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Perceptions of first line nurse managers managing in a culturally diverse environment Lim, Virginia 1995

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P E R C E P T I O N S O F FIRST LINE N U R S E M A N A G E R S MANAGING IN A C U L T U R A L L Y DIVERSE ENVIRONMENT by VIRGINIA LIM B.S.N., McMaster University, 1988 A THESIS SUBMITTED IN PARTIAL FULFILLMENT O F T H E REQUIREMENTS FOR THE D E G R E E OF MASTER OF SCIENCE IN NURSING in T H E FACULTY OF GRADUATE STUDIES The School of Nursing We accept this thesis as conforming to the required standard T H E UNIVERSITY OF BRITISH COLUMBIA August, 1995 © Virginia Lim, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Date DE-6 (2/88) Abstract Canada is a culturally diverse society with immigration trends that continue to accentuate the cultural diversity. In health care, staff from diverse cultural backgrounds provide care for equally diverse patient populations. Transcultural care poses several challenges for nurses. Unfortunately, there is growing evidence that the needs of culturally diverse clients are not always met. This has implications for first line nurse managers who are responsible for ensuring a high quality of patient care and a harmonious work environment. There are few studies that examine first line nurse managers managing in a climate of cultural diversity of staff members and patients. The purpose of this study was to examine the perceptions of first line nurse managers managing in a culturally diverse environment. A descriptive design was used given the limited research on this topic. A purposive sample was selected from each of three hospitals in the Lower Mainland of British Columbia for the purpose of focus groups. Each of these hospitals had staff members from diverse cultural backgrounds serving diverse patient populations. Between six and eight first line nurse managers participated in each of three focus groups. Data were examined using latent content analysis, with segments of data coded into categories from which themes emerged. ii The findings of the study revealed that managing in a culturally diverse environment is very complex and challenging for first line nurse managers. The challenges of difficulties in communication, differing expectations and behavioural norms, and conflict resolution were areas of major concern for first line nurse managers. Both facilitators and barriers to managing in a culturally diverse environment became apparent. Facilitators included the hospital philosophy and policies, resources and services, matching cultural profiles, and celebrating cultural differences. The absence of any of these facilitators can create a barrier to valuing cultural diversity. Additional barriers included discrimination, lack of knowledge about other cultures, and decreasing financial resources. Finally, it appears that culturally diverse patients may receive a lower standard of care in some instances due to the inability of staff to meet their unique needs. The quality of transcultural care is dependent to some extent on the presence or absence of facilitators and barriers. Implications for nursing practice, research, education, and hospital administration were identified from the findings. iii Table of Contents Page Abstract ii Table of Contents iv List of Tables vi Acknowledgements vii Chapter 1: Introduction 1 Background to the Problem 1 Purpose of the Study 4 Concept of Culture 4 Definition of Terms 5 Significance of the Study 6 Chapter 2: Literature Review 8 Overview 8 Roles of First Line Nurse Managers 8 Cultural Diversity 12 Nursing 12 Business 19 Summary of Literature Review 21 Chapter 3: Method 22 Research Design 22 Sample and Setting 23 Data Collection Procedures 24 Focus Groups 24 Interview Guide 30 Data Analysis 31 Rigor 34 Ethical Considerations 35 Limitations 36 iv Chapter 4: Presentation and Discussion of Findings 38 Sample Characteristics 38 Themes 40 Challenges 40 Difficulties in Communication 41 Differing Expectations and Behavioural Norms 45 Conflict Resolution 53 Summary 55 Facilitators 55 Hospital Philosophy and Policies 56 Resources and Services 59 Matching Cultural Profiles 63 Celebrating Cultural Differences 65 Summary 66 Barriers 67 Discrimination 67 Lack of Knowledge about Other Cultures 72 Decreasing Financial Resources 76 Summary 78 Ethical Issues 78 Summary. 82 Chapter 5: Summary, Conclusions, and Implications 83 Summary 83 Conclusions 86 Implications 86 Nursing Practice 87 Nursing Education 88 Nursing Research 91 Health Care Administration . : 92 References 96 Appendix A: Survey Questions 105 Appendix B: Interview Guide 106 Appendix C: Demographic Sheet 109 Appendix D: Consent Form 110 v List of Tables Page Table 1: Description of Sample 39 vi Acknowledgements The writing of this thesis has been a long journey. There are several people I would like to acknowledge for their support along this journey. Throughout, my family and friends have been there to inspire and encourage me. I thank them for their patience and believing in me. I would like to thank the members of my thesis committee, Dr. Sonia Acorn, Marilyn Crawford, and Dr. Marilyn D. Willman, for their time, commitment, and encouragement throughout the thesis process. A special thanks to Dr. Sonia Acorn for her extra effort in this endeavour. Special thanks also to my husband, Terry, without whose love, support, and encouragement this thesis would never have been completed. vii Chapter 1: Introduction 1 Canadians are a heterogeneous people. Fundamental differences are reflected in health care where culturally diverse staff care for an equally diverse patient population (Burner, Cunningham, & Hattar, 1990). Hence, first line nurse managers (FLNMs) are challenged to manage effectively in a culturally diverse environment. However, relatively few resources are available to assist them to meet this challenge (Burner, et al.; Kerfoot,1990; Poteet, 1986). Background to the Problem Canada is a multicultural society with 9.6 % of an estimated 2.5 million people representing visible ethnic minorities (Shareski, 1992). Demographic population changes through immigration are accentuating its cultural diversity (Dorais, 1994). It is estimated that by the year 2001, the ethnic population will represent 17.7 % of the projected population (Shareski). British Columbia is a popular destination for immigrants to Canada, surpassed only by Ontario (BC STATS, 1994). Moreover, the majority of British Columbia immigrants come from Asia (BC STATS). This influx of immigrants is reflected in the nursing workforce. The Registered Nurses Association of British Columbia (RNABC) membership statistics for 1993 indicated that 18.2% of new registrants received their nursing education outside of Canada (RNABC, 1993). These demographic changes lead to 2 new demands and challenges for FLNMs in health care settings in British Columbia. The government of Canada enacted the Charter of Human Rights and Freedoms (1984), the Multiculturalism Act (1987), and the Canada Health Act (1984). These documents specify that the cultural origins of Canadians are to be respected and taken into consideration by health care providers (Toumishey, 1991). Further, Canadians have the right to culturally sensitive and appropriate health care. However, there are no guarantees that such care will be provided (Toumishey). Government agencies and the public sector treat individuals equally based on universal needs such as income, health care, and education (Taylor, 1992). However, Taylor notes that the individual cultural identities of individuals are still not recognized. FLNMs are not unique in their concerns of managing in a culturally diverse environment. Many managers are expected to accommodate individual differences while simultaneously building a cohesive work unit. Thus, managing diversity so that the potential productivity of all employees is maximized is important (Ellis & Sonnenfeld, 1994; Hubbard, 1993). Why manage cultural diversity? The differences in values, beliefs, and cultural norms of employees have an impact on their job satisfaction and performance (Rubaii-Barrett & Beck, 1993). Furthermore, costs associated with an inability to manage a culturally diverse staff are 3 reflected in a high turnover rate (Fitzsimmons & Eyring, 1993). Control of these costs is paramount in this climate of fiscal restraint. In addition, conflict, prejudice, and miscommunication are workplace problems that inhibit team building and productivity (Ellis & Sonnenfeld, 1994; Kirchmeyer & McLellan, 1991; Lowenstein & Glanville, 1991). Health care settings are not immune to these problems. The advantages of a culturally diverse environment include enhanced creativity, problem-solving, and decision-making by nurses and other health care professionals (Ellis & Sonnenfeld, 1994; Kirchmeyer & McLellan, 1991). Also, matching the cultural profiles of nurses and patients facilitates more comprehensive health care (Haratani, 1993; Spicer, Ripple, Louie, Baj, & Keating, 1994). FLNMs are in a pivotal position as they have daily contact with nursing staff, patients, and other health care professionals within the hospital. Cultural differences exist among these interacting individuals. In addition, the nursing and organizational cultures contribute to the complexity of the work environment (Scott III, 1993). Thus, the interplay of cultural norms exemplifies the cultural diversity of the overall environment within which FLNMs function. FLNMs need skills, resources, and education in order to manage effectively in a culturally diverse environment. However, scant literature and few resources are presently available. Industry has taken the initiative in acknowledging cultural diversity issues. Now, health care 4 managers must increase their attention to these issues (Kerfoot, 1990). Research is necessary to identify approaches to effective management in a culturally diverse environment. Furthermore, practices and programs which address cultural diversity need to be developed and evaluated (Kirchmeyer & McLellan, 1991). Purpose of the Study The purpose of this study was to describe the perceptions of first line nurse managers of managing in a culturally diverse environment. Concept of Culture Three definitions of culture were examined in order to establish an operational definition of culture for the purpose of this study. Webster's Dictionary (Webber, 1984) defined culture as "the beliefs, customs, arts, and institutions of a society at a given time" (p. 171). Leininger (1989a) defined culture as "shared values, beliefs, norms, and lifeway practices of a particular group that are learned, used, and transmitted, and which guides individual and group thinking, decisions, and actions in patterned ways" (p. 26). Tripp-Reimer (1984) defined culture as "learned patterns of values, beliefs, customs, and behaviors that are shared by a group of interacting individuals" (p. 226). Culture implies more than ethnicity. It takes into account ways in which people are similar or different; these include race, religion, national origin, and language (Lappetito, 1994). These fundamental similarities or differences are expressed through the attitudes and 5 behaviours of individuals. Culture is very complex and shapes our perceptions of the world around us (Lea, 1994). Cultural origins relate to all aspects of life. Beliefs and practices surrounding health, illness, death and dying, and care-giving are no exception (Shareski, 1992). It is noteworthy that cultural differences exist not only between cultural groups but within cultural groups (Lea). Social differences such as socioeconomic status, gender, and age may outweigh shared cultural origins (Lea; Shareski). Aspects of culture are passed from generation to generation and are constantly evolving (Lea). Given the above, the following definition of culture was adapted for this study. Culture represents a system of values, beliefs, and customs shared by a group of individuals on the basis of race, religion, national origin, and language. Definition of Terms For the purposes of this study, key terms were defined in the following way: Culturally diverse clients/staff - clients or staff who differ from the Canadian majority (Caucasian) in terms of race, religion, national origin, and/or language. Culturally diverse environment - managers, nursing staff, clients and family members, and other health care professionals having a variety of cultural backgrounds interacting with one another within a given environment. 6 First line nurse manager - a registered nurse who has 24-hour responsibility for one or more units within a health care organization (Acorn & Crawford, 1993). Transcultural care - nursing care which takes into account the values, beliefs, customs, and behaviours of the client to provide holistic nursing care (Eliason, 1993). Significance of the Study This descriptive study was intended to increase knowledge about first line nurse managers (FLNMs) managing in a culturally diverse environment. The study was indicated for four reasons. First, cultural diversity is increasing with changing demographics affecting the population and the work force. Second, unmanaged diversity results in a higher employee turnover rate (Fitzsimmons & Eyring, 1993) which is costly, especially given the present climate of fiscal restraint. Third, identification of skills, resources, and education to manage diversity effectively is needed. Findings could prove useful in planning educational programs for FLNMs and nursing staff to assist them to understand the many facets of practice in a culturally diverse environment. Finally, this study expands the limited research examining perceptions of first line nurse managers (FLNMs) managing in a culturally diverse environment. Research findings may provide information to enhance management practices and programs targeting cultural diversity. Capitalizing on cultural diversity may enhance team building efforts, and increase job satisfaction and performance of employees. In addition, the study may stimulate future research questions relevant to managing in a culturally diverse environment. Chapter 2: Literature Review 8 Overview A review of the literature is presented to establish a foundation for the study. The roles of first line nurse managers (FLNMs) are explored in order to gain perspective on changes in the last decade and managing in a culturally diverse environment. The cultural diversity of the Canadian population presents nurses with numerous challenges as nurses continually encounter and provide care for clients with cultural origins different than their own (Lea, 1994; Leininger, 1989b; Shareski, 1992). Transcultural nursing literature and research has begun to explore these challenges. This is followed by a review of research and non-research literature from the domains of nursing and business on managing cultural diversity. Roles of First Line Nurse Managers In recent years, the roles of the FLNM have changed dramatically. Decentralization of decision-making and flattening of organizational structures have initiated role changes for FLNMs from a clinical focus to a management focus (O'Neil & Gajdostik, 1989). Traditionally, the FLNM was viewed as a clinical expert (Fullerton, 1993). Today, the skills required to be a competent FLNM are broad and far-reaching with the emergence of managerial responsibilities. FLNMs are responsible for 9 maintaining high standards of patient care, budgetary control, and a healthy work environment (Duffield, 1992). The increase in cultural diversity of both patient populations and health care workers compounds these responsibilities. Duffield (1992) noted that "changing demographic profiles and value systems of both nurses and their patients are affecting role interpretations and modifying patterns of response" (p. 49). FLNMs' positions and their competency requirements are further complicated by organizational, nursing, and patient variables (Duffield). O'Neil and Gajdostik (1989) conducted a study to compare head nurses' and nursing supervisors' perceptions of tasks essential to the managerial role of head nurses. The convenience sample was comprised of 48 head nurses and 20 nursing supervisors employed at six hospitals in Wisconsin. Participants were asked to indicate which of the 71 tasks, appearing on a revised version of the Head Nurse Managerial Role Questionnaire (HNMRQ), were essential to the head nurse's managerial role. The HNMRQ grouped the 71 tasks under the following seven categories: planning, organizing, staffing, leading, communicating, decision-making, and controlling. A return rate of 85% was reported for the questionnaire which was analyzed using descriptive statistics. Findings highlighted a discrepancy between head nurses' and nursing supervisors' perceptions of the amount of time spent performing management responsibilities. Thirty-five percent of head nurses and 10 65% of nursing supervisors indicated that head nurses spent 80% or more of their time performing management responsibilities. A majority of both groups indicated that 93% of the 71 tasks were essential to the head nurses' managerial role. Duffield (1991) conducted a study to examine the role competencies expected of FLNMs in public and private hospitals of 100 beds or more in New South Wales. A list of 168 competencies was compiled by Duffield from the literature. Each managerial competency was further classified as either functional management, staff management, patient care management, or leadership. A panel of 16 expert registered nurses, managers, and educators were asked to rank the competencies on two occasions. The Delphi technique was used to indicate the panel's general agreement on the majority of competencies. Duffield's (1991) findings highlighted competencies illustrating four aspects of the FLNMs' role. One, FLNMs have a substantial role in structuring an effective, harmonious work environment. Indicators of FLNMs' success in achieving this environment pertain to the infrastructure which must be sufficient for accomplishing care of a suitable standard and allocate resources for effective staff functioning. Therefore, FLNMs must be competent at recruiting and scheduling staff and in resource allocation. Other competencies relating to shaping the work environment included managing conflicts and team building. Two, FLNMs must also be able to assist nursing staff in understanding the 11 scope of their role and in providing support, education, and feedback. FLNMs act as role models for staff. Three, FLNMs also need competencies that facilitate the clinical excellence of their staff. Finally, there are several general competencies which pertain to computerization, nursing practice, quality assurance, research process, power, and politics. Whether the position title is head nurse, supervisor, coordinator, or director, FLNMs need to obtain and maintain the skills essential to fulfill their complex roles. Baxter (1993) conducted an exploratory, descriptive study examining head nurses' perceptions of their roles. A convenience sample of 20 head nurses was selected from a large tertiary level hospital in the British Columbia Lower Mainland. Semi-structured interviews were based on Mintzberg's (1973) framework of ten managerial roles. Content analysis revealed that seven of ten managerial roles described by Mintzberg were familiar to the subjects. "These were the roles of monitor, disseminator, entrepreneur, disturbance handler, resource allocator, leader, and liaison" (Baxter, p. 11). Participants identified the roles of leader and resource allocator as being most important. Additional conclusions were drawn from the findings. One, "the emphasis on individual managerial roles varies with the situational requirements and skills of the manager" (Baxter, p. 12). Two, head nurses expressed a need for more knowledge and skill in the areas of conflict resolution and budget management. 