Racial Cultural perceptions of Registered Nurses - Dissertation Example

?Racial Cultural perceptions of Registered Nurses associated with screening for PPD As discussed previously, postpartum depression (PPD) is a common disorder which inflicts women belonging to all ages, races and cultures. Nurses play a pivotal role in screening, diagnosing and treating this disorder. In the surveys conducted at our center (Cleveland Clinic) in order to elucidate the common perceptions of Registered Nurses, varying themes were identified. This section/paper reports the findings from the conducted survey and discusses the themes identified with reference to the existing literature in this regard. One of the most important questions asked in this survey was the method used by the RNs to screen for PPD. None of the nurses reported using any screening tools for the evaluation of PPD. The commonly used methods for the evaluation of PPD were found to be: asking general questions or identifying risk factors during the postpartum office visit; telephonic questioning when patients called to inquire about any queries, concerns or symptoms that they have; as a part of the documentation for the admissions database during the admission for delivery and during chart review or as a part of the routine history during the obstetric visits. Amongst these, the most common method was chart review or while obtaining obstetric history, during which the two main questions asked were whether the patient has had any prior episodes of PPD in previous pregnancy or a history of pre-existing depression and whether she was taking any medications. This practice is in stark contrast to the recommendations for the screening of PPD in the existing literature. Recent literature recommends the widespread use of pre-validated screening questionnaires for the screening of PPD amongst women in order to effectively identify women suffering from this disorder, since it carries with it significant morbidity and risks to both the mother and the child (Zubaran, Schumacher, Roxo, & Foresti, 2010; Anne E Buist, et al., 2002). Although no particular screening tool was used, the nurses did mention using open ended questions such as “How are you doing?”, “Are you getting any sleep?”, “Are you eating?”, “Are you drinking okay?”, “Do you have any problems?” and “What kinds of concerns do you have? “ to develop a rapport with the patients and enable them to share their experiences. This practice is in concordance with the existing literature as some studies advocate the use of simple, open ended questions such as “Are you sad and depressed?” and “Have you had a loss of pleasurable activities?” as an initial screen for PPD. The use of such questions helps the women in opening up and sharing their experiences and concerns (Goldbort, 2006). There are also several shortcomings of the above mentioned methods for the screening of PPD. First, for women who are having their first baby, the question whether they experienced PPD in any prior pregnancies becomes void. Similarly, most patients who are experiencing PPD for the first time might not be on any medications and thus the question whether they are using any medications currently, is not of any use in such patients. It is thus important to use effective screening strategies which are designed to encompass all patients, including those who are pregnant for the first time, so that none of the patients is missed. The most common setting for PPD identified in this survey was during obstetric visits or on admission for delivery. This was followed by screening for PPD during the postpartum visit. There have been various studies conducted in order to determine the most effective screening method and setting for the screening for postpartum depression. The most appropriate and convenient settings for the screening as recommended by the current literature is during the mother’s post-partum visit or during the well child visit of the baby (Gjerdingen & Yawn, 2007; Callister, Beckstrand, & Corbet, 2010). Moreover, recently, other novel innovative strategies for screening have been identified. These include screening over the telephone or via internet based questionnaires and via home visits by nurses, but the effectiveness of such strategies is yet to be proven (Callister, Beckstrand, & Corbet, 2010). Thus, the settings for screening used at our center are in confirmation with those suggested by recent literature. Another aspect of screening for PPD evaluated by this survey was how the screening strategies and experiences with culturally diverse women differed from routine screening for native women carried out by the nurses. There was a wide variety of responses obtained for this question and this was one of the strengths of this survey that open ended questions were used so that a variety of responses and themes could be entertained. The most common responses to this question included the fact that although most RNs were at ease with screening American women, they encountered some difficulty in interviewing patients belonging to particular ethno-cultural backgrounds such as those patients who belonged to India, Middle East and Asia. Although the survey revealed that the basic needs of all the patients were the same, there were certain barriers encountered