s nursing program). They write interpretive articles for Communiqué, CNO’s member journal.
In short, the College’s practice consultants must be effective communicators on paper, one-on-one or in front of large groups. They must be forward-thinking and quick on their feet. Are we talking super-nurses here? Not at all, says Denise Dietrich.
"If you’ve been a nurse for a long time, if you’ve watched and listened, you’ll have an instinct for what nurses need," she says. "That’s what this job is about."
A SHOUT of Healing: Reaching Out to Gay and Lesbian Street Youth
Registered Nurse Sandra Pettey used to work in a trauma unit at a large Toronto hospital.
"I loved the technology there," she recalls, "but I really didn’t have a whole lot of contact with the patient. Twelve years ago I moved into community health, and it gave me a whole new appreciation of the social context for health problems. This kind of work is a natural extension of a nurse’s holistic approach to health."
Today, Sandra is one of three nurse practitioners (part of a multi-disciplinary team) at the SHOUT Clinic on Jarvis Street in downtown Toronto, a community health centre for street-involved youth under 25. Most of her clients are homeless and with few resources, many of them are gay or lesbian, and the array of health problems is daunting, from skin diseases to depression to substance abuse.
"We don’t make any judgements or assumptions here," she says. "Our job is to heal, and to do that we have to build trust with these kids who don’t have a lot of reasons to trust anybody. We spend a lot of our time listening, acting as a sounding board. Soon a range of health issues will emerge, and we can start to deal with them."
The people at SHOUT estimate that 30 to 40% of street youth are gay or lesbian; part of the reason they’re on the street is that their families have rejected them, and they feel isolated and powerless. On the street, they are very much exposed to sexually transmitted diseases, especially since some of them resort to prostitution in order to survive. The poor hygiene which accompanies street life only makes the problems worse.
"When we speak with them, sexual orientation is only a part of the health history," says Sandra. "We focus on their sexual practices, and on staying safe, on getting healthy and staying that way."
The SHOUT Clinic offers a multitude of services for street youth, ranging from dental work to counselling, to free health snacks and hygiene products. Recently, with the support of individuals and corporations, they have begun a bursary program, intended to get kids off the street and into post-secondary education. They also act as a referral service for a variety of other programs aimed at streeet youth.
There are no appointments at the clinic; opportunities for "failure" are not built in from the outset. "The key to success for us is creating access, making the clinic as welcoming as possible," says Sandra. "Once they are in the door, they see that we really do care about them. Then they will open up and let us teach them how to take care of themselves."
Working at SHOUT Clinic is complex and constantly challenging, says Sandra. But it is also continually rewarding. "Despite their problems, maybe because of them, these kids are very dynamic, very flexible. I learn something from them every day."
Reflections: Developing an In-Hospital Aboriginal Cultural Program on Manitoulin Island
Debra Bennett, RN, is the Director of Patient Care for the Manitoulin Health Centre, two small acute care hospitals on Manitoulin Island near the north shore of Lake Huron. Manitoulin Island has a population of about 12,000 people. About 40% of the hospital clients are aboriginal. Over the past few years, the Manitoulin Health Centre and the seven First Nation reserves on the Island have been taking steps to bridge the gap between the values of modern medicine and traditional native cultural beliefs, by creating a greater awareness and accommodation of native customs, traditional native medicines and spirituality. These are some of Debra’s reflections on that journey.
I’ve been reading the June 1999 edition of Communiqué (the quarterly journal from the College of Nurses of Ontario). There is a section called A Guide to Nurses for Providing Culturally Sensitive Care (see editorial). It encourages nurses to examine their own beliefs and values and how they might influence their relationship with a client from another culture, with different beliefs. It makes me think back on how beliefs and values have changed in the past few years at the hospital where I work.
In the beginning, there were many questions, but no one was sure how to go about getting the answers. Members of the First Nation communities, and hospital staff, realized instinctively that through a better understanding of native culture, the needs of the First Nation clients could be better served. Could the hospital become more culturally sensitive to traditional native spirituality, its ceremonies and its traditional medicine? Could the scientific methods of the modern acute care hospital be adapted to include native rituals, healers, and remedies?