12 Several roles were identified as common to all managers (Baxter, 1993). FLNMs focus their attention on personnel management, patient care management, and unit management. FLNMs are further removed from making patient care decisions but remain responsible for setting the standard and direction for nursing practice on their units. Some aspects of the FLNM's role warrant more emphasis in managing in a culturally diverse environment. Thus, it is vital, given the increasing cultural diversity of staff and patient populations, that FLNMs are conscious of transcultural nursing in order to set the standard and direction for nursing practice. Also, they are responsible for managing the staff delivering the care and for creating a harmonious work environment (Baxter). Cultural Diversity Nursing Anderson (1990) contends that nurses need to be more attentive to the cultural context of health care and provide nursing care in a way that is culturally acceptable to patients and their respective family members. Transcultural nursing care takes into account the values, beliefs, customs, and behaviours of the client to provide holistic nursing care (Eliason, 1993). Nurses' knowledge about their patients' cultural backgrounds is integral to the provision of individualized nursing care (Leininger, 1989b). Shareski (1992) contends that the key to transcultural care is an awareness of the nurse's own cultural background. Culture shapes an 13 individual's experiences and responses to nursing care (Anderson, 1990). Therefore, nurses need to recognize the cultural differences between themselves and their patients since their expectations and understanding of the situation may be totally different (Anderson, 1987; Shareski, 1992). Nurses can gain an understanding of patients' perspectives through a thorough assessment of their cultural beliefs, values, and customs (Anderson, 1987). It is the application of principles of transcultural care in nursing practice in any setting that facilitates individualized care (Lea, 1994). Jones and van Amelsvoort Jones (1986) examined communication patterns between the ethnic elderly and nurses in a long term care facility. They observed significant differences between the nurses' communication with ethnic patients and with Caucasian patients. Poor communication was observed between nurses and ethnic minority patients. Kubricht and Clark (1982) distributed a questionnaire to nurses employed at a Louisiana hospital to examine problems encountered by nurses when caring for foreign clients. Communication was cited as the most significant problem. Inadequate communication led to an inability to provide patient teaching, obtain a health history, and explain daily routines. Nurses also expressed feelings of frustration and inadequacy in the provision of nursing care for foreign clients. They viewed the availability of cultural information, such as religious practices and food 14 preferences, and resources, such as translators, as necessary yet often unavailable. Minimal information regarding the study design was provided in the research report. Murphy and Clark (1993) interviewed 18 nurses about their experiences of caring for ethnic minority clients. Again, communication was identified as a major problem, followed by a lack of knowledge about cultural differences. Participants expressed frustration at their inability to develop a nurse-client relationship with ethnic minority clients. In addition, participants stated that interpreter services and dietary facilities were inadequate to met the needs of ethnic minority clients. Reimer (1995) explored nurses' descriptions of the experience of caring for culturally diverse clients. Eight recent nurse graduates employed in hospitals in the Lower Mainland of British Columbia were interviewed twice. The process of constant comparative analysis revealed the complexity and challenge of caring for culturally diverse clients. Reimer conceptualized a continuum of commitment to cross-cultural nursing which ranged from resistance to competence to passionate or impassioned. Findings indicated that contextual factors such as the setting, the support of colleagues, the commitment of the institution, and the nurses' educational backgrounds influenced the quality of care provided to culturally diverse clients. There was a wide variation in the preparation the participants received in nursing school to care for culturally diverse clients. Findings indicated that education is 15 important for the provision of transcultural care. Reimer concluded that overt and covert racism is present in Canadian health care organizations and that nurses passively accepted the presence of racism at an individual and institutional level. The transcultural nursing care literature and research suggest that culturally diverse clients may receive a standard of nursing care that is lower than that received by Caucasian clients. Several explanations have been put forth. One explanation is a lack of knowledge about other cultures (Leininger, 1976). Another is the overgeneralization of reference material and/or past experience which can contribute to stereotyping (Lea, 1994). An ethnocentric viewpoint can affect the quality of care given to culturally diverse clients (Leininger). Also, the presence of racism and discrimination in health care organizations can have a detrimental affect on the quality of care (Farr, 1991; Reimer, 1995). Finally, the health care organization and the resources and services available influence the quality of care (Kubricht & Clark, 1982; Murphy & Clark, 1993; Reimer). This has implications for FLNMs who are responsible for maintaining high standards of patient care. Managing in a culturally diverse environment poses many challenges for FLNMs attempting to create a cohesive unit. Thiederman (1989) outlined four problem areas in a discussion of cultural health care which can interfere with effective management of foreign-born nurses. Language was identified as the most difficult aspect of managing 16 foreign-born nurses as "numerous problems can arise from incomplete or inaccurate communication" (p. 13). Second, many foreign-born nurses appeared reluctant to admit a lack of understanding of instructions. Third, differing concepts of family involvement in aspects of patient care, such as bathing and feeding the patient, may exist between foreign-born nurses and patients and their family members. Fourth, although foreign-born nurses have excellent technical skills, their proficiency in psychosocial skills may be considered inadequate. Although Thiederman's illustrations were confined to Asian culture in the United States, similar problem areas in managing a culturally diverse staff have been reported by other authors (Burner, et al., 1990; Lowenstein & Glanville, 1991; Martin, Wimberley, & O'Keefe, 1994). Poteet (1986) reported the results of a telephone survey among nursing administrators to identify challenges and problems in managing a culturally diverse staff. The main problems identified were language and communication problems and racism. Moreover, 90 % of the nursing administrators indicated a need for additional education to assist them to deal with these problems. Poteet's findings are consistent with those of other authors who reported racism as a major problem (Farr, 1991; Lowenstein & Glanville, 1991; Reimer, 1995). Problems of language and racism reappear throughout the literature addressing cultural diversity. Farr (1991) reported on a forum in which approximately 20 nurses participated to discuss racial discrimination. 17 Findings indicated that racism was evident in the Ontario health care system. One participant described "the hurt that comes with overhearing racial slurs, even unintended ones, from patients and other staff in the workplace: the frustration of promotions being denied for no apparent reason..." (Farr, p. 9). Another participant viewed racism as subtle but systematic. Moreover, Farr noted that most complaints about discrimination related to language proficiency. A more formal study is warranted based on Farr's findings. Lowenstein and Glanville (1991) examined staff perceptions of racial and class conflict in health care settings. Data from a pilot study involving six black and six white registered nurses were provided. However, the design and data collection method were not identified. Data indicated that 75% of the nurses reported the presence of racial prejudice and 92% reported the presence of cultural prejudice. Communication was also cited as a problem. Effectively resolving conflict is an important aspect of managing in a culturally diverse environment. Five areas were discussed by Jein and Harris (1989) in their exploration of this topic among American nurse managers. One, different ways of viewing conflict exist among different cultures. An assertive style predominates in Western culture whereas other cultures may seek cooperation or mediation. Two, decision-making is influenced by cultural norms which may consider either group interest or personal interest. Three, different cultures emphasize and pursue 18 different hierarchies of needs which can affect job performance. Four, the use of language, verbal and non-verbal, differs and misunderstanding and conflict can result. Five, different behavioural norms and role expectations exist among nurses from different cultures. Burner, Cunningham, and Hattar (1990) conducted a case study at the Robert F. Kennedy Medical Center to describe and resolve the problems generated by staff cultural diversity. Seventy percent of the nursing staff were either foreign-born and/or minority group members at this 274-bed acute care, community hospital near Los Angeles. Some of the problems included language, lack of awareness of cultural norms, differing cultural values surrounding delivery of health care, and the inexperience of nurse managers in dealing with a culturally diverse staff. Action was taken to address differing language and cultural differences since these two issues were identified as having the greatest impact on team building. Although Burner et al. detailed the actions taken, there was no mention of evaluation to measure the effectiveness of these actions. Martin, Wimberley, and O'Keefe (1994) conducted a case study to identify challenges and obstacles in resolving conflict among multicultural nursing staff and patient population at the 608-bed Jersey City Medical Center. Staff and managers identified the following 10 problems arising from cultural diversity: differing role expectations, conflicts among staff, patients reporting a perceived lack of caring by foreign nurses, American nurses reporting a feeling of isolation when 19 working with predominantly foreign staff, lack of assertiveness, differing languages, foreign nurses' more paternalistic relationships with physicians, a more functional approach to care, differing values in the areas of grief, death, and dying, and differing expectations surrounding documentation issues. A cultural education program was developed to resolve conflict among staff. A questionnaire was distributed to 20 staff who attended the program and their respective nurse managers to evaluate the program and its impact. Thirty-five responded, resulting in an 88% return rate. Staff and nurse manager responses indicated slight to moderate improvement in staff communication, cultural awareness, and patient/family interactions. Business Managing cultural diversity effectively implies accommodating individual differences while treating all employees as equal. Burke (1991) examined perceptions of differential treatment among 295 white and minority business school graduates in a comparative study. A copy of the questionnaire utilized to collect data was not provided by the author. Findings highlighted a greater perception of discriminatory treatment by the minority group. Unfortunately, these findings are tentative due to the low response rate of 25% reported by Burke. Rasmussen (1994) conducted a study to explore employees' perceptions of diversity issues at the Nestle Beverage Company: Individual qualitative interviews were conducted using a purposive 20 sample of 28 participants reflecting a variety of ages, ethnic backgrounds, and positions in the company. Analysis of the interview data produced the following six themes. One, management genuinely cared about employees and everyone was treated with the same degree of respect. Two, employees believed that the right image was critical for career success. Three, assertion of new ideas was valued by management. Four, there was a "hands-off" management style which trusted an employee's judgment; however, some employees indicated that clearer job expectations and feedback were necessary. Five, personal communication was difficult to maintain because the company was growing in size and diversity. Six, opportunities for growth were good especially for the "right type" which has different definitions. Two thirds of respondents reported experiencing or hearing about bias consisting of jokes and putdowns in the work environment. Cuneo (1992) reported a case study of Levi Strauss & Company which is recognized as one of the most culturally diverse companies in the United States. Fifty-six percent of its 23,000 employees belong to minority groups. The cornerstone of company efforts is "Valuing Diversity" educational programs. Managers participate in a three and one half day workshop with a shorter version being offered for all employees. The Company's management philosophy promotes diversity as its goal through an aspiration statement which forces managers to appreciate diversity. Cuneo stated that Levi Strauss & Company 21 believes that diversity makes good business sense despite the difficulties incurred. A description of the difficulties would have been informative. Summary of Literature Review In summary, the literature review has highlighted the research examining managing in a culturally diverse environment. A brief review of the roles of FLNMs and transcultural care was included to gain perspective on managing diversity. The nursing literature and research suggest that nurses may fail to meet the needs of culturally diverse clients. Several authors highlight inadequate communication and a lack of knowledge about cultural differences as major problems in the provision of transcultural care (Jones & van Amelsvoort Jones, 1986; Murphy & Clark, 1993; Shareski, 1992). Predominant issues also include conflict, racism and discrimination, and differing concepts of nursing (Farr, 1991; Jein & Harris, 1989; Reimer, 1995). The limited research on the issues surrounding managing in a culturally diverse environment was carried out in the American work environment. The differences in the Canadian work environment indicate the need to examine this issue in the Canadian context. Furthermore, additional research is warranted on these important issues prior to the introduction of education since educational programs should be tailored to meet the needs of each institution (Ellis & Sonnenfeld, 1994). Chapter 3: Method 22 The design, sample and setting, data collection procedures, data analysis, and ethical considerations are discussed in this section. Limitations of the study are also outlined. Research Design A descriptive exploratory design was used to examine the perceptions of first line nurse managers (FLNMs) managing in a culturally diverse environment in acute care hospitals in British Columbia. This study is part of a more comprehensive study by Acorn and Crawford (1995). Data were collected by Acorn and Crawford through open-ended questions (Appendix A) in a survey completed by 200 FLNMs in 38 acute care hospitals throughout British Columbia. The FLNMs were asked to identify challenges and skills/resources needed when managing in a culturally diverse environment. These qualitative data were analyzed by this investigator using latent content analysis to identify common themes. Themes arising from the data provided by the FLNMs included language and communication problems, differing work ethics which are reflected in nursing care of clients, racism and discrimination, difficult working relationships among staff, and a need for additional education on cultural issues. The current study used focus group interviews to augment the 23 qualitative data collected by Acorn and Crawford (1995) pertaining to managing in a culturally diverse environment. Therefore, these data will triangulate with the data already collected. Triangulation in this study refers to the use of two data sources in order to accurately reflect reality (Polit & Hungler, 1995). Moreover, the focus group interviews permit validation or refutation of survey data, clarification of responses, and allow for discovery of the unexpected (Swanson, 1986; Wilson, 1993). Sample and Setting A purposive sample was selected from each of three hospitals in the Lower Mainland of British Columbia for the purpose of focus groups. These multi-level client-based hospitals serve diverse cultural populations. Two of the hospitals have 121 and 123 general acute beds and 150 and 75 long term care beds respectively, and focus primarily on adults of advancing years. The third hospital has 345 general acute beds and is a tertiary referral centre for the Lower Mainland. Between six and eight FLNMs participated in each focus group. It was assumed that the groups of FLNMs were fairly homogeneous, which is an important consideration for focus group interviews (McDaniel & Bach, 1994; Morgan, 1993). Participants for the survey (Acorn & Crawford, 1995) were selected based on the following eligibility criteria: 1. A registered nurse with 24-hour accountability for one or more units. 