Currently researching end-of-life decision-making among Haitians and Haitian Americans in a South Florida faith-based community.  I am neither. My inspiration derives from clinical practice as an oncology nurse in a local community hospital where I observed a disconnect between these patients, including their families, and the various healthcare providers.  Some of my nursing colleagues, among the most caring people I've ever known, found it difficult to care for these patients.  The barriers appear to include language and a profound unfamiliarity with Western medicine..  

Ann Boykin's & Savina Schoenofer's theory of nursing as caring requires a partnership between nurses and their patients. The most important step to take to cross the cultural boundaries requires cultural humility to find out what is most important to the patient and their families, who are also our patients.  Here in the cultural soup of South Florida, so-called "cultural competence" is an overwhelming target.  Instead, we nurses must reflect on our own values and experiences, then leave them at the door and LISTEN to what is most important to our patients.

We share a similar view of nursing as a caring and compassionate relationship with patients and families. I am currently teaching a Family Nursing course while here in Oxford, UK.  Just today we discussed the need for nurses to reflect on their own values as they navigate complex and challenging care situations.  We talked about suspending judgment.  We stressed the need for reflection, presence, and listening. I will research Ann Boykin's work and the work of Savina Schoenofer. Thank you for your response, Charlotte. I will share your message with my nursing students. Joan Miller

Hi - yes, I would agree that the concept of self reflection is central to understanding cultural issues and differences.  In NZ within nursing we follow a model of cultural safety, which position the recipient of care (patient, family, community) at the centre of the relationship, rather than the nurse.  Many models of cultural care seem to focus on the nurse learning about 'others' and often in relation to a list of behaviours that are deemed 'acceptable' within a particular culture.  This inevitably places the focus on the nurse; within cultural safety the emphasis is on seeking individualised information from each patient, rather than generalising cultures and assuming that all members of a cultural group will value the same behaviours/interactions.  Central to this model is the notion that we can only understand others if we also acknowledge what we bring to the interaction - ie our values, beliefs and assumptions.  This is achieved through self reflection.  At its most basic, cultural safety suggests that by applying the 3 R's, (respect, rights, recognition) we are more likely to behave in a culturally safe manner; conversely by avoiding the 3 Ds (disempower, demean and diminish) we can hopefully avoid  being culturally unsafe.  From the practitioners position, the 3 S's (self reflection, situational assessment and solution focussed) can then guide the nursing practice.  From this model, the definition of 'good work' in nursing would need to be defined by the recipient of care, and would be variable across situations.  As you can see, the theoretical component of this approach are based in critical social theory, and  there is a clear recognition of power differentials and that the nurse (as clinical expert) holds power within the relationship.  The originator of the model is Irihapiti Ramsden, and there is a considerable body of knowledge in relation to this (happy to provide references should you wish to follow this up).

Sandra - Many thanks for the references - I will look for them.  I am intrigued by the notion of cultural safety and certainly applaud placing the patients at the centre of our understanding . A new group, Patient-centred outcome research institute, PCORI,  might interest you: http://www.pcori.org/ 

For the reflective practice, I have a well-thumbed copy of Christopher John's Becoming a reflective practitioner.

Sandra, I would like the references as well.  I appreciate the link to the patient centered outcome research institute. I am reminded of a scholar, Donald Schon, who published a book, The Reflective Practitioner. You may enjoy just learning about his thoughts on reflection in practice. Also, Dr. Howard Gardner from Harvard University, known for his theory of multiple intelligences, comments on the concept of Good Work (and related research). I have been working with him and welcome ideas about future research around the topic of good work. He talks about the three Es: Excellence, Ethics, and Engagement.  To perform good work the values of the person (in this case, the nurse), the institution (where one works), the profession (those who make decisions about the profession), and society (those who are the recipients of care) must be aligned (three Es and one A).  Gardner goes on to say that there is one more letter: W (We). We work in relationship to one another, colleagues, patients, families, the community. I wonder if a research endeavor is possible. I will attach documents in the next post.