At the request of the Manitoulin Health Centre Board, and with the assistance of Dr. Jack Bailey, well respected for his many years of service on the island, an advisory committee was established, with hospital representatives and members appointed by the Chief and Council from each First Nation community. It was decided that the Committee should function independently from the hospital, and so the Anishinabe Mekwaatawgsajig Council was born. The Council then appointed me as a resource person to assist in the areas of education, communication, and facilitation of native cultural practices. The Council’s Mission Statement was adopted in February of 1996:
"In the healing path of the Anishinabe, the Anishinabe Makwaatawgsajig bring and share the Anishinabe culture through a working partnership with the Manitoulin Health Centre for the holistic healing and wellness of our people."
The first role of the Council was to begin regular education sessions for hospital staff. There are speakers and other presentations four times a year, one session for each of the four seasons. So far, we have learned about the meaning of a smudging ceremony, the burning of sweet grass and sage, the spirituality associated with traditional medicine, the medicine wheel, the healing circle, and the sweat lodge ceremony.
Day tours were arranged for hospital staff to Wikwemikong, a First Nation community of 2,500 people. We were welcomed in the Medicine Lodge by the Chief of Wikwemikong, Ron Wakegijig.
The day began with a prayer in Ojibwa and smudging ceremony. Chief Wakegijig, who is also a healer, told the meanings of the medicines which are used in the smudging ceremony. Everyone was invited to participate. He explained that the Medicine Lodge – a teepee-shaped structure which is physically included in the community health facility (built in 1988) – is the first of its kind. Here Western medicine and traditional Aboriginal medicine are offered together. When the community health plan was developed, a survey of about 350 homes in Wikwemikong indicated that 77% of the people wanted traditional Native medicine available in their new community health centre. Members of the community are able to consult a traditional healer and a physician in the same visit.
How were we to accommodate traditional medicines at the Manitoulin Health Centre? Many native people take these remedies at home and wanted to continue to use them while in the hospital. The legal aspects of using such medicines were reviewed by local pharmacists and physicians. Ways to allow traditional healers to view patient records were developed.
The College of Nurses was contacted for advice on how nurses could assist in the use of traditional medicines. The response was that the nurse must understand what the medicine is expected to do, and its possible side effects. The traditional medicine has to be compatible with the modern medication the patient is already receiving.
The First Nation communities were continually informed about what was being done to make a culturally sensitive hospital, and what was being allowed for families and patients in the hospital. A pamphlet was developed by the Anishinabe Makwaatawgsajig Council and distributed to all health care agency waiting rooms and Band offices on the Island.
It all started with a couple of unintentionally insensitive remarks made by staff members who did not understand what a smudging ceremony was about. Today, we have an increasing understanding of native spirituality and traditions amongst the non-native staff, resulting in native patients and their families feeling more welcome at the Manitoulin Health Centre.
It makes for a richer and warmer hospital community.
The smudging ceremony, whereby sweetgrass, sage, cedar and/or tobacco are burned in a small bowl to create smoke, is a ritual of spiritual purification often requested by our First Nation patients. How do we avoid discomfort to other patients? How do we avoid setting off the hospital’s smoke alarms? The ultimate solution is to hold the ceremony in a well-ventilated room, and have a maintenance staff member at the ready to turn off the alarms before the ceremony, and turn them back on once the smoke has dissipated.
A native couple asks that when their child is born, the birthing bed be turned toward the east. They also ask to take the placenta to put it in the earth near their home, so as to give the child spiritual roots there. Some requests are very easy to accommodate!
In the custom of "standing vigil" for a dying native person, all the patient’s relatives, which may number dozens, could wish to be present at the hospital during his or her waning hours, so that the patient will not die alone. How do we handle this large number of people? How do we take care of everybody? We’re still working on this one...
Where This Newsletter Goes
Nursing and You is distributed free of charge to all hospitals, nursing homes, community health centres, and family physicians’ offices across Ontario, for placement in waiting rooms and other places of general access. Its target audience is the general public, the consumers of health care and nursing services. We invite you to take this copy home, to share it with family and friends, and we welcome your comments.
Contact Us
For further information about any aspect of nursing regulation in Ontario, including how to express a concern about a nurse's conduct or practice, please contact:
College of Nurses of Ontario
101 Davenport Road
Toronto, Ontario, M5R 3P1
cno@cnomail.org
Telephone: 416-928-0900 or Toll Free 1-800-387-5526
Fax: 416-928-9841
[top]