24 2. Presently employed as a first line nurse manager at one of "the 41 acute care hospitals of over 100 beds in British Columbia as listed in the 1993 Canadian Hospital Directory" (p. 6). 3. A minimum of six months experience in present first line nurse manager role. 4. Willing to complete the survey. Participants for the focus group interviews were selected on the following additional eligibility criteria: 5. FLNMs who manage in an environment where cultural diversity of staff and patients is present. 6. Willing to share their perceptions about the culturally diverse work environment in a focus group. Nurse administrators in the three hospitals were requested to determine the willingness of FLNMs to participate in the focus groups. The nurse administrators indicated a willingness on behalf of their FLNMs to participate in focus group interviews and they reported having staff and patients from diverse cultural backgrounds. Therefore, it was assumed that these FLNMs could best illuminate the data as they manage in a culturally diverse environment. Data Collection Procedures Focus Groups Focus groups are useful as a data collection method for qualitative research. A focus group is designed to gather insights, opinions, and 25 perceptions from a small group of participants on a topic of interest (McDaniel & Bach, 1994; Morgan & Krueger, 1993; Nyamathi & Shuler, 1990). Thus, the investigation of a multitude of perceptions on a specific topic can occur. Focus groups have been used predominately in marketing research (Gray-Vickrey, 1993; Krueger, 1994; Morgan, 1993). However, more knowledge of focus groups permits their application to other areas of interest. More recently, focus groups as a data collection method are receiving considerable attention in nursing (Gray-Vickrey; Krueger; McDaniel & Bach, 1994; Morgan). According to Krueger (1994), there are several valid reasons to use focus groups. Focus groups can be used for the exploratory phase of research, pilot testing, triangulation with quantitative research to provide a larger data base, or as the sole method for gathering data. Focus groups are not intended to replace individual interviews; rather they have a specific goal and purpose which is to obtain the perceptions of participants in a dynamic group interaction (Morgan & Krueger, 1993; Nyamathi & Shuler, 1990). There are several advantages of focus groups, group synergy being the primary one. Group synergy refers to the dynamic nature of group interaction which has the potential to discover insights, opinions, and perceptions that are not accessible without the stimulus of group discussion (Krueger, 1994; McDaniel & Bach, 1994). Morgan and 2 6 Krueger (1993) affirm that "the interaction in focus groups often creates a cueing phenomenon that has the potential for extracting more information than other methods" (p. 17). Thus, focus groups have the potential to uncover perceptions which may be lost with individually generated data (Kingry, Tiedje & Friedman, 1990). Focus groups clarify arguments and reveal diversity in the views and opinions of participants (Frey & Fontana, 1993). Focus groups are advantageous to explore the range of participants' opinions (Morgan & Krueger, 1993). They can compare and contrast their views, thus becoming more explicit about their own views. Also participants can agree or disagree with statements made by others, and thus, provide immediate validation (Gray-Vickrey, 1993). Another advantage of focus groups is the empowerment of people with limited power and influence by allowing them to express their perspective (Morgan & Krueger). A final advantage of focus groups is the friendly environment; participants typically enjoy their interactions within the focus group. On the other hand, focus groups are not without disadvantages. Forced compliance, the desire for people to be polite and fit into the norm, is a major criticism of focus groups (Nyamathi & Shuler, 1990). Individuals may feel they are expected to adapt to the group norm. However, protection against this can be achieved by explaining to participants that a consensus is not required; rather a range of opinions 27 on the topic of interest is sought (Morgan & Krueger, 1993; Krueger, 1994). Thus, focus groups differ from the Delphi technique and brainstorming which strive for a consensus. Another disadvantage is that a limited number otquestions can be adequately answered in a focus group. Gray-Vickrey (1993) estimated that no more than 10 questions can be adequately discussed per focus group interview . Focus groups last from one to three hours and are repeated several times with similar yet different participants (Kingry et al., 1990; Morgan, 1993). Generally, a minimum of three focus groups permits the identification of trends in perceptions (Krueger, 1994). Careful planning of the focus group interview with respect to several dimensions is crucial to success. These dimensions include the moderator, an observer, interview guide, setting, and participants (Morgan & Krueger, 1993). Each of these dimensions is discussed in greater detail. The moderator should be familiar and comfortable with group process (Kingry et al., 1990; Morgan & Krueger, 1993; Nyamathi & Shuler, 1990). The moderator conducts the focus group by skillfully directing and refocussing the discussion and encourages participation without biasing responses. The skilled moderator ensures that the perceptions of all group participants are voiced since passive participants may be inhibited and/or influenced by active participants (Nyamathi & Shuler). The moderator must be careful not to make judgments or communicate approval or disapproval of responses (Krueger, 1994). Furthermore, 28 the moderator should be knowledgeable about the topic of interest. An observer is also necessary to assist the moderator in handling distractions, taking field notes to supplement the recorded focus group, and managing the tape recorder (McDaniel & Bach, 1994). . The interview guide questions are dictated by the purpose of the study. Generally, an unstructured interview guide is used with predetermined open-ended questions (Frey & Fontana, 1993; Krueger, 1994). Questions for the interview guide should be carefully constructed and sequenced permitting a range of responses on the topic of interest (Kingry et al., 1990). It is important that the setting be comfortable, nonthreatening, and conducive to discussion (Kingry et al., 1990; McDaniel & Bach, 1994; Morgan & Krueger, 1993). Either a formal prearranged setting or an informal field setting can be used. Again, the setting is dictated to some extent by the purpose and needs to be a central location which is accessible by all participants (Frey & Fontana, 1993). Participants should be greeted by the moderator as they arrive. Focus groups are preferably conducted around a table to allow participants to see one another and, thus, facilitate conversation. Refreshments are provided to create a more comfortable, social atmosphere and act as an ice breaker on arrival (Gray-Vickrey, 1993; McDaniel & Bach, 1994). Participants' knowledge and the topic of interest need to be matched (Morgan & Krueger, 1993). Focus group interviews are ideally composed 29 of six to ten participants, as focus groups "must be small enough for everyone to have opportunity to share insights and yet large enough to provide diversity of perceptions" (Krueger, 1994, p. 17). Groups smaller than 4 and larger than 12 may restrict the expression of perceptions by participants. The composition of the focus group is critical. Participants need to be selected who have one or more of the following characteristics in common: occupation, social class, educational level, and age (Krueger, 1994). This facilitates homogeneity which is important for group cohesiveness as participants are more willing to express themselves in a homogeneous group (Kingry etal., 1990; Krueger; McDaniel & Bach, 1994; Morgan & Krueger, 1993). Ideally, participants in a focus group should not be acquaintances (Morgan & Krueger, 1993). However, this is not always possible. This limitation can be minimized by thoughtful preparation of the interview guide and gathering data from several focus groups to gain a broad perspective. Also, the moderator must be particularly sensitive to group dynamics when group members are acquainted with one another (Frey & Fontana, 1993). In summary, focus groups are intended to collect qualitative data for research. They require a great deal of planning, effort, and resources. Krueger (1994) noted that the success of focus groups impinges on the participants' perceived needs in terms of products, services, or programs. 30 In this study, focus groups were selected over individual interviews in an attempt to capitalize on group synergy. Furthermore, the topic of interest is such that it was anticipated that FLNMs would discuss it in a relaxed setting. Thus, focus groups were considered appropriate. It was assumed that three focus groups would be sufficient to augment the qualitative data collected in the Acorn and Crawford survey (1995). However, if questions remained, a fourth focus group would have been arranged at another hospital. The focus groups were conducted in a conference room in each hospital. The setting was comfortable, non-threatening, and conducive to discussion. Furthermore, interruptions were minimized. Participants were greeted on arrival by this investigator and an observer. Participants were seated around a table to ensure visibility of each other throughout the interview. The observer was present throughout the focus group interviews to manage the tape recorder and observe group dynamics and interactions. The observer was a nursing Masters student with experience in group process. Interview Guide An interview guide (Appendix B) containing open-ended questions was used to gather the opinions and ideas of the focus group participants (Morgan, 1993; Swanson, 1986; Wilson, 1993). Questions for the interview guide were formulated based on two sources: latent content analysis of qualitative data obtained by Acorn and Crawford (1995) and 31 the available literature. The questions were developed by the co-investigators of the Acorn and Crawford study, a research assistant, the investigator, and a consultant in focus group methods. The interview guide was pretested on a small group of FLNMs to evaluate the clarity of the questions and the degree to which they captured the essence of the topic. The consultant attended the pilot focus group to evaluate the investigator's skill in conducting focus groups. Revisions to the interview guide involved slight changes in the wording of questions following the pretest. The focus groups did not exceed two hours in duration. A brief windup followed each interview and participants were asked to complete a brief demographic questionnaire (Appendix C). Each focus group was audiotaped for verbatim transcription by a professional transcriber. This investigator conducted the focus groups and analyzed the data. Data Analysis The qualitative data from the focus group interviews were examined using latent content analysis. "Content analysis is essentially a coding operation" (Babbie, 1983, p. 278), the purpose of which is the reduction of qualitative data to workable units (Catanzaro, 1988). Latent content analysis is concerned with finding meaning in qualitative data. Specifically, latent content analysis examines the underlying meaning of the communication within the context of the entire text (Babbie; Waltz, Strickland & Lenz, 1984). 32 The transcribed interviews were analyzed following the multistep procedure as described: 1. Identify the unit of analysis. 2. Construct the appropriate categories. 3. Develop the coding rules. 4. Pretest the coding rules. 5. Perform the analysis by reducing the data into categories and then themes. The first step involved determining the unit of analysis. For the purpose of this study, the unit of analysis was segments of content (Holsti, 1969; Polit & Hungler, 1995). Segments of content may be a few words, a sentence, or paragraph which impart more meaning (Waltz et al., 1984). Therefore, each segment of content was reduced into its component themes and then placed in a proper category. Holsti refers to this process as unitizing. The second step involved the construction of appropriate categories. Category construction adhered to the following general principles. First, the purpose of this study was reflected in the categories. Second, the categories were mutually exclusive, independent, and exhaustive (Waltz et al., 1984). Third, characteristics of the categories were defined to increase reliability (Holsti). Categories were constructed, using the trial and error method, after reading the entire transcripts several times to develop a sense of the 33 data. "This process consists of moving data back and forth from theory to data, testing the usefulness of tentative categories, and then modifying them in light of the data" (Holsti, 1969, p. 104). Each segment of data was coded and compared with previously coded materials in the same category. The third step in latent content analysis of qualitative data was the development of coding rules. A code is a category label with code names closely aligned to the concept being described (Miles & Huberman, 1994). The codes were compiled alphabetically on a single sheet of paper for easy reference. Coding rules enable the investigator to classify the content into meaningful groupings (Polit & Hungler, 1995). Coding rules were based on the previous decisions about unit of analysis and categories and were as specific and complete as possible. The fourth step involved pretesting the coding rules by applying them to the transcripts. After the categories and codes were developed, the investigator's thesis committee members and the focus group observer evaluated the categories and codes for relevance, clarity, and completeness. Categories and codes were then redefined, added, and deleted. The final step involved the actual data analysis. Transcripts were reviewed after each focus group to ascertain the content, and the actual analysis began after all three focus groups had taken place. The transcripts were cleaned prior to data analysis to ensure that there were 34 no discrepancies between the tapes and the transcripts. This was done by this investigator reviewing the transcripts while listening to the focus group tapes and making corrections to the transcripts as necessary. Data were then coded with the code placed along the left margin of the transcript and marginal notes scribbled in the right margin. Themes were then identified across the coded categories. Rigor Methodological rigor was ensured in this descriptive study using the four criteria identified by Sandelowski (1986): auditability, credibility, fittingness, and confirmability. The first criterion, auditability, refers to the consistency of qualitative findings. A study and its findings are auditable with the rigorous development of a decision trail (Burns, 1989; Sandelowski). The entire study was described in detail from the purpose through to the analysis in order to permit another researcher to arrive at comparable, but not contradictory, conclusions. In addition, the investigator provided rationale for decisions made throughout the study. The second and third criteria for rigor are credibility and fittingness. Credibility ensures a faithful description or interpretation of human experience. Therefore, a study is credible when others (researchers and/or readers) can recognize the experience (Sandelowski, 1986). Fittingness refers to findings being viewed as meaningful and applicable in contexts outside the study situation (Sandelowski). 