Thank you, Judie,

The Good Work Project seeks opportunities for collaborative research.  if you, or any of the respondents, would like to learn about the research protocol to learn about how good work is perceived in different cultures, please let me know. I can facilitate the process.  In the Netherlands,  professionals (but not nursing) formulated workshops to reflect on the meaning of good work and at the end learned that time to reflect on what we do (as nurses) is so important. Yet, time for reflection is not always supported or valued in nursing.  We are so task oriented.  We may be developing a cohort of researchers interested in a project.  I am happy to work with Harvard to make this happen.  We need to overcome the issues related to image, time, value, and opportunities for reflection. I treasure the transcripts of nurses interviewed from different cultures.  Their voices need to be heard. 

How can I help?  By the way, Judie, I have extended family members from India (Kerala).  Nursing has been part of this extended family.

Joan Miller

Judie, I can share with you the interview protocol I used in my initial research to learn about good work in nursing and the related opportunities and obstacles.  The protocol is attached. Feel free t share with colleagues.  We can continue the dialogue.  Thank you for your interest. 

Respectfully,

Joan

Good morning Joan, I study partners from Turkey to get involved and would love to work with you ...

best regards

Also Is it ethical to make changes in the culture of a society? Which cultures (food, clothing, etc.) to make the change is more ethical? Lately you've been reading on this subject I would like to get their opinions. best regards

Thank you for the interesting discussion. I want to share with you the website of a colleague in the Netherlands, Dr. Myra van Zwieten. Myra and her husband have created a website, The Good Worker.: http://www.moralmap.com

The purpose of the website and  other programs offered through The Good Worker Academy are to:

- Facilitate (health care) professionals in articulating their personal drive of being a good worker and to integrate this in their daily work

- Facilitate (health care) professionals to cope with everyday ethics in a constructive approach to integrate professional and personal growth

The website includes exercises to help sort through situations and values and become mindful professionals..

I hope you find their work helpful and pracical in exploring the concept of good work in nursing.

Excellent website.  Too bad it limits references to doctors.  This limits its utility for my nursing students.

Thank you all for your responses and links.  I sense the need to add strength to the message of 'good work in nursing' across cultures.  If any would like to have a conversation about forming a multi-site project using the Good Work Nursing Protocol (attached and subject to revision), I am happy to facilitate. In the responses above, we have the beginning of a shared dialogue. I look forward to continued conversation. For colleagues in the Netherlands, have you heard of Goed Werk Hub? Another resource!

Hi Joan, in my view answering to your question 'Cultural diversity is the key word for good works. For a nurse to be in good works across culture it is important to understand that nurse-patient encounters include the interaction of three cultural systems: the culture of the nurse, the culture of the client and the culture of the setting. Recognizing cultural diversity, integrating cultural knowledge, and acting, when possible, in a culturally appropriate manner enables nurses to be more effective in initiating nursing assessments and serving as client advocates'

I come from a rather homogenous part of rural Pennsylvania US. However, the cultural landscape is changing rapidly. Thank you for your reflection on the interaction of the three cultural systems. I look forward to gathering a few investigators to explore the ways differing cultures impact the good work they want to do. The interview protocol is attached for your review. Professional organizations, such as Sigma Theta Tau International Honor Society, are interested in hearing the voices of nurses for the purposes of appreciation and comparison.

For any nurse to consider her work  as 'good work', considerations would need to be mad on the recipient of the 'work', how satisfied that recipient is, the environment of the work, and of course how adaptable that nurse is to the recipient''s culture - the culture here is multi faceted to include language, attitude, acceptance, provision of needed care irrespective of age, sex, social status, to mention a few. Joan, looking through your interview guide you have provided for responsibilities, and even obstacles and pressures and even extending to preparation for future nurses - good. Are there aspects of these questions that provide for the recipients of care to make their inputs? I feel they have more to say than the nurse

Hi Joan.

The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (an Australian organisation representing Aboriginal and Torres Strait Islander Nurses and Midwives at a national level) we believe that "good work", should, inter alia, be culturally safe.

Cultural safety is viewed by CATSINaM as the final step on a continuum of nursing and/or midwifery care that includes cultural awareness, cultural sensitivity, cultural knowledge, cultural respect and cultural competence.

