Perspectives of Providing Culturally Competent Care in the NICU Leonora Hendson, Misty D

JOGNN R ESEARCH Health Care Providers’ Perspectives of Providing Culturally Competent Care in the NICU Leonora Hendson, Misty D. Reis, and David B. Nicholas Correspondence ABSTRACT Leonora Hendson, MBBCh, MSc, FRCP(C), Objective: To examine the experiences and perceptions of health care providers caring for new immigrant families in South Health Campus, the neonatal intensive care unit (NICU). 4448 Front Street SE, Design: Qualitative design using grounded theory methodology. Calgary, Alberta, Canada T3M 1M4 Leonora. Setting: Two tertiary-level NICUs of two large metropolitan hospitals in western Canada. Hendson@ Participants: Fifty eight (58) health care providers from multiple disciplines. albertahealthservices.ca Methods: Health care providers were interviewed during seven focus groups. We recorded and transcribed focus group Keywords data. We analyzed transcripts via line-by-line coding, categorization of codes, concept saturation, and theme generation culture/cultural competence assisted through NVIVO software. grounded theory health care professionals Results: Health care providers identified the nuanced construct of fragile interactions that is embedded within care of immigrants/migrants the new immigrant family in the NICU. During crisis, decision making, differing norms and beliefs, and language and NICU communication are barriers that affected the fragile nature of interactions. During transition home, fragile interactions relationships patient-provider. were affected by unintentional stereotyping, limited time for intangible activities, and lack of intuitive perceptions of the needs of new immigrant families. Health care providers employed caring and culturally competent strategies to overcome the fragile nature of interactions. Conclusion: Within the premise of providing family-centered care is the concept of honoring cultural, ethnic, and socioeconomic diversity; it is imperative that culturally competent care be considered and implemented as a separate stand-alone aspect when caring for new immigrant families. JOGNN, 44, 17-27; 2015. DOI: 10.1111/1552-6909.12524 Accepted October 2014 Leonora Hendson, MBBCh, MSc, FRCP(C), is aring for infants and their families in the NICU Culture is defined as a set of values, beliefs, and a neonatologist and clinical C presents a myriad of complexities for health norms that direct the thinking and decision making associate professor, Section care providers. Integrated within care delivery, of a group (Leininger & McFarland, 2006). Cul- of Neonatology, the philosophy of family-centered care specifically tural competence in health care is the ability of Department of Pediatrics, University of Calgary, honors ethnic, cultural, and socioeconomic diver- systems to provide care to patients with diverse Calgary, Alberta, Canada. sity (Eichner, Johnson, & Committee on Hospital values, beliefs, and behaviors and to tailor deliv- Care & Institute For Patient & Family-Centered ery to meet patients’ social, cultural, and linguistic Care, 2012). In the past several decades, Canada needs (Betancourt, Green, & Carillo, 2002). Mod- (Continued) has experienced an increase in the number of new els for culturally competent care are available to immigrants (Statistics Canada, 2012, 2013), which assist health care providers in providing effective emphasizes the importance of providing cultur- care (Betancourt et al., 2002; Campinha-Bacote, ally competent care in health care facilities. The 2002; Leininger & McFarland, 2002; Purnell, 2002; NICU, with its unique patient population, acuity, Schim, Doorenbos, Benkert, & Miller, 2007). Al- and circumstances (birth, death, parental roles), though these conceptual models provide a basis is an area where further understanding of family- for our understanding, they may not address the centered, culturally competent care is required for practical barriers health care providers face dur- optimal care delivery. ing direct bedside care for diverse populations. The authors report no con- flict of interest or relevant financial relationships. http://jognn.awhonn.org C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 17 R ESEARCH Health Care Providers’ Perspectives of Providing Culturally Competent Care in the NICU and community levels and strategies that health Limited research exists on the perspectives of health care care providers used to mitigate these influences. providers on the provision of culturally competent care in the NICU. We further examined the experiences of health care providers and their perceptions of providing culturally competent care to new immigrant families in the NICU at the individual level. Our specific Background research question was “What are the experiences Limited research exists on care