35 Two strategies were used by the investigator to enhance credibility. First, the categories and coding rules were pretested on segments of the transcripts. The investigator, two thesis committee members, and the focus group observer reviewed and reached agreement on the categories and coding rules. Finally, the themes that emerged from the data analysis were reviewed by two thesis committee members to determine the degree to which they recognized the descriptions and interpretations. Fittingness was enhanced through the use of purposive sampling. The participants were selected because of their knowledge about the topic of interest. Confirmability is the final criterion of rigor for a qualitative approach. Confirmability is achieved when auditability, credibility, and fittingness are established (Guba & Lincoln, 1985; Sandelowski, 1986). Ethical Considerations The proposal for the more comprehensive study by Acorn and Crawford (1993) was approved by the University of British Columbia Behavioural Sciences Screening Committee For Research and Other Studies Involving Human Subjects. This approval encompassed the current study. Several strategies were instituted in this study to insure that the rights of participants were protected (Burns, 1989). A verbal explanation of participant involvement was provided prior to each focus group. Agreement to participate in the study was obtained by written consent 36 (Appendix D). The participants' signatures on the consent form indicated their willingness to be interviewed. Voluntary participation was emphasized and the participants were assured that they were free to ask questions and withdraw at any time (Field & Morse, 1985). The tapes and transcriptions were coded which ensured anonymity of all participants since no names were linked to the data (Munhall, 1988). . Once the transcriptions were completed and reviewed by the investigator, the tapes were erased and transcriptions were stored in a locked file drawer. Access to the transcripts was limited to the investigator and thesis committee members. The research did not harm the participants, rather they may have benefited by providing input into an issue that is pertinent to FLNMs (Brink & Wood, 1988). Furthermore, an ethical obligation to describe and report in the most authentic manner possible the themes that unfolded was acknowledged, even if the findings were contrary to the aims of this study (Munhall, 1988). Limitations The following four limitations were identified at the outset of the study. The first limitation is the limited generalizability of study results since purposive sampling within a convenience sample of FLNMs was used. The second limitation involves elite bias as a direct result of purposive sampling within three hospitals in the Lower Mainland. Elite bias refers to the assumption that those who participate in this study are frequently 37 the most articulate, accessible, or high status members of their group (Sandelowski, 1986). The third limitation is the collection of data in focus groups since this method may restrict interview responses due to the perceived need to conform. As a facilitator, the investigator utilized group process techniques to permit all participants equal opportunity to voice their opinions and emphasized that a consensus was not desired. The final limitation is the investigator's inexperience in the area of managing in a culturally diverse environment, which could have decreased credibility with participants so that they talked less in the focus groups. 38 Chapter 4: Presentation and Discussion of Findings This chapter contains the findings of this study which explored perceptions of FLNMs managing in a culturally diverse environment. Findings are presented in two sections. Characteristics of the participants are described in the first section and the four themes that emerged from the focus groups are presented and discussed in the second section. The themes were identified as: challenges, facilitators, barriers, and ethical issues. Each of these themes, with the exception of ethical issues, are comprised of several subthemes. Also, the findings of this study are compared to currently available literature. Sample Characteristics Nineteen FLNMs participated in the interviews. The mean age of the participants was 46 years, with a range of 31 to 59 years (see Table 1). All of the FLNMs were female with an average of 12 years of supervisory experience that ranged between 4 and 30 years. Three held a nursing diploma, five held a nursing diploma with additional certificate/courses, and eight held a baccalaureate degree in nursing. One participant held a Master's degree in nursing and two held a Master's degree in a discipline other than nursing. Eight of the 19 participants had completed the questionnaire in the Acorn and Crawford (1995) study. 39 Table 1 Description of Sample Mean Range Age at Last Birthday 46 Years of Supervisory Experience 12 31-59 4-30 Percent Gender Female Male Education Nursing Diploma Nursing Diploma with additional certificate/courses Baccalaureate Degree in Nursing Master's Degree in Nursing Master's Degree Other Completed Questionnaire in Spring 1994 Yes No 19 0 5 8 1 2 8 11 100 15.8 26.3 42.1 5.3 10.5 42.1 57.9 40 Participants confirmed that they managed in a culturally diverse environment; that is, there were staff members from diverse cultural backgrounds caring for a culturally diverse clientele. However, the cultural diversity of the staff was not necessarily representative of the diversity of the patient population. One FLNM stated that, "having worked in a couple of other facilities, when I came to this facility four years ago it struck me as a particularly diverse group of people, staff and clients alike." Another FLNM indicated that, "The community here has changed over the last ten years..the staff's length of service is fifteen years so there's a ten year lag between representation in staff versus the actual community." Thus, the FLNMs participating in the interviews were deemed good informants for this study as they were knowledgeable about the topic of interest. Themes This section is organized around a discussion of the four themes, challenges, facilitators, barriers, and ethical issues, and their corresponding subthemes. Challenges Challenges encountered while managing in a culturally diverse environment were a major concern for the majority of FLNMs who were interviewed. Similarly, the literature tends to focus on problems of managing diversity. Three challenges of managing in a culturally diverse environment emerged from the data: difficulties in communication, 41 differing expectations and behavioural norms, and conflict resolution. Each of these challenges is discussed in greater detail. The order in which the challenges are presented is not hierarchical. Relevant literature will also be incorporated to facilitate an understanding of the challenges. Difficulties in communication. Communication was the major challenge for FLNMs in this study. This finding is consistent with those of Burner et al. (1990), Kubricht and Clark (1982), Martin et al. (1994), Murphy and Clark (1993), Poteet, 1986), and Thiederman (1989) who also found this to be the major problem encountered by nurses in caring for foreign clients. One FLNM simply stated that "language was a major issue." And another FLNM stated that, "there's great difficulty communicating." In culturally diverse health care settings, this is an expected outcome given the number of languages spoken and differing communication styles (Kavanagh & Kennedy, 1992). Communication refers to more than language. Shareski (1992) noted that "words can mean different things to different people" (p. 12). It encompasses the verbal and non-verbal exchange of ideas, messages, or information (Webber, 1984). Dawes (1986) noted that individuals must be able to understand, interpret, and respond in order to communicate effectively. Shareski (1992) emphasized that more than 100 lingual groups exist in Canada. FLNMs noted that numerous different languages and 42 dialects were spoken by their staff and patient population. For many staff and patients, "English is the second language." One FLNM indicated that, "on our unit there's nine different languages spoken among just the nursing staff;" these included Cantonese, Mandarin, Punjabi, Vietnamese, Philipino, and Japanese. The number of patients in Canadian hospitals who do not speak English is growing. Communication styles vary greatly within and between cultural groups (Kavanagh & Kennedy, 1992). FLNMs noted that the use of verbal and non-verbal communication by some cultural groups differs substantially from the Caucasian majority. One FLNM provided the following example, "she's like quite vocal and very expressive and she uses her hands and gestures and her voice tone rises." Differences in communication styles can be detected in the tone and volume of voice, in the use of hand gestures, and by silence. FLNMs indicated that lack of understanding of different patterns of communication could potentiate conflict. Concerns were clearly expressed by FLNMs participating in the focus groups that an inability to speak English could lead to miscommunication and misunderstanding among staff, patients, and family members. One FLNM stated, "...language, and I know that that's been a source of sometimes misunderstandings." Another FLNM explained that misunderstandings occur even when "their English was seemingly good." 43 Literacy is another important aspect of language (Shareski, 1992). Nurses often care for patients who speak a language other than English. In many cases, these patients may be unable to read or write their own language which poses an increased challenge to nurses in the provision of nursing care. Language and communication is a problem consistently cited in the literature (Burner, et al., 1990; Martin, et al., 1994; Poteet, 1986; Thiederman, 1989). Epting, Glover, and Boyd (1994) noted that communication difficulties may arise that include language and literacy issues. In an exploration of cross-cultural conflict, Jein and Harris (1989) noted that the use of language and verbal and non-verbal communication differs among cultural groups. Two studies were examined in more detail as they focused more on communication, rather than the identification of problems of transcultural care. Kubricht and Clark (1982) interviewed foreign patients through an interpreter regarding the quality of care they received during hospitalization. "They identified feelings of loneliness, boredom, anxiety and fear" (p. 55). A major concern was the inability to communicate with nursing staff. Jones and van Amelsvoort Jones (1986) found significant differences between nurses' communication with ethnic patients and Caucasian patients in a long term care facility. Murphy and Clark (1993) emphasize that difficulties in communication affect the quality of care provided to culturally diverse clients. Also, the 44 use of non-verbal communication was highlighted when there was no other way to communicate. Therefore, communication is essential to establish a relationship between a nurse and a patient. Language barriers challenge nurses to identify and meet patient needs (Headley, 1992). FLNMs participating in this study identified several issues surrounding communication which may provide some indication of why language barriers create challenges. FLNMs noted that an increase in time and effort is essential to communicate with patients who speak a different language and with their family members. One FLNM stated: They [staff] say how much easier their job is and how much more they can get done without having to interpret, to get people to, sign language, explain when there's a language barrier, it takes more time, it definitely takes more time. FLNMs indicated that the completion of nursing assessment, nursing history, and the provision of patient education are difficult with the presence of a language barrier. FLNMs indicated that several issues involving communication pertain specifically to staff. For example, language was suggested as an important consideration when hiring staff since a basic level of English is essential to understand, communicate, and document nursing care. One FLNM indicated that" I end up spending an inverse amount of time with them [staff] because of their problem understanding and communicating." 45 Another staff issue surrounding communication arises when staff are "speaking their own language amongst themselves." FLNMs indicated that this was often the case at nursing stations and in the cafeteria. Similarly, Martin et al. (1994) found that nurses reported feelings of isolation when working with nurses of different cultural backgrounds generally related to different languages being spoken especially in charting areas and the cafeteria. FLNMs indicated that this was damaging to a cohesive workforce and was a source for conflict. Thus, language and communication are important considerations when working with staff, patients, and their respective family members. This is both a patient care issue and management issue in a culturally diverse environment. Differing expectations and behavioural norms. Differing expectations and behavioural norms was another challenge identified by FLNMs participating in the focus groups. Differing expectations and behavioural norms exist between patients and their respective family members and staff, and between staff and FLNMs. Expectations of the hospital experience were seen to vary among different cultural groups and individuals. These expectations can be based on cultural norms and/or previous experiences. One FLNM stated, "they come in with their own perceptions from where they've been before in their own countries and they're often not updated to how things are being done in most of these facilities." For example, the desire for 46 patients and families to participate in the delivery of care is more prevalent in some cultures than in others (Burner et al., 1990). In Canada, patients are expected to participate in their own care which may be in conflict with expectations in other cultures. These differences are based on different beliefs and different health care delivery systems in other countries (Jein & Harris, 1989). A FLNM commented that "some of their perceptions are that the nurse, its the nurse's duty to do everything for the patient." FLNMs provided other examples of differing expectations. One FLNM provided an example where "there were nine children...she also had something like five brothers and four sisters and all of their spouses they all were part of the decision-making process." At another hospital one FLNM noted that "their expectation is such that all the nurses are Cantonese-speaking or Mandarin-speaking or both so they can communicate." Differing behavioural norms are also expressed by a culturally diverse patient population. Two common examples were family visitation and food. One FLNM stated that there are often "eight and ten people around the bedside." Another FLNM stated, "20 visitors" at the same time. She continued by saying "...you will ask them please only two at a time in the room...and you will go away and two minutes later they all will be back in the room." FLNMs perceived this to impinge on the rights of other 47 patients and interfere with nursing activities. Also, the number of visitors and visiting hours are reinforced by existing hospital policy. Food is very important in some cultures. One FLNM stated "their whole perception is the patient has to eat and drink in order to get better." This caused problems when it interfered with protocols such as pre- and post-surgery and fasting for various procedures, or when patients were on a special or restricted diet. Another FLNM indicated that "they give them drinks, they'll bring in their own pills, they'll bring in their own herbs." In this case, the behavioural norms were perceived to conflict with the regimen prescribed for the patient. Murphy and Clark (1993) noted issues relating to the nurse-client relationship and issues relating to relatives when nursing in a culturally diverse environment. They noted that there were difficulties in establishing a good relationship with the client because of communication difficulties. They also noted that relatives' behaviour was often found by nurses to be difficult to understand. Also, the sheer number of relatives visiting caused problems. Differing expectations and behavioural norms between staff and FLNMs presented a challenge for the FLNMS; that is, accommodating cultural differences among staff while treating each staff member fairly and equally. However, the role expectations in a Canadian health care organization can differ from those of a nurse's