when screening women from culturally diverse backgrounds. For example, a commonly encountered hindrance was language barrier, which not only made questioning and effective communication difficult, but also limited the availability and access of educational material for these patients as most of them were not able to read or comprehend English. This survey identified that there was a lack of available interpreters at our center to effectively facilitate communication between the nurses and women from different cultural backgrounds. For a transcultural approach to screening for PPD, as proposed by Leininger, current literature suggests the use of screening tools and educational material in the women’s native language (Goldbort, 2006; Leininger, 1998). Moreover, as identified in literature, the family roles and cultural practices related to pregnancy and childbirth differed in this culturally diverse subgroup of women presenting to our centre too. Most nurses reported that patients from India, Middle East and Asia were less forthcoming as compared to American women. Moreover, they were mostly accompanied by their husbands who were actively involved in the screening process and also at times served as the interpreters. It has been proposed in literature that the encounter between the nurse and the woman should preferably happen in the absence of other family members, in particular their husbands, as women might be uncomfortable in expressing their feelings and concerns in the presence of their family (Bashiri & Spielvogel, 1999). In our setting, however, this becomes difficult as often, the women’s husband serves as the interpreter and the only means of communication between the nurse and the patient due to the presence of language barriers. Other important issues that we aimed to address through this study were to elucidate what were the perceptions of Nurses regarding cultural competency and what were the lessons they had learnt from their experiences of dealing with women from diverse backgrounds suffering from postpartum depression. In response to the question regarding what the Nurses had learnt from their experiences, a variety of responses were obtained. While some nurses believed that the most important aspect of counseling and screening for PPD was to make the patient understand that PPD is a medical disorder occurring due to chemical imbalance, over which the patient had no control and thus, it wasn’t the patient’s fault; others felt that the patients would themselves call to report their symptoms, if they were experiencing any. A few of the nurses interviewed reflected that they were surprised at how common depression was in our community and how PPD is often misdiagnosed. This observation on the part of the nurses is supported by current literature which reveals that since in certain groups of individuals, depression can present in the form of somatic symptoms, it may be often be misdiagnosed (Bashiri & Spielvogel, 1999). A common theme that emerged was that most nurses believed in developing a rapport with the patient initially, using proper communication skills such as actively listening and making use of non-verbal gestures and cues in order to make the patient comfortable. They reported that it is very likely that the patient might not open up easily initially but when probed further by asking open ended questions regarding their overall well being, their mood and whether they had any feelings or urges to harm oneself or the baby, patients are willing to share their problems and concerns. As discussed previously, such a practice is supported and recommended by the existing studies conducted in this regard (Goldbort, 2006). When inquired about their perceptions regarding cultural competency, most nurses interviewed displayed an adequate understanding of this phenomenon. They reported that they viewed cultural competency as the ability to identify and understand the cultural background of the patient and offer solutions for their problems accordingly. Moreover, they also felt that an important aspect of cultural competency was being aware of the differences between one’s own culture and the patient’s culture and open-mindedly accepting and respecting those differences while providing them with options for care within their own framework and cultural domain. However, a small percentage of nurses did report being unaware of what the term meant and a few required clarification regarding what was being asked and related examples of their encounters of dealing with women from a culturally different background than their own. The definition of cultural competency provided by most nurses was correct and in concordance with the different definitions which have been accepted in health care literature. Although a variety of definitions for this term can be found in the existing literature, the most commonly accepted definition of cultural competency from the nursing perspective is “The knowledge and skills nurses should posses to care for a patient from a cultural background different from their own (Betancourt, Green, & Carillo, 2002).” According to Leininger, every individual’s expectations and experiences with care are related to his or her own cultural background. Thus, while dealing with individuals from culturally