experiences in of health care providers in providing care to re- the NICU from a culturally competent perspective, cently immigrated families (within five years of im- and researchers have typically focused on the ex- migration) whose children were admitted to the perience of the new immigrant family. Wiebe and NICU.” Young (2011) interviewed 21 families from a broad spectrum of cultural backgrounds whose infants had been hospitalized in NICUs. A key finding Methods of this study was the importance of the relation- Because little is known about the phenomena of ship between the parent and health care provider interest, we implemented an exploratory research in developing confidence and trust in the care design drawing on a grounded theory approach to provided. The authors described respectful and generate theory (Corbin & Strauss, 2008; Hutchin- appropriate communication, culturally responsive son, 2001). This allowed inquiry of the perspec- and accessible social and spiritual supports, and tives of participants with respect to relational a welcoming and flexible organizational environ- interactions between health care providers and ment as important components of a relational, cul- new immigrant families (Sbaraini, Carter, Evans, turally congruent paradigm. & Blinkhorn, 2011; Streubert & Carpenter, 2011). We intentionally selected mixed disciplinary fo- Hurst (2004) focused on Mexican American moth- cus groups as a data collection method to ers’ experiences in the NICU and highlighted offer conversational depth through constructs ini- the importance of adequate resources to ensure tiated and explained by interdisciplinary staff family-centered care, including transportation and (Nicholas et al., 2014). This approach offered an translation services. Cleveland and Horner (2012) efficient means for thorough, reflective, and team- illustrated the importance of cultural values such based exploration of professional experience. The as sympatia (kindness), personalismo (formal University Research Ethics Board approved the friendliness), respeto (respect), familismo (devo- study. All participants provided written informed tion to extended family), and fatalismo (fate) when consent prior to focus group commencement. delivering care to Mexican American mothers. Among first-generation Chinese American par- Participants ents, Lee and Weiss (2009) identified perceived We employed purposive sampling to obtain a rich incompetence, self-blame, blame from others, fil- description of the phenomenon being explored ial piety, lack of support, communication issues, from an interdisciplinary viewpoint (Patton, 1990). and cultural differences as stressors for families. We recruited participants by advertising broadly The use of parent buddy matching has been found in the NICUs (e-mail and posters) and by invita- to be effective in alleviating stress for non-English tions (e-mail) to specific groups (social workers, speaking mothers in the NICU (Ardal, Sulman, physicians, and administrative leads) to ensure Misty D. Reis, MN, BScN, & Fuller-Thomson, 2011). Systemic supports such representation from all disciplines. We conducted NP, is a pediatric nurse as a multicultural committees, needs assess- the focus groups in two tertiary-level NICUs of two practitioner in the Neonatal ments, and staff access to cultural interpreters large metropolitan hospitals in western Canada. and Infant Follow-up have been identified as strategies to facilitate cul- We arranged the dates and times of focus groups Clinic, Northern Alberta Neonatal Program, tural competence (Bracht, Kandankery, Nodwell, to accommodate different shifts (day, evening, Edmonton, Alberta, & Stade, 2002). and night) to mitigate any barriers to participation. Canada. All health care providers were invited to participate David B. Nicholas, PhD, Nicholas, Hendson, and Reis (2014) examined regardless of years of experience. RSW, is an associate the experience of delivering care in the NICU to professor at the University new immigrant families from the perspective of Fifty-eight health care providers participated in of Calgary, Faculty of the health care provider. They identified aspects seven focus groups with three to 15 partici- Social Work, Central and Northern Alberta Region, of connection and disconnection that health care pants per group (Table 1). Of note, 62% of the Alberta, Canada. providers experience on individual, institutional, participants were nurses (registered nurses and 18 JOGNN, 44, 17-27; 2015. DOI: 10.1111/1552-6909.12524 http://jognn.awhonn.org Hendson, L., Reis, M. D., and Nicholas, D. B. R ESEARCH Table 1: Demographic Characteristics of 58 Table 2: Semistructured Interview Guide for Health Care Provider Participants Focus Groups Characteristic n % Initial study questions Prompt

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