cultural background (Jein & Harris, 1989). There was some difference of opinion noted as some of 48 the FLNMs could not relate to what other FLNMs were describing. One 5 FLNM stated that "our expectations of their performance are the same...they have to understand that we have certain standards and v- expectations that they conform to." The word "conform" implies that there is little room for individuality among staff. Some FLNMs indicated that nurses from diverse cultural backgrounds needed to be "westernized" or "Canadianized," as the performance expectations were the same for all nurses. However, FLNMs commented that there were additional expectations for nurses of different cultural backgrounds to act as interpreters. One FLNM stated: It's sort of an expectation here like there's a lot of, not a lot but quite a bit of imposition on the staff that do speak these other languages...she's called away constantly like she has her job to do but then she's called away to interpret...their expectation is that they wouldn't say no and they would do it and it's really not, you know, it's added on to their work load. Thus, nurses from different cultural backgrounds may be expected to carry this additional responsibility in order to meet the expectations of their employers. Often the expectations of the staff member and the FLNM can differ. One FLNM noted that "it's interesting if you ask them what they expect 49 from you which I often do and there's enormous difference among the cultures." Another FLNM stated that" it's interesting on how you work with the people is different based on what you think they need from you and so that's why I ask the question quite often is what are they expecting and what am I doing." Other FLNMs in the same focus group responded positively towards this way of exploring and validating differing expectations. Duffield (1991) examined role competencies for FLNMs in New South Wales and found that FLNMs must be able to assist nursing staff to understand the scope of their roles. These differences in expectations were evident in the approach to shared governance with its accompanying participation in decision-making. Again, there was variation among hospitals as two of the three hospitals participating in this study had implemented shared governance structures. One FLNM stated: You're trying to get them onto committees, trying to get them to participate and make their own decisions, set their own standards and a lot of times you sometimes, yeah, but you're boss, that's what you should do. Another FLNM commented that "their perception of the boss is that we make the decisions." The FLNMs participating in the focus groups suggested two factors that contribute to differing expectations and behavioural norms at work. These factors are basic nursing education and the home situation. As 50 one FLNM stated, "nurses coming from the Phillipines, their training is different ...whereas the nurses who have been trained here of course in the last few years have been trained quite differently." FLNMs made particular reference to psychosocial skills and problem-solving skills, as the emphasis on these skills has increased in Canadian nursing over the last few years. FLNMs implied that North American trained nurses had these skills whereas foreign trained nurses generally did not. A lack of assertiveness by foreign trained nurses was another complaint by FLNMs, who cited several difficulties arising from this lack. Another FLNM stated, "they're not assertive...but they sort of circumvent the system a lot because that's the only way they have of dealing with it." A FLNM with third and fourth generation Canadian-born staff from differing cultural backgrounds disagreed by indicating that this was not the case, as unit staff were observed to be "assertive, almost to an extreme." The home situation of culturally diverse staff was suggested as another factor contributing to differing expectations and behaviours between staff and FLNMs. FLNMs indicated that many culturally diverse staff carry an additional workload in their home environment. One FLNM referred to one staff member where "the cultural issue of her home environment really became an issue at work." This FLNM gave the example of a nurse who had an increase in sick time and decrease in productivity at work because of an abusive home situation. In some 51 instances, FLNMs held the opinion that the abusive home situation was culturally driven while noting that abuse could occur in any culture. Another FLNM stated, "we also have to deal with issues to do with their family problems because of their culture." FLNMs provided examples of staff in abusive situations which had an impact on their work, and of staff asking spousal permission to come to work. FLNMs hypothesized that the home expectations of staff might be related to the status of women in their culture. The literature cited several issues relating to differing expectations and behavioural norms. Epting et al. (1994) noted a hesitancy among women and minorities to ask questions since they felt that their competency would be questioned due to their admitted lack of knowledge. They also noted that foreign-born female nurses may perceive a lack in their own competencies relative to male physicians. Thiederman (1989) noted that many foreign-born nurses are reluctant to admit a lack of understanding of instructions. She also noted that foreign-born nurses have differing concepts of nursing in relation to family involvement in patient care such as bathing and feeding the patient. Jein and Harris (1989) found that American nurse managers noted that different behavioural norms and role expectations exist among nurses from different cultural backgrounds. Their findings also indicated that "conflicts occur when nurses from different cultures do not achieve 52 consensus on role expectations" (p. 18). Burner et al. (1990), in a case study at Robert F. Kennedy Medical Center, noted differing cultural values surrounding the delivery of health care. Martin et al. (1994), in a case study at Jersey Medical Center, identified differing role expectations, a more functional approach to care, lack of assertiveness and differing expectations surrounding documentation as problems. The findings of this study are consistent with the findings of the above studies that there are differing expectations and behavioural norms among individuals of different cultural backgrounds. There is a paucity of literature that discusses differing expectations and behavioural norms within a culturally diverse environment. Perhaps this is due to the lack of knowledge about cultural differences that undermines this challenge. It is essential that expectations be clear, otherwise conflict can ensue. Also, it may be difficult to obtain cooperation when expectations are unclear. Either formal or informal education may be beneficial to increase knowledge about various cultural groups and norms. Above all, it is important, as stated by one of the FLNMs, to "treat everybody as individuals and have respect for their beliefs." It is the responsibility of FLNMs to establish unit cohesiveness and a harmonious work environment. It is important that staff members have similar goals and clearly understand their employer's expectations of them (Kerfoot, 1990). This becomes more crucial in an environment 53 where culturally diverse staff care for a culturally diverse patient population. Conflict resolution. The presence of conflict on the unit presented another challenge to FLNMs managing in a culturally diverse environment. The mixture of nurses and patients from different cultures can create cross-cultural conflict (Jein & Harris, 1989). Conflict can originate in the actions of one or more persons within a group (Erwin, 1992). Erwin also noted that conflict can be viewed as negative or positive since conflict may serve to air problems and stimulate interest. Challenges stemming from differing languages and differing expectations and behavioural norms can potentiate conflict. One FLNM stated that conflict is encountered "when you've got different cultures, different languages, different beliefs, and expectations." Another FLNM stated, "I guess the cultural diversity I experience creates conflict to some degree." A FLNM indicated that conflicts occur between "patient to patient, patient to nurse, and nurse to nurse." Similarly, this study's finding of conflict in a culturally diverse environment is consistent with those of Jein and Harris (1989). In a study exploring conflict, they found that conflicts related to differing hierarchies of needs and to differences in language, decision-making, viewing conflicts, behavioural norms, and role expectations. Another FLNM noted that "language conflict comes into play." FLNMs in this study indicated that conflict was often spurred by a lack of understanding of 54 another individual's cultural background. Leininger (1989b) acknowledged a lack of knowledge about other cultures as a source of conflict. Finally, the literature suggests that racism and stereotypes can give rise to conflict. Most FLNMs indicated that conflict arose because of cultural differences. However, one FLNM commented that, in her area, "conflict has arisen because of cultural similarity rather than difference." Another FLNM gave an example of "nurses'...bickering or criticism of one another." Moran (cited in Jein & Harris, 1989) noted that individuals with similar cultural backgrounds are more likely to perceive situations in similar ways. FLNMs can easily assume that the values of their staff are the same (Jein & Harris, 1989). Therefore, FLNMs emphasized the importance of understanding different cultures and the beliefs and expectations of staff and patients in order to avoid conflict. It is the role of the FLNM to act as a facilitator toward resolution when conflict occurs (Burner et al., 1990). FLNMs need to develop effective means for managing cross-cultural conflict and need conflict resolution skills to resolve conflict when it occurs. Conflict was cited as a problem by several authors. Jein and Harris (1989) explored conflict resolution among American nurse managers. They discovered that different ways of viewing conflict exist among different cultures. Also, decision-making is influenced by cultural norms. 55 Martin et al. (1994) conducted a case study in which a cultural education program was developed to resolve conflict among staff since they perceived conflict as resulting from a lack of knowledge about other cultures. Fullerton (1993) examined the changing role and educational requirements of the FLNM and found that conflict management and resolution was a commonly identified development need for FLNMs. Baxter (1993) similarly noted that FLNMs in British Columbia expressed a need for more knowledge in the area of conflict resolution. Summary. Managing in a culturally diverse environment presents several challenges for FLNMs. To summarize, the challenges identified by FLNMs in this study include difficulties in communication, differing expectations and behavioural norms between patients and their respective family members and staff, and between staff and FLNMs, and conflict resolution. Several authors have explored problem areas generated by a culturally diverse staff. The studies which address challenges or problem areas identify challenges similar to those emerging from this study. Facilitators The second theme emerging from the focus group data relates to facilitators or factors that would make managing in a culturally diverse environment easier for FLNMs. The facilitating factors that emerged from the data were: hospital philosophy and policies, resources and services 56 such as interpreters, volunteers, and food services, matching cultural profiles, and celebrating cultural differences. The quality of culturally sensitive care provided to clients is influenced by these facilitating factors. Hospital philosophy and policies. Schwartz and Sullivan (1993) contend that the health care organization must be visibly committed to cultural diversity. That is, the mission and goals statement of the organization should embrace cultural diversity. FLNMs at one hospital indicated that their hospital philosophy specifically recognized cultural diversity. A FLNM at that hospital acknowledged that an appreciation of cultural diversity was "in the mission statement." Another FLNM at the same hospital stated, "a lot of that stems from the roots of the hospital really I think oriented towards serving multicultural groups and doing all of that sort of language things and acknowledging culture." The other two hospitals did not overtly acknowledge cultural diversity in the mission statement. Acknowledging cultural diversity in the hospital philosophy is crucial since hospital policies and practices stem from the philosophy statement. Also, resource allocation to better serve a culturally diverse patient population will be influenced by the philosophy. Some of the business literature suggests that if cultural diversity is valued, it should be acknowledged in the philosophy of the institution (Cuneo, 1992; Epting et al., 1994). 57 The commitment and support of management is also important to effectively manage diversity (Epting et al., 1994; Schwartz & Sullivan, 1993). A FLNM at one hospital indicated that "the administration is very supportive" of a culturally diverse environment. According to Cuneo (1992), Levi Strauss & Company is considered one of the most culturally diverse companies in the world. Both managers and employees participate in "Valuing Diversity" educational programs. The Company's management philosophy promotes cultural diversity and managers are encouraged to appreciate cultural diversity. FLNMs indicated that some hospital policies and practices accommodate cultural differences. For example, one FLNM indicated that "there's been a lot of changes in the visiting, in the visitation hours." Another FLNM confirmed that we "allow the family in as much as we can." Another FLNM stated that "we allow visiting in the recovery room if it benefits the patient and for a lot of these culturally diverse people it does benefit the patient." Thus, family visitation is one example of a policy and practice that can accommodate cultural differences. However, this appears to be the exception rather than the norm, as only one of the three hospitals in this study had changed its visitation policy to accommodate for cultural differences. Another example of a policy which accommodates cultural diversity was provided by a FLNM: 58 You're having interpreters, people that have been trained to interpret for different treatments, pre signing consents, and that to me is real policy driven in terms of ensuring people are aware of what they are going to be signing for. Hospital policies and practices can also present a barrier to managing effectively in a culturally diverse environment as many policies and practices require patients to conform to the culture of the majority (Kavanagh & Kennedy, 1992). For example, one FLNM stated, "we're so routinized with a number of things and there's nothing I can do about a lot of these routines to meet the cultural needs." She continued by saying that "...some of the constraints are difficult to work around." Another FLNM stated, "some cultures expect that to get good care you must buy people...give them gifts, okay, and our hospital policy says you're not allowed to take gifts." Another FLNM stated, "hospital policy says you conduct your business in English unless you are specifically doing something different." These three examples demonstrate how cultural differences can be suppressed by hospital policies and practices. Kavanagh and Kennedy indicated that this has repercussions such as a different standard of care. Finally, one FLNM commented that "we get caught in the middle between our hospital policies...very difficult in that sort of situation too, when the culture insists and the hospital says you can't." 59 The importance of a commitment by the hospital to cultural diversity is consistent with the findings of Reimer (1995) who emphasized the importance of this commitment to the provision of high quality care to culturally diverse clients. Resources and services. The availability of resources and services to accommodate cultural differences is critical to managing successfully in a culturally diverse environment. Several key resources and services were identified by FLNMs participating in the focus groups. These include translation services, the volunteer mix, and the food services. Each of these resources and services is discussed in greater detail below. The availability of interpreters was a key resource. One FLNM indicated that "we certainly utilize the staff in the hospital to interpret or we'll use an outside agency also to interpret or a family member." Another FLNM at a second hospital stated, "there's a list of names of staff in every department of the hospital that speak a foreign language." One hospital offered workshops for staff who interpret to help them in the legalities and formalities of interpreting. However, one FLNM noted that "sometimes an interpreter can't get it all, you know, if it's the building services person who is interpreting." Also, a family member or staff member acting as an interpreter may be unable to completely understand the medical terminology and translate appropriately therefore, access to a professional interpreter is warranted. One FLNM stated," we do have interpreters that can be called if