diverse backgrounds, interventions should be individualized and tailored in a culture appropriate manner (Leininger, 1995). One of the last areas of focus of this research was an attempt to obtain in insight to the resources provided to the nurses at our center by their employer to become culturally competent. This question helped in identifying the various resources available at the Cleveland to help the medical personnel to deal with patients belonging to culturally diverse backgrounds. The resources identified included a diversity center which was available for the health care providers to acquire help regarding how to deal with patients from different cultures, periodic workshops and courses and online resource materials. Interestingly, a few nurses felt that the most important resource available to them was prior experience of encounters with patients of different cultures which helped them to improve their cultural competency via the process of self learning. Moreover, one participant also reported obtaining help from interpreters which were available, however, the overall impression of the nurses was that there was a dearth of available interpreters to facilitate meetings between the nurses and the patients, and the nurses often had to resort to seeking help from the patient’s family members to interpret for the patient. This, as discussed above, is not the recommended practice. Literature recommends that while the health care providers should take steps to acknowledge the family members accompanying women when they are being screened for PPD and make use of the family support structures to help women deal with their condition, they should ensure that the screening process is conducted in privacy. This is because at times the interference of the family members can lead to misunderstandings or the family members might not convey the true picture to the Nurses by censoring or withholding some of the information offered by the patient (Bashiri & Spielvogel, 1999). Moreover, taking the help of family members for translation and serving as the interpreter is strongly discouraged as the patients might not be comfortable in the family’s presence and might be unable to express their distress or concerns regarding their family, which is a common aspect of PPD whereby women are dissatisfied with certain family members such as their spouses or mother-in-laws and feel that they are being pressurized by them (Bashiri & Spielvogel, 1999). There are a variety of resources identified in the existing literature which have been found to useful aids for health care professional in order to improve their cultural competency. These include resource materials available online such as consensus statements, brochures and guidelines developed by the State’s perinatal centers and regular conferences and teaching sessions for the health care professionals(Goldbort, 2006). Another recommended practice is arranging and conducting weekly/monthly journal clubs which would provide the nurses with a platform to discuss the most recent literature on this topic and would help them to keep themselves upto date with the recommended practices (Goldbort, 2006). Thus, in conclusion, this study helped to increase our understanding of the existing perceptions and practices regarding postpartum depression at our centre and enabled us to identify the current shortcomings in the quality of care provided in this arena. In order to improve the existing practices, we recommend that there should be a proper screening procedure for PPD in place to correctly identify all women suffering from PPD, the nurses should be encouraged to access all the available resources to increase their knowledge regarding cultural competence and apply that knowledge to improve their current approach to patients PPD from different cultural backgrounds and the center should take measures to recruit more interpreters from a variety of cultural backgrounds to facilitate communication between the nurses and the patients. References Anne E Buist, B. E., Milgrom, J., Pope, S., Condon, J. T., Ellwood, D. A., Boyce, P. M., et al. (2002). To screen or not to screen — that is the question in perinatal depression. Medical Journal of Australia , 101-105. Bashiri, N., & Spielvogel, A. M. (1999). Postpartum Depression: A cross cultural perspective. Primary Care Update Obs/Gyne , 82–87. Betancourt, J., Green, A. R., & Carillo, J. (2002). Cultural Competence in health care; Emerging frameworks and practical approaches. The Commonwealth Fund. Callister, L. C., Beckstrand, R. L., & Corbet, C. (2010). Postpartum Depression and Culture: Pesado Corazon. Mother and Child Care Nursing , 254-261. Gjerdingen, D. K., & Yawn, B. P. (2007). Postpartum Depression Screening: Importance, Methods, Barriers, and Recommendations for Practice. Journal of American Board of Family Medicine , 280-288. Goldbort, J. (2006). Transcultural Analysis of Postpartum Depression. The American Journal of Maternal/Child Nursing , 121-126. Leininger, M. M., (1998). Leininger’s Theory of Nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1,152-160. Zubaran, C., Schumacher, M., Roxo, M. R., & Foresti, K. (2010). Screening tools for postpartum depression: validity and cultural dimensions. African Journa of Psychiatry , 357-365. Read More