The rapidly changing demographics of the country are causing cultural and linguistic misunderstandings in health care -- a problem that nursing schools are just beginning to address.
As the percentage of minorities increases in the United States, the need for nurses equipped to deal with cultural differences has convinced many nursing schools to update their curricula.
According to Rosalyn Watts, Penn's director of diversity affairs, by the year 2040, 40 percent of the nation's population will be minorities.
This rising number encompasses multitudes of ethnic groups, all with different concerns -- Hasidic Jews who do not allow male nurses to care for female patients, Jehovah's Witnesses who do not permit blood transfusions, Asians who only eat certain types of foods, and the list goes on.
American nurses must care for all of these patients, thus making it important for them to have the sensitivity, awareness, knowledge and skills necessary to provide proper care.
The issue "presents a challenge for those of us involved in the education of nurses for the 21st century," Watts said.
In a recent effort to educate Penn student nurses about cultural concerns, the School of Nursing has begun to offer the "Seminar Series on Diversity and Cultural Competence."
The series, which was formed three years ago and is open to the community, invites consultants and experts to give guest lectures on a range of cultural issues.
In addition, in an effort to advance the diversity agenda, Dean of the Nursing School Afaf Meleis is starting a Master Teacher's Group on cultural competence, which will begin next month.
Watts, one of the co-chairwomen, said the group will frame the issues that need to be addressed, outline plans to add a significant cultural awareness component to the nursing curriculum, discuss the theoretical foundations of the issue and decide the best way to teach and disseminate the information.
"Not many people are doing it in the country," Watts said. "We're like pioneers."
Many of the nursing courses already have a cultural component, such as the "Advanced Clinical Practicum" course which spends about a week discussing the topic.
According to Nursing professor Sean Clarke, who teaches the course in the fall, the most important thing to establish is respect and trust between the nurse and the patient.
"It's so important not to be defensive," Clarke said concerning nurses. "It's about the patient."
In the "Advanced Clinical Practicum" course, various cultural practices, such as "coining," are taught so students are prepared to deal with these issues after they graduate.
Coining is a practice in many Asian cultures in which hot coins are placed on a sick child's skin in order to draw out evil spirits. Upon finding these marks on the skin of patients, Clarke stressed that nurses should not react strongly and call Child Protective Services, but instead should try talking to the family to convince them to use Western medicine.
"If you don't understand the person's entire persona, then you can't give adequate care," said Maya Clark, a Penn Nursing graduate and current nurse at the Hospital of the University of Pennsylvania.
Watts cautioned that nurses "must be in touch with their own biases and prejudices, too."
Although family wishes can be overridden, Sean Clarke said that "usually a decent solution can be found."
Nursing students also become educated about cultural competency issues through clinical experience in their junior and senior years. Some students even participate in trips abroad led by Nursing professors in which they can become immersed in another culture.
Nursing master's student Bryan Gardner said he gained first-hand experience with cultural problems during his junior clinical experience, when he cared for a Chinese man who could only speak Mandarin, a language that Gardner could speak.
"Because I used his language, he was able to get a higher score," Gardner said, referring to the Glasgow Coma Scale, a test which quantifies someone's level of consciousness following a traumatic brain injury.
Communication has become a major issue in nursing, because if nurses do not speak the language of the patient, they cannot get the information they need to assess health and provide proper care.
Ethical issues are raised when family members or friends are used as interpreters -- a situation which may compromise the confidentiality of the doctor-patient relationship.
In addition, such a setup might diminish the patient's willingness to disclose vital information to the nurses, and may prove problematic if the interpreter is dishonest and decides to censor or change the patient's language.
In response to this problem, most hospitals now hire interpreters, and a law is being formed to require all hospitals to do so.
Both Watts and Clarke agree that cultural problems will persist unless nurses actively engage themselves in the issues.
"To me, philosophically, when you work with such bright kids who really want to be in nursing, ... the challenge is to get people to think that just having good intentions is not enough," Clarke said.
However, not all Penn Nursing students are satisfied with the cultural competency component of their education.
"It doesn't seem very well explored, but people try," Gardner said. "It's not just something you can spend 15 minutes a semester talking about."
Penn Nursing is also planning the Summit on American Indian Healthcare, which will take place next June.