necessary, not all 60 24 hours a day." FLNMs indicated that it would be beneficial to have access to professional interpreters "24 hours a day" since it is always as one FLNM stated, "when you need them the most and you can't get them." To assist with translation services, one FLNM indicated that, "we hired a coordinator and, she's called Coordinator of Interpretive Services." FLNMs at this hospital viewed this as positive since it made access to interpreters easier and more readily available. Perhaps if staff were more aware of the availability of interpreters they would make use of their services more often. There are a number of ways to deal with language barriers when interpreters are unavailable. FLNMs provided examples of several strategies that staff utilize to cope with language barriers. One FLNM reported that "the staff have made up a little pamphlet of commonly used phrases." Another FLNM stated, "...a few words of the language, sign language, finding interpreters, not expecting my questions to be answered instantaneously, knowing that I'm going to have to go to some length to get it [information]." Another FLNM identified the use of "plastic coated translation sheets" as an aid for nurses when language barriers exist. FLNMs participating in this study did not give any indication of how often these resources were used to facilitate communication. The literature suggests that even though these resources are available, 61 nurses may not be aware of them or use them effectively (Kubricht & Clark, 1982). FLNMs at another hospital indicated that other available hospital-wide resources included ministerial support and the social work department. The latter was available to research the values, beliefs, and customs of different ethnic groups for staff. FLNMs at another hospital identified resources to assist with patients and staff. A FLNM indicated that, "there's a lot of resources available and they're certainly not just for one culture, they're for everybody." Another FLNM provided further clarification by adding, "there's the employment assistance program, there's occupational health, ministerial support." Many of these resources are available to culturally diverse staff members. FLNMs and staff also rely on various outside groups who volunteer their services. One FLNM stated, "it's very useful to create a bond there with volunteers." Volunteers can interpret and/or provide information about the cultural background of patients, thus providing staff with general information about a patient's cultural background. Food services was another valuable resource for managing in a culturally diverse environment. Health care organizations need to be aware of and attempt to meet differing dietary cultural preferences as food is very important to patients during their hospitalization. Some FLNMs indicated that this was one area where improvement was needed 62 to meet the needs of a growing culturally diverse population. In relation to food, one FLNM acknowledged that "food is about the most important thing that exists and we do not adequately in any way, shape or form meet the needs of our ethnic groups." FLNMs indicated that it was often left to family members to bring ethnic food in from home. However, difficulties were incurred when patients were on restricted or special diets. As one FLNM stated, "the diabetic patients or patients who are on special diets, they will bring in their food for them and give it to them." A FLNM at another hospital stated, "there's all kinds of different things in place, even the food, we have six different kinds of Conjiis [Oriental rice soup]." One FLNM summarized by stating, "the signage, the interpreter services, the volunteer mix,... even the food... I am amazed at what we do to accommodate culture." Variation was evident in the availability of resources and services to meet the needs of culturally diverse clients at the three participating hospitals. One FLNM simply stated, "we haven't found the right resources yet." Reimer (1995), in exploring nurses' experiences of caring for culturally diverse clients, found that three resources and services were instrumental in the provision of transcultural care. They included food services, client education resources, and translation services. The findings of this study involving FLNMs are similar to those of Reimer. 63 Matching cultural profiles. Recruitment of staff to match the cultures represented by the patient population is another valuable strategy. Kerfoot (1990) and Solomon (1992) acknowledge that it is easier to hire and work with people who are similar to oneself. However, this does not meet the needs of an increasingly culturally diverse patient population. Cultural diversity of staff can be advantageous to a health care organization (Kerfoot). Marston (1992) criticizes the notion of matching the cultural profiles of staff to the patient population, stating that it is too simplistic given the intercultural variation that exists. One FLNM simply stated that culturally diverse staff are "a really good resource." Another FLNM admitted that she and other FLNMs examined "the diversity of our staff in how you're going to meet these needs when we know that, that's, those are the audiences that we're targeting." Thus, staff with cultural backgrounds similar to those of patients are viewed as a valuable resource as they are able to provide interpretation and possess a knowledge of the cultural norms. One FLNM stated, "we certainly do call upon their expertise." Another FLNM commented that culturally diverse staff "have a really very strong knowledge of that particular type of background by virtue of knowing about their cultural background that they can contribute something that maybe the rest of the group didn't know." Yet another FLNM stated, "it's wonderful...when we have a patient that comes in and I've got staff who can speak their language." Another FLNM stated, "they 64 can have a richer understanding of the experience the patient is going through." Another FLNM stated, "they sometimes can stave off problems...because they have the foresight or they'll be able to tell us about it, we can avoid it." However, other FLNMs saw language as a trade-off for a North American trained nurse with other skills. As one FLNM stated," their [North American] teaching is more progressive, that they problem-solve, that they treat the whole patient." Another FLNM stated that there is "a lot of hiring of casuals of a very multicultural group of people...technically we're not supposed to test English writing or speaking etc. but it does create major problems..." That is, miscommunication and misunderstandings occur with poor English skills. Also, documentation issues arise due to literacy problems. Hence, a North American trained nurse with a cultural background matching the patient population and able to speak the language is a most desirable resource. The literature focusses on problems associated with cultural diversity, but fails to address resources. The matching of cultural profiles of nurses and patients facilitates more comprehensive health care (Haratani, 1993; Spicer et al., 1994). The importance of a culturally diverse staff as a resource was clearly indicated by the FLNMs who participated in this study. Retention of culturally diverse staff depends on effective management strategies employed by FLNMs (Kerfoot, 1990). Kerfoot offers several suggestions to help attract and retain culturally diverse 65 staff. One suggestion is to use the knowledge base of all employees on the unit. Another suggestion is to recognize and acknowledge the unique attributes of all employees. Yet another suggestion is to establish mentoring or preceptor programs to help staff learn role expectations and reach their highest level of productivity. Celebrating cultural differences. The sharing of ethnic food and partaking in ethnic celebrations can foster an appreciation of diverse cultural backgrounds and contribute to a harmonious work environment. All of the participants agreed that food and celebrations involving diverse cultural groups was an advantage of managing in a culturally diverse environment. One FLNM indicated that "food is a great unifier" and another FLNM stated that, "the food and that, the celebratory stuff that all the different cultures bring is really nice." In summary, one FLNM acknowledged that, "despite all our cultural diversity, that [food] is one area in which there is very little conflict." Celebrations that recognize various cultures are one way of valuing diversity (Kerfoot, 1990). Examples of such celebrations are Chinese New Year and Philipino Independence Day. Ethnic food days in the cafeteria and on the nursing unit is another way of celebrating cultural differences. FLNMs at one hospital indicated that some of their staff were involved in activities and inservices celebrating cultural awareness week. None of the studies examined the advantages of cultural diversity; rather they focused predominantly on problems. However, there are 66 examples in the business literature where cultural diversity of staff is perceived to enhance problem-solving, decision-making and creativity (Ellis & Sonnenfeld, 1994: Kirchmeyer & McLellan, 1991). One FLNM shared that culturally diverse staff members may "stave off a potential problem which could become a problem because they have the foresight." No other advantages were suggested by the FLNMs participating in this study. However, one FLNM commented, "I wonder if it's because we've been so culturally diverse for so long that you can't recognize it." Summary. In summary, there are several facilitating factors that can make managing in a culturally diverse environment easier for FLNMs. These include the hospital philosophy and policies, resources and services, matching cultural profiles, and celebrating cultural differences. Each of these factors contributes to the quality of transcultural care. However, absence of these facilitators can make managing in a culturally diverse environment more difficult. Great variation in the presence of these facilitating factors was noted among the three health care organizations. It is crucial that health care organizations be committed to effectively managing cultural diversity. This requires a commitment by the institution, all levels of managers, appropriate finances, and recruitment and retainment of culturally diverse staff (Schwartz & Sullivan, 1993). In general, FLNMs have limited control over these factors with the exception 67 of staff recruitment; FLNMs are now involved in hiring staff for their units. This enhances the unit work environment which influences the retainment of staff. There is very little discussion of facilitators in the literature. There may be two explanations for this. One, the nature of the questions asked in this study and other studies influences the responses of participants. This study specifically asked FLNMs what would make managing in a culturally diverse environment easier, whereas other studies focused on problems of managing diversity. Two, the culturally diverse nature of the three health care organizations where the focus groups took place may account for differences in responses. Barriers The third theme emerging from the focus group data relates to barriers to managing effectively in a culturally diverse environment. Barriers are viewed as directly influencing the quality of care provided to culturally diverse patients and contribute to the treatment of culturally diverse staff. The barriers identified include discrimination, lack of knowledge about other cultures, and decreasing financial resources. Discrimination. Prejudice, discrimination, and racism are three interrelated terms with similarities and differences that need to be clearly articulated. Prejudice "is a dislike of people on the basis of a personal characteristic" (Tomlinson, 1990, p. 34). Prejudice refers to an inaccurate perception of others (Schwartz & Sullivan, 1993). This perception may 68 be based on ignorance about other cultures (Lea, 1994; Solomon, 1992) and or a lack of knowledge about one's own culture (Thiederman, 1986). Either way, prejudice is the result of an inaccurate perception of others. When prejudice is combined with power, discrimination results (Tomlinson, 1990). Discrimination can be defined as distinguishing between individuals on the basis of prejudice (Webber, 1984). In other words, discrimination is the enactment of prejudice (Kavanagh & Kennedy, 1992). Racism refers to discrimination on the basis of race (Webber) and is one form of discrimination. Discrimination can also arise on the basis of other personal characteristics such as gender, socioeconomic status, religion, age, and disability. Prejudice may always exist since it is based on beliefs. However, behaviour can be changed to demonstrate mutual respect (Solomon, 1992). Discrimination may go so far as to result in unfair treatment or mistreatment of individuals (Lea, 1994; Schwartz & Sullivan, 1993). Kavanagh and Kennedy (1992) argue that discrimination is built into society. "The racism that exists in the community exists in the workplace" (Barclay cited in Solomon, 1992, p. 30) and health care organizations are no exception. Discrimination can be individual or institutional (Kavanagh & Kennedy). Institutional discrimination occurs when subtle barriers are incorporated into the organization. Consequently, individuals consciously or unconsciously perpetuate the discrimination. Discrimination will affect how individuals access health care, interact with 69 health care professionals, and the quality of health care provided to culturally diverse patient populations (Howie, 1988; Lea, 1994). A great deal of effort is required to change the barriers and prevent discrimination (Kavanagh & Kennedy, 1992). Barriers exist due to rigid hospital schedules and hospital policies that do not accommodate individual differences. Health care organizations cannot treat individuals equally unless they recognize cultural differences in addition to universal needs (Taylor, 1992). In this study, discrimination took the form of physicians refusing to have nurses from a particular cultural background working with them and patients refusing to be cared for by physicians of a particular cultural background. Discrimination was also perceived to be present amongst the nursing staff and between nurses and patients. One FLNM stated that "discrimination amongst nursing staff even nurse to nurse and nurse to patient and that patient feels the strain." Another FLNM revealed that "my attitude and judgment towards that patient...I've already got a stymied viewpoint and some of our staff have the same and other patients." Another FLNM revealed that she "had a few, a couple of situations where a person would say well you're just saying that because I'm black." Reverse discrimination was also identified as an issue. One FLNM stated: 70 When they [float nurses] get on a ward that's heavily staffed with another culture whether it's Oriental, East Indian, whatever, they have a very difficult time becoming part of the team even for one shift, they are, um, almost ostracised. Schwartz and Sullivan (1993) acknowledge that actual or perceived reverse discrimination can be encountered in a culturally diverse health care organization. The issue of abuse surfaced in relation to women and children. As one FLNM stated, "abusive situations which involve white Caucasians as well and our attitudes towards them are probably a little softer than what they are towards the East Indian population." Discrimination was also noted amongst individuals of the same cultural group as one FLNM stated, "Oriental patients will discriminate actually against having an Oriental nurse." Examples provided by FLNMs seemed to imply that discrimination was not only on the basis of race but also included language, gender, and socioeconomic status. Some FLNMs were hesitant to label their examples as discrimination. One FLNM stated, "not necessarily being discriminatory, um, sometimes not understanding or not knowing." Another FLNM stated, "the discrimination you see actually is just, I think, personalities and people not because of their nationalities." Another FLNM stated that "a lot of these people [patients] come from racially pure backgrounds and are not familiar or comfortable with, um, an interracial kind of environment." FLNMs in another focus group denied the 71 presence of racism. One FLNM indicated that "I certainly can't think of any situation where there's been racial issues." Institutional inequalities are perpetuated when individuals overlook or ignore or avoid the issue of discrimination. Individuals have a tendency to ignore rather than discuss discrimination as it is an unsettling issue (Schwartz & Sullivan, 1993). Avoidance of the issue can be mistaken for absence of prejudice and discrimination (Kavanagh & Kennedy, 1992). Avoidance also maintains the status quo. Schwartz and Sullivan hold the opinion that managers can either perpetuate or reduce discriminatory behaviour through role modelling. The presence of discrimination impairs team building and unit cohesiveness and can affect job performance (Solomon, 1992). Health care organizations "haven't been flexible in responding to the differing needs of the population" (Howie, 1988, p. 18). That is, the needs of culturally diverse clients haven't been recognized and incorporated into the provision of services (Howie). One FLNM stated, "all our systems and all our nursing interventions are based on research