A more detailed explanation on this can be found at: http://catsinam.org.au/?page_id=495.

http://catsinam.org.au/?page_id=495

Thank you,  Ted.

I hope to gather educators interested  in studying the concept of good work in nursing across cultures. Please let me know if you are interested. The concept of 'culturally safe' care needs to be explored.  Please let me know if you are interested.

Thank you,

Joan Miller

Hi Joan,

Absolutely – count me in! The concept isn't new by any stretch of imagination, but any collaboration that adds to our understanding of culturally safe practices is a lead item on our agenda.

My (other) email is: [email protected].

Ted Murphy

An interesting discussion and this highlights the intrinsic difficulty in reaching a consensus of 'good work' when entertaining cultural priorities. The promotion or obstruction of nursing excellence will of course be guided by resources, education, immediate and future health demands and professional representation. Within the UK, following the Francis inquiry into Mid Staffs hospital, there were many recommendations and few made accountable. Of these recommendations the resource aspects were largely disregarded and a revisit to the 6 C's was advocated, Communication, Commitment, Courage, Compassion, Care and Competence. www.changemodel.nhs.uk/dl/cv_content/30520

These 'attributes', that should already be present, are heralded as fundamental and care is delivered to a culturally diverse society. This snappy use of acronyms obfuscates the very poor nursing care delivered or omitted. In taking a global inclusive view such as nursing in some parts of Africa here is a more realistic and applied additional acronym to deliver 'good work'.... the 3 R's. Resilience, Resourcefulness and Respect (for life). The different cultural priorities.

Regards,

Jason  

Hi John;

My country is very rich in terms of culture. We care for them during the regional characteristics and cultural structures are trying to keep in mind. However, some cultural characteristics can be very useful for health and care. I think these features should be protected, as well as the identity of society is cultural characteristics. This should be supported without losing identity. cultural studies should be made to do so, and those useful while staying in that culture maybe another culture should be only be utilized as an alternative. Is it ethical to change the culture so I asked. Been in a large-scale work, so we want to take the saddle. Dr. Nermin Gürhan

HI Joan, the dialogue is developing nicely here - some very interesting posts.  Apologies, as I had intended to respond sooner with some references around cultural safety but have them now, and hope you find them of interest.  I look forward to see how the Good Work Project develops.

References:

Papps & Ramsden (1996) Cultural Safety in Nursing: The New Zealand Experience. International Journal of Quality in Health Care 8. 5. pp. 491-497, http://intqhc.oxfordjournals.org/content/8/5/491.full.pdf+html 

Woods, Martin (2010) Cultural safety and the socioethical nurse Nurs Ethics November 2010 vol. 17 no. 6 715-725  doi: 10.1177/0969733010379296 

Richardson, S.  (2004).  Aoteaoroa/New Zealand nursing: from eugenics to cultural safety ...Nursing Inquiry  Volume 11, Issue 1, pages 35–42 DOI: 10.1111/j.1440-1800.2004.00195.x

Ramsden, I.M.   Cultural safety and nursing education in Aotearoa and Te Waipounamu: A thesis submitted to the Victoria University of Wellington in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing.

Dr. Joan Miller

There must be dialogue and some of the international standards have been developed and are being developed. However, the existing culture of every nation is its identity within the same identity or the world is not ethical to make a single identity. It is important to be well cared for in the nation's culture. Even the standards developed by the culture, where individuals will be detected. As broad as possible a study that culture and cultural features should be identified correctly by those who want to be continued to be used or similar cultures. But I think impositions failure causes. Dünyaya learn the cultural wealth are very important nutrients for nursing and care to people in other cultures in their own country in order to give gerekmektedr to say I did not know. Such a discussion has been initiated thank you so much I use you for my own.

Hi Joan,

When you start work, I'm going to create intercultural and we want to be in working with the team. At the same time also as Turkey Psychiatric Nursing Association would like to take part in this study [email protected] I'm in my e-mail address

Thank you, Nermin,

Does the attached interview protocol used in US, UK, and Iran seem applicable for use across cultures?

It is the protocol the Good Work Project has used across cultures in different disciplines.  I hope to crate a group of invesitgaors interested in interviewing nurses at different levels of professional development using a consistent interview protocol.

