Nurses' descriptions of caring for culturally diverse clients.

Changing patterns of immigration and increasingly diverse societies have resulted in numerous theoretical perspectives and practical prescriptions regarding culturally sensitive nursing. Despite this increased academic attention, little research has examined the actual experience of the nurse working with culturally diverse clients in health care settings. Whether the theories and prescriptions are actually providing helpful direction in the provision of nursing care to culturally diverse clients is unknown. Kavanagh (1993) maintains that "while the culture of nursing and the nursing of culture have been studied, most nurses remain in a quandary about what to do with all of this" (p. 9). At the same time, there is a growing body of literature documenting that culturally diverse clients in health care settings may be treated in different and potentially harmful ways (Andrews, 1992; Jones & Van Amelsvoort Jones, 1986; Murphy & Clark, 1993; Rootman, 1988: Windsor-Richards & Gillies, 1988; Wollett & Dosanjh-Matwala, 1990). With this small-scale study, the researcher set out to evaluate the current state of the provision of nursing care by recently graduated nurses to culturally diverse clients.

In reviewing the literature regarding the experience of nurses in caring for culturally diverse clients, three key themes emerge. First, the predominant description of the experience in anecdotal and research literature is one of challenge and frustration (Adams, Briones, & Rentfro, 1992; Bernal, 1993; Kubricht & Clark, 1982; Manio & Hall, 1987; Rothenburger, 1990; Shareski, 1992; Thobaben & Mattingly, 1993), although positive aspects are also described (Bartz, Bowles & Underwood, 1993; Bernal, Pardue, & Kramer, 1990; Leininger, 1994). Second, the sources of difficulty within the experience of caring for culturally diverse clients are acknowledged. These sources of difficulty include cultural differences in values, beliefs, and customs (Adams et al., 1992; Dawes, 1986); communication difficulties, particularly those associated with language barriers (Bernal, 1993; Hartog & Hartog, 1983; Kubricht & Clark, 1982; Louie, 1985; Pauwels, 1990; Steffensen & Colker, 1982); and barriers from within the environmental context, such as bureaucratic health care systems (Bernal et al. 1990). Third, specific nurse-related factors influencing and/or enabling the individual nurse in caring for culturally diverse clients are identified. These factors include education (Bernal & Froman, 1992; Gunter, 1988), multicultural exposure (Bernal & Froman, 1992), open attitudes (Bonaparte, 1979), and previous work experience (Pope-Davis, Eliason, & Ottavi, 1994).

THE RESEARCH STUDY

The research question guiding this study was the following: How do recently graduated nurses describe nursing care provided to culturally diverse clients in hospital settings? Recent nursing graduates offer Insight into both the experience of caring for culturally diverse clients and the effectiveness of nursing curricula in preparing nurses for the experience of caring for such clients because they draw primarily on the knowledge gained prior to and during their educational programs, rather than on years of nursing experience.

A qualitative study examining British nurses' experiences of caring for ethnic-minority clients completed by Murphy and Clark (1993) was of particular interest because it addresses a question similar to that of the present study. These authors conclude that issues in communication, nurse-client relationships, dealing with relatives, nurses' feelings of frustration, stress, and helplessness, and a lack of knowledge about cultural differences were significant for nurses. Many of the respondents felt that the care ethnic-minority clients received fell below a desirable standard. None of the respondents felt that their education had prepared them for the problems and difficulties experienced in caring for ethnic-minority clients. Focusing on a group of recently graduated nurses, I aimed to extend Murphy and Clark's description.

An interpretive-descriptive design in the qualitative tradition (Thorne, Reimer Kirkham, & MacDonald-Emes, 1997) was selected to address the question. The design permitted a focus on shared elements within the experience of caring for culturally diverse clients. The use of such a design allowed for the anticipated multiplicity of experiences by nurses, although acknowledging shared themes and elements. Participants were sought from hospitals in communities that have a high population of culturally diverse clients. A volunteer sample of 8 recently graduated nurses (i.e., registered nurses who had graduated from a Canadian diploma or a bachelor's program within the past 2 years) from a total of six hospitals participated. The nurses worked in a variety of settings; 3 nurses worked on surgical units, and 1 nurse worked on a medical unit. Other areas represented were oncology, psychiatry, pediatrics, and obstetrics. Efforts were made to recruit participants from outside dominant Canadian culture. One participant was Chinese, another Jewish, and another was White but had grown up in the American South. All of the participants were female. The participants were each Interviewed twice. Orienting structure to the initial interview was provided by open-ended questions such as "Tell me about what it is like for you to care for culturally diverse clients" and "Tell me about an experience of caring for a culturally diverse client that stands out for you. How did you feel caring for this client? What contributed to make this the experience it was?" Subsequent interviews permitted clarification and elaboration of emerging themes. All interviews were audiotaped and transcribed with permission from the participants. Inductive data analysis proceeded concurrently with the interviews through the processes of unitizing and categorizing (Lincoln & Guba, 1985). The first step was to read and reread the transcripts to apprehend a sense of the whole (Thorne et al., 1997). Unitizing involved coding or aggregating smaller units of raw data into distinct meaning units. Categorizing was the process whereby these units of meaning or codes were grouped into categories on the basis of likeness. Data collection and analysis continued to the point of category saturation. The conceptual structure that emerged from the thematic analysis was validated and expanded with the participants during the second interviews.

The rights of the participants were protected by ethical review by the educational institution, by gaining agency approval to recruit participants, by obtaining informed written consent prior to the first interview as well as process consent (Munhall, 1988; Ramos, 1989), by assuring confidentiality in limiting access to the data and not using names, and by offering participants summaries of the study results. Rigor, or trustworthiness, was ensured in this research project by addressing Lincoln and Guba's (1985) criteria for qualitative approaches: credibility, transferability, auditability, and confirmability. For example, the strategies of reflexive journal writing, member checking, and discussions with other nurses regarding the emerging themes ensured credibility; the generation of thick data, continual comparisons between the accounts of all participants, and theoretical sampling contributed toward transferability. Auditability and confirmability were achieved through having another researcher review the transcripts and data analysis and by leaving a clear decision …