on the North American white people." Another FLNM stated, "they're treated just like everybody else, there's no special rules for anybody from a foreign country." There needs to be an effort on the part of the health care organization to eliminate practices and policies that are tailored to the culture of the majority or a uniform rather than diverse culture (Kavanagh & Kennedy, 1992). Health care organizations need to 72 acknowledge that racism exists and to take positive action to reduce and eliminate the existence of discrimination in health care (Howie). The presence of racism and discrimination identified in this study is consistent with the findings of Poteet (1986), Lowenstein and Glanville (1991), Farr (1991), and Reimer (1995) all of whom reported discrimination and racism as problems in health care settings. The disturbing presence of discrimination in the Canadian health care setting was identified by Farr and Reimer who examined perceptions of Canadian nurses and this study which explored the perceptions of FLNMs. Lack of knowledge about other cultures. FLNMs who participated in the focus groups identified the need for more knowledge about various cultures. Education is essential to the provision of quality nursing care to culturally diverse patient populations. Also, FLNMs require knowledge and skills to enable them to function successfully in a culturally diverse environment. Educational preparation about culturally sensitive care varied among the FLNMs. The majority of the FLNMs interviewed had limited exposure to education on caring for a culturally diverse patient population in their basic nursing education. One FLNM stated, "in student training we used to have, spend a lot of time talking about the different cultures." Overall, they did not perceive their education as helpful in preparing them to provide transcultural nursing care. 73 FLNMs identified formal and informal means of acquiring knowledge about other cultures. A few FLNMs indicated that a reference book providing information about various cultural groups would be useful. Other FLNMs indicated a need for staff inservices to assist staff to become, as one FLNM stated, "more knowledgeable about protocols and practices of the different cultures." Another FLNM stated, "educate all the staff so that they recognize what the norms may be for different cultures." This supports the misconception that transcultural care involves memorizing cultural norms and characteristics for various groups (Shareski, 1992). Shareski contends that nurses do not need explicit details. Rather, they need an understanding of the concept of culture and basic cultural particulars for some groups. As one FLNM stated, "I appreciate the general principles but I do not like seeing specific things about specific populations because then it causes me to start thinking stereotypically." Knowledge of other cultural perspectives can also be acquired through informal education. One FLNM acknowledged a broader perspective from "listening to the stories of staff that come from different countries and they've worked in other countries." Another FLNM stated, "talk to them and learn about them and you know, have conversations." The preparation of FLNMs is vital as the manager has a strong influence on the unit culture. Thus, education was one aspect that could be better addressed in the future through formal and informal education. 74 Nursing schools need to provide more content on culture and transcultural care. However, special attention needs to be paid so that stereotypes are not reinforced. Health care organizations can provide education to staff in the form of inservices. The literature cautions against the use of a single educational program for all situations. Rather, cultural diversity educational programs should be unique to the needs of each institution (Ellis & Sonnenfeld, 1994; Solomon, 1992). Cultural issues should be addressed in management courses so that prospective nurse managers are exposed to managing in a culturally diverse area while in school. Many of the FLNMs participating in the focus groups have learned to manage in a culturally diverse environment through "trial and error." One FLNM stated, "if you were a student, not yet a nurse manager, it would be helpful to get some real life experience." Generalizations about cultural groups contribute to stereotyping (Kerfoot, 1990; Shareski, 1992). A lack of knowledge or too much knowledge about one or more cultural groups can lead to stereotyping. Stereotyping can be defined as an overgeneralized or simplified opinion, conception, or belief (Webber, 1984). Stereotyping can be detrimental as it fails to acknowledge the uniqueness of individuals. Stereotyping was evident throughout the focus group interviews in relation to staff, patients, and their respective families. In many cases, the FLNMs recognized their overgeneralizations. For example, one FLNM stated, 75 "Philipino nurses are more emotional, seem to fall more in and again it's generalizing too much." Another FLNM stated, "this concept of maybe doing something wrong by sort of pigeon-holing people, saying okay you're Japanese therefore you are artistic and creative and delicate ...don't just make assumptions but you actually validate things." However, not all FLNMs recognized that they were stereotyping. FLNMs also emphasized that respect and understanding of the uniqueness of individuals was critical. FLNMs indicated that it is by taking the time to get to know staff and patients that an appreciation and understanding develops. One FLNM stated, "you treat everybody as an individual and have respect for their beliefs," that is, appreciate the uniqueness of individuals and their situations. Another FLNM stated, "you're managing people and you get to know your staff as individuals." Thus, the notion of individualizing rather than stereotyping is important whether it be to meet patient needs or staff needs. FLNMs hypothesized that too much knowledge about different cultures could lead to stereotyping. The findings of this study indicate that more attention should be directed toward the issue of stereotyping individuals based on their cultural affiliation. The continuing practice of stereotyping individuals hampers the development of a culturally sensitive climate for both staff and patients. The finding that education is extremely important in promoting harmony in cultural diversity environments is consistent with those of 76 Reimer (1995) and Poteet (1986). Both emphasized education as , important for the provision of quality transcultural care. Decreasing financial resources. Lack of time and/or money was seen as presenting a barrier to managing in a culturally diverse environment. Schwartz and Sullivan (1993) contend that a substantial financial commitment is important for effectively managing in a culturally diverse environment. The current health care climate is one of forced restraint with governments, at both the federal and provincial level, attempting to contain the escalating costs of health care (Acorn & Crawford, 1995). Many hospitals are reducing their services because fewer health care dollars are available. Thus, FLNMs are faced with a decrease in hospital-wide resources and must develop strategies to decrease costs while maintaining quality of care. This becomes more challenging in a culturally diverse environment where staff and resources are essential for transcultural care (Acorn & Crawford). One FLNM indicated that "it does come down to time, fiscal restraint, and personnel restraint like we just sometimes don't have enough people to do what you'd all like to do." Another FLNM stated, "sign language, explain when there's a language barrier, it takes more time, it definitely takes more time." More specifically, FLNMs noted that it takes an inverse amount of time to communicate when there is a language barrier, to validate expectations, and to accommodate cultural differences. 77 As one FLNM stated, "there isn't the time factor that you, that I think needs to exist in hospitals." Another stated "I'm not sure we had the time to spend with these [culturally diverse] people." Another FLNM stated, "we are pressed for time and even if we're aware [of cultural beliefs], um, are we going to be able to accommodate a lot of these things." In addition, shortened patient stays, same day admissions, increased turnover rate, and day care services imposed by hospital-wide restraint reduce the time necessary to accommodate for cultural differences. One FLNM stated "it's just a challenge for the entire hospital to, in times of fiscal restraint and not enough time and shortened patient stays and coming in the same day as surgery is to be able to, um, educate all the staff so that they recognize what the norms may be for different cultures." Nurses do not have enough time to adequately accommodate cultural differences. However, FLNMs stated that an effort is still made, particularly with dying patients. Time constraints also have an impact on FLNMs' ability to foster an appreciation of cultural differences among their staff. Fiscal restraint also imposed challenges which affected FLNMs' ability to manage effectively in a culturally diverse environment. This challenge was not specifically addressed in the literature in relation to managing cultural diversity, rather it presented a challenge for FLNMs to manage effectively overall. The impact of fiscal restraint was perceived by FLNMs to be greater where cultural diversity of staff and patients was present. 78 FLNMs indicated that "more money, more time" would be helpful in managing in a culturally diverse environment. Summary. Several barriers were identified by FLNMs participating in the focus groups that make it more difficult to manage in a culturally diverse environment. These barriers included discrimination, lack of knowledge about other cultures, and decreasing financial resources. Although there is little literature about discrimination in the Canadian health care system it was identified in this study as being present. Lack of knowledge of principles of transcultural nursing care is commonly cited as an important issue that needs to be addressed. Fiscal restraint further contributes to the complexities of managing in a culturally diverse environment. Decreasing financial resources was to some extent an unexpected finding. Each of these factors can influence the quality of care received by culturally diverse clients. Ethical Issues The fourth theme emerging from the focus group data relates to ethical issues that can arise from providing care to culturally diverse clientele. Eliason (1993) contends that "nursing practice cannot be ethical unless the culture and beliefs of the client are taken into consideration" (p. 225). Nurses have been educated to believe that all patients should be treated equally. However, various cultural groups have unique needs which are not always taken into account in the provision of nursing care (Grypma, 79 1993). "There is growing recognition that to treat all clients equally means to treat some of them poorly" (Eliason, p. 225). Grypma (1993) noted that the health care system was established before the increase in non-European immigrants and, therefore, reflects the predominance of white middle class values and beliefs. Similarly, the values of the Caucasian majority, to the exclusion of those of other cultures, are reflected in the nurses. This is slowly changing with the recruitment of culturally diverse staff. Some of the FLNMs participating in the focus groups were aware of and frustrated by their inability to meet the unique needs of culturally diverse clients. One FLNM stated, "it's very unfair to a patient, a resident, to be cared for by someone that cannot meet their needs, communicate with them." Another FLNM stated that "I'm quite frequently frustrated by the inability to meet their needs." A third FLNM stated, "we're so routinized with a number of things and there's nothing I can do about a lot of those routines to meet the cultural needs." FLNMs provided several specific examples where ethical issues arose surrounding cultural differences. Informed consent was one area for concern, as one FLNM stated, "sometimes when we're asking for consents for things and even though it's translated or whatever, um, because it is, I mean it's so foreign to that person or their culture...but does the other person really understand." Another common example was provided by a FLNM who stated, "they'll say we don't want the 80 patient to know, the family make a decision the patient is not to be told so we're dealing with a patient who does not know." In both of these examples, nurses were faced with an ethical dilemma as they were not convinced that the patients fully understood the implications of their situation. FLNMs provided numerous examples of discharge planning and death and dying where cultural differences can lead to ethical issues. One FLNM summarized by stating that, "he who speaks the language and knows the Western medicine ways will probably benefit most fully from the system." The nursing literature puts forth several explanations to support the claim that culturally diverse clients receive a lower standard of care. One explanation is a lack of knowledge of other cultures (Leininger, 1976). Another explanation is an ethnocentric viewpoint held by nurses (Leininger). Ethnocentrism refers to the belief that the values and beliefs of our own culture are the best and all other cultures should hold those values and beliefs (Eliason, 1993; Leininger; Thiederman, 1986). A lack of knowledge about other cultures may contribute to ethnocentrism which in turn can lead to prejudice (Eliason). A third explanation is the presence of discrimination in health care organizations (Farr, 1991; Lowenstein & Glanville, 1991; Poteet, 1986; Reimer, 1995). Discrimination occurs when individuals are treated differently on the basis of a personal characteristic such as race or religion. Finally, the philosophy of the health care organization and the resources and 81 services available can influence nursing care (Kubricht & Clark, 1982; Murphy & Clark, 1993; Reimer). Each of these factors can decrease or increase the quality of care provided to culturally diverse clients. Reimer (1995) explored nurses' experiences caring for culturally diverse clients. She concluded that culturally diverse clients may receive a lower standard of nursing care in some situations. Reimer postulates that the quality of care is dependent on three factors: the nurse's commitment to transcultural nursing, the strategies employed by the nurse, and contextual factors. Contextual factors included the influence of the health care setting, support of colleagues, commitment of the institution, and the foundation of education. The findings of this study of FLNMs are consistent with those of Reimer who examined perceptions of staff nurses in the Lower Mainland of British Columbia. The knowledge that individuals of differing cultural backgrounds may receive a different or, in some cases, lower standard of care presents very compelling ethical issues for FLNMs to address. FLNMs are responsible for setting the standard and direction for nursing practice on their units (Baxter, 1993). FLNMs are in a pivotal position as they have daily contact with individuals throughout the health care organization. FLNMs who are committed to meeting the needs of culturally diverse clients will seek ways to improve the quality of care to those clients. It should be noted that one of the hospitals participating in this study is in 82 the process of developing multicultural programs in an effort to provide transcultural care. Summary The challenges identified in this study will persist as the diversity of the Canadian population continues to increase. Thus, FLNMs must explore the challenges of difficulties in communication, differing role expectations and behavioural norms, and conflict resolution in a culturally diverse environment. Several facilitators and barriers to culturally sensitive care emerged in the study. Facilitators included the hospital philosophy and policies, availability of resources and services, matching cultural profiles, and celebrating cultural differences. It is noteworthy that managing in a culturally diverse environment can be more difficult in the absence of these facilitators. Barriers included discrimination, lack of knowledge about other cultures, and decreasing financial resources. These factors influence the quality of nursing care provided to culturally diverse clients. As has been shown, many of the findings of this study are congruent with those of other studies. 