We can then analyze results and look for cultural similarities and differences.

All respondents to date are invited to participate.

Please see attached interview protocol.

[email protected]

Joan, thanks. I might give it a try

After reviewing responses, it may be time to gather investigators across cultures willing to address 'good work' in nursing, work that is at once excellent, performed to the highest standard of one's profession/nursing; ethical, performed in the interest of another; and engaging, found to be personally meaningful. Voices from nurses from different cultures may shed light on the opportunities (supports) and obstacles (difficulties) nurses experience in their unique settings. I have attached the Harvard University Interview Protocol.  I seek three or four partners in an investigation that may lead to presentation at an international nursing conference. I am able to facilitate Ethics Committee application. Each partner would have to review his or her university requirements.  It may be possible to simply document  multicultural exchange.  I welcome suggestions.

Hi Joan, I would be interesting in collaborating with this - what is your proposed methodology and study design? in particular, how many interviews would be looking for from partner sites? are you seeking any particular type of sample population?

Hello Sandra,

I will upload tomorrow the article that describes the methodology used for the US study.

I believe the voices of nurses from differnet cultures will inform 

Hi Joan and all other respondents,

As a student to gain my Bachelor Degree in Nursing (Registered Nurse) I participated in an international research project and subsequent study tour to Thailand conducted by the University of Newcastle, Australia, and think you might find the outcome of this nursing research project interesting. It was published in the peer approved journal “Handover”, and since 2014 you can find it in Online Wiley: “Awakening to the other”, DOI: 10.1111/nhs.12139

Encouraged by this experience, and as I studied and practiced aged care nursing in Australia, I also took a voluntary practicum/clinical experience time in an outback Area Hospital with a large proportion of Australian Indigenous people and patients, and a large international tourist patient ratio. Cross Cultural Nursing is a mandatory subject here due to Australia’s multi-cultural society. Naturally there are many books and journal articles about the subject. A worthwhile mentioning to this subject are the annual worldwide International Nursing Conferences dealing with various main topics but where intercultural nursing collaboration has been a subtopic for some time now. The International Council of Nurses might also be interesting to explore for Ethic Conferences addressing Cross Cultural Nursing. The International dialogue is happening but it seems to be on too many venues as to be effective immediately. However, in the overall a step forward in the right direction is made and your inquiry is prove to that. I therefore thank you for your initiative and hope I could help a little to further your inquiry.

Thank you for your thoughtful response, Edith. Sigma Theta Tau International Honor Society of Nursing partners with ICN.  I will consult the international team.  I wonder how we can bring the dialogue to the point where it is an effective way to empower nurses in their different settings.  The Good Work Project has developed a Good Work Toolkit.  We may have to gather colleagues to develop a Cross Cultural Good Work Toolkit. I wish you well in your educational journey and I am interested in how you feel you may be able to help to further the inquiry.  Take a look at the Interview Protocol. Does it have relevance in your setting?  Feel free to share with faculty and mentors.

Hello to All Respondents:

At this time, it may be opportunistic to design a study. One researcher from Turkey has expressed interest in interviewing nurses in the particular professional association involved using the protocol I attached in previous answers. I will attach the protocol again.  This protocol has been used internationally in several disciplines.  Dr. Howard Gardner from Harvard University and his team designed the protocol. Studies are qualitative in nature.  I have recorded my interview responses.  Focus groups may be used as well, with recording and note-taking.The main focus would be the values/beliefs that led to one's entry into nursing, the supports one receives to achieve his or her goals and the obstacles one may encounter in today's time/culture.

I welcome your interest and/or questions.

If we have input from at least three cultures, we will add to the literature of nursing.

Each potential investigator must consider his/her relative Ethics Committee requirements.

I can help with previous experience.

I hope to hear from you!

Dr. Joan Miller

Thank you for all your responses and, please forgive the delay in the update for the study.

We are currently looking at research in different cultures to determine the perception of good work in nursing, the factors that lead to nurse turnover, and ways to retain quality nurses in their respective practices.

If you have any research you would like to cite, I would appreciate your responses.

Please confirm your interest in participating in this study.

Thank you,

Joan Miller