83 Chapter 5: Summary, Conclusions, and Implications Summary The purpose of this study was to examine the perceptions of first line nurse managers (FLNMs) managing in a culturally diverse environment. Canada is becoming more multicultural every year through immigration. In health care, culturally diverse staff provide nursing care to patient populations with cultural backgrounds different than their own. Thus, FLNMs are challenged to manage effectively in a culturally diverse environment. The cultural diversity of Canadians presents nurses and FLNMs with numerous challenges in attempting to treat all patients equally. However, there is evidence that culturally diverse patients may receive a lower standard of care in some situations. This has important implications for FLNMs. Transcultural care, the roles of FLNMs, and managing diversity were briefly explored in the literature review in order to gain a perspective on managing in a culturally diverse environment. In the literature, nurses described difficulties in communication and a lack of knowledge as problems encountered while caring for culturally diverse individuals. Also, the availability of resources and services influenced the quality of care provided to culturally diverse patients. The roles of FLNMs have changed dramatically over the last few years. Whether the title is head nurse, supervisor, coordinator, or 84 director, FLNMs are responsible for maintaining high standards of patient care and a harmonious work environment. Managing in a culturally diverse environment presents FLNMs with several challenges. Predominant issues in the literature included communication, differing concepts of nursing, conflict, and the presence of discrimination. Also, reported in the literature were FLNMs' needs for education and accessible resources and services to assist them to meet these challenges. A descriptive design was used to examine the perceptions of FLNMs managing in a culturally diverse environment. This study is part of a more comprehensive study by Acorn and Crawford (1995) in which data were collected through a survey completed by 200 FLNMs in 38 acute care hospitals throughout British Columbia. The study utilized focus groups to augment the qualitative data collected in the survey pertaining to managing in a culturally diverse environment. A focus group was conducted at each of three acute care hospitals in the Lower Mainland of British Columbia. Nurse administrators at each of these hospitals reported having staff members from diverse cultural backgrounds serving culturally diverse patient populations. Between six and eight FLNMs participated in each focus group. The focus groups were audiotaped for verbatim transcription. Data were examined using latent content analysis, that is, segments of data were coded into categories and themes emerged across the coded categories. 85 The findings of this study revealed that managing in a culturally diverse environment is very complex and challenging for FLNMs. Four themes emerged from the focus group data, identified as challenges, facilitators, barriers, and ethical issues. Challenges are an area of major concern for FLNMs and include difficulties in communication, differing expectations and behavioural norms, and conflict resolution. FLNMs also identified facilitators and barriers to managing in a culturally diverse environment. The presence of both facilitators and barriers influences the quality of care provided to culturally diverse patients. Facilitators refer to factors that would make managing in a culturally diverse environment easier for FLNMs. The FLNMs described the hospital philosophy and policies, resources and services, matching cultural profiles, and celebrating cultural differences as important facilitators. Managing in a culturally diverse environment is more difficult for FLNMs without these facilitators. Barriers identified by FLNMs included discrimination, lack of knowledge about other cultures, and decreasing financial resources. A disturbing finding is the ethical issue that patients with differing cultural backgrounds may receive a lower standard of care in some situations. 86 Conclusions The study findings suggest the following conclusions: 1. Managing in a culturally diverse environment is a complex and challenging experience for FLNMs. It is becoming a role expectation rather than the exception as the diversity of Canada continues to increase through immigration. 2. The needs of culturally diverse patients are not always met. 3. The presence and nature of facilitators and barriers influences the quality of care provided to culturally diverse patient population. 4. Discrimination is present in hospitals in the Lower Mainland of British Columbia, on both an individual and institutional level. 5. Education is a key factor for successful management in a culturally diverse environment. A lack of knowledge can serve to perpetuate stereotypes. 6. Ethical dilemmas may occur as a result of several factors, such as difficulties in communication and differing cultural expectations and behavioural norms. Implications The findings of this study have implications for nursing practice, education, research, and health care administration. The implications are expressed as recommendations aimed at ensuring a high standard of health care for all clients. 87 Nursing Practice Persons with differing cultural backgrounds may receive a lower standard of care in some instances. Therefore, nurses must acknowledge the unique needs of culturally diverse clients. Meeting the needs of patients with diverse cultural backgrounds is dependent on several factors. One, FLNMs participating in this study indicated that communication difficulties arise in transcultural care. On the basis of this finding, nurses need to attempt to communicate verbally and non-verbally with culturally diverse clients. It is imperative that information be accurately translated when clients are making decisions about their care such as signing informed consents. There are ethical implications for nurses who witness consents without being convinced that the client fully understands. This can be accomplished with the assistance of interpretive services. Family members and other hospital staff can be used to translate if necessary; however, use of a professional interpreter is ideal. Two, FLNMs also indicated that difficulties can arise when differing expectations and behavioural norms exist. Nurses must gain an understanding of the patient's expectations of care. Also, it is important to examine differing family involvement and decision-making for culturally diverse patients and their respective family members. Nurses can gain an understanding of patients' cultural perspectives by asking whom they wish to include in their decision-making and care. With this 88 as a starting point, nurses and patients can work together to identify and meet patients' unique needs. This can also help avoid potential conflict between staff and patients and their respective family members. Findings of this study indicate that conflict may arise from differences in communication and differences in expectations and behavioural norms across cultures. Three, nurses need to be aware of and use the resources and services available to them in the provision of care to culturally diverse clients. FLNMs participating in this study identified resources and services such as interpreter services, volunteers, and food services. Utilization of these as appropriate helps to meet the needs of patients with diverse cultural backgrounds. Four, the presence of individual and institutional discrimination can interfere with the quality of care provided to culturally diverse patients. Findings of this study indicate that discrimination is present in health care organizations and needs to be addressed. All levels of managers must acknowledge the presence of discrimination on both an individual and institutional level. Once discrimination is identified within institutions, steps can be taken to eliminate it. Nursing Education Nursing curricula need to include transcultural care which includes the concept of culture and the role that culture plays in everyday life. FLNMs participating in this study indicated they need additional knowledge 89 about cultural care as they had limited exposure to caring for culturally diverse clients in their nursing education. Undergraduate nursing curricula can foster an appreciation of cultural jdiversity and the importance of accommodating cultural differences to meet patient needs. It is important that nursing students learn that, in order to treat all patients equally, culture must be taken into account. However, content should not be too specific regarding different cultures. JA lack of knowledge or too much knowledge can lead to e-vergeneralizations and stereotyping. Stereotyping fails to acknowledge the uniqueness of each individual. Thus, education that fosters a respect for individuals and their cultural beliefs is crucial to transcultural care. It would be helpful for nursing students to be exposed to individuals rom various cultures within educational programs. This can be accomplished in a variety of ways. Nursing students from diverse cultural backgrounds can share their experiences with others, thus fostering an linderstanding and appreciation of other cultures. Also, nursing students can be assigned to care for culturally diverse clients in the clinical setting. They can begin to explore ways to meet patient needs using resources and services to assist them in the provision of care. Finally, the sharing of experiences in caring for culturally diverse clients can be valuable. Nursing students should examine their attitudes toward different cultures. An ethnocentric attitude can lead to an inability to provide quality care to culturally diverse patients. Prejudice may always exist; i 90 however, individuals should learn the importance of respect for others and their beliefs. Therefore, prejudice and discrimination should be addressed at both an individual and institutional level in nursing curricula. Discrimination acts as a barrier to transcultural care and interferes with working relationships among culturally diverse staff members. These implications for nursing students also have implications for faculty members since they guide student learning and act as role models in the clinical setting. Graduate nursing curricula for prospective nurse managers should examine issues of managing in a culturally diverse environment. FLNMs participating in this study indicated that they learned to manage in a culturally diverse environment through trial and error and identified the need for continuing education. Nurse managers need to understand concepts and principles of culture, techniques for managing a culturally diverse staff, and the effects of diversity on staff performance. A substantial effort must be put into building a cohesive workforce. Hence, nurse managers should begin to examine business practices for managing diversity that have been successful. Finally, FLNMs play an important role in managing conflict. FLNMs participating in this study stated that conflict can occur in nurse to nurse, nurse to patient, and patient to patient situations. It became apparent from this study that FLNMs did not perceive that they have sufficient conflict resolution skills. This is another area that needs to be addressed 91 so that all nurse managers can effectively deal with conflict when it arises from cultural diversity. Nursing Research This study has implications for further research in several key areas. One, additional research is needed that explores how nurses can better meet the needs of culturally diverse clients. This includes the identification of resources and services to further facilitate meeting the needs of diverse patient populations in the health care setting. This is crucial as nurse managers are responsible for the provision of quality care to culturally diverse clients. Further research should examine the presence of discrimination in the Canadian health care system. Ways to reduce and eliminate discrimination need to be explored at an individual and institutional level. Also, the effect of discrimination on the quality of care and the recruitment and retainment of culturally diverse staff needs to be explored. Another key area in which more research is warranted is the identification of effective strategies and techniques for FLNMs to manage cultural diversity of staff and patients. However, the situation at each health care organization is unique; therefore, each institution must examine its own unique situation. Research should be undertaken by individual health care organizations to identify the needs of staff and patients prior to instituting any educational program as educational programs need to fit the needs of the organization. 92 Further research should also examine existing hospital philosophies and policies that impede and/or facilitate meeting the needs of culturally diverse clients. Some hospitals have taken action to embrace cultural diversity and their efforts should be commended. Finally, this study should be repeated at other institutions given the small sample size and close proximity of the three hospitals. Also, some individuals may speak more freely regarding the issue of discrimination in health care organizations during an individual interview. Thus, there may be some advantage to using individual interviews over focus groups to further explore this sensitive topic. Health Care Administration Management must make it a priority to value cultural diversity and address workplace issues arising from cultural diversity of staff and patients. The findings of this study indicate that several facilitators and barriers to cultural diversity can exist within health care organizations. Management must be cognizant of the existence of these facilitators and barriers and strive to eliminate the barriers and enhance the facilitators. Each health care organization needs to begin by examining its philosophy and policies in relation to culturally diverse patients. Findings of this study indicated that some hospitals explicitly acknowledge their commitment to cultural diversity in their philosophy and other hospitals do not. This is important since the philosophy of an institution provides direction for patient care. Policies can either accommodate cultural 93 diversity or discriminate against patients from cultural backgrounds. Examples in this study included visitation policies and informed consent policies. Also, the hospital must be committed to cultural diversity by ensuring that resources and services are available for staff to meet patient needs. Resources and services identified by FLNMs in this study included 24-hour access to professional interpreters and food services that cater to cultural food preferences. Hospitals need to emphasize their commitment to provide culturally sensitive care in the orientation of new staff. This would introduce staff to the hospital's commitment to valuing cultural diversity. Orientation can emphasize respect and awareness of cultural value systems; however, orientation in itself is insufficient. Other suggestions to address staff diversity are mentoring programs for new staff, role modelling, continuing education programs, and action to deal with discrimination. FLNMs can initiate mentoring programs to assist all staff. Mentoring can occur with a staff member of the same culture and another staff member representing a different culture. Mentoring can facilitate the exposure of new staff to the resources and services available within the health care organization to assist them to meet the needs of culturally diverse clients. Role modelling is a very powerful tool since individuals tend to emulate the behaviours of influential individuals. Therefore, nurse managers need to be aware of their influence and, through the use of 94 intentional role modelling, help to socialize nurses into providing quality transcultural nursing care. The hospital needs to provide continuing education programs or inservices to educate staff and address issues such as discrimination. Such educational programs or inservices need to be tailored to the individual needs of the health care institution. Also, the promotion of team building and mutual understanding can be fostered through participation in a cultural awareness week and celebrations for various cultural holidays. Discrimination within the health care organization needs to be addressed at an individual and institutional level and action must be taken to rectify the situation. Provision of a lower standard of care for culturally diverse patients is unethical. Quality of care for culturally diverse patients needs to be examined and the situation addressed. Discrimination affects the quality of patient care and the working relationships among health care providers. Finally, sufficient funds must be set aside for the commitment to recognizing cultural diversity in the provision of care. Findings of this study indicate that the climate of fiscal restraint has had an impact on FLNMs' ability to manage effectively. The perceived effect is even greater in a culturally diverse environment. 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(1992). Multiculturalism and "the politics of recognition". Princeton, NJ: Princeton University Press. Thiederman, S. (1986). Ethnocentrism: A barrier to effective health care. Nurse Practitioner. H (8), 24-26. 104 Thiederman, S. (1989). Managing the foreign-born nurse. Nursing Management. 20(7), 13. Tomlinson, C. (1990). Racism in nursing: Biting the hand. Nursing Times. 86 (39), 34-35. Toumishey, H. (1991). Cultural and racial sensitivity: Implications for health curricula. Report of the Multicultural Health Curriculum Project Committee. Toronto: CCMH/MHC. Tripp-Reimer, T. (1984). Cultural assessment. In J. Bellack & P. Bamford (Eds.), Nursing assessment: A multidimensional approach, (pp. 226-245). Belmont, CA: Wadsworth. Waltz, C , Strickland, E., & Lenz, E. (1984). Measurement in nursing research (2nd ed.). Philadelphia: F.A. Davis. Webber, H. (Ed.). (1984). Webster's dictionary II: New riverside dictionary. Boston, MA: Houghton Mifflin Co. Wilson, H. (1993). Introducing research in nursing (2nd ed.). Menlo Park, CA: Addison-Wesley. 105 Appendix A: Survey Questions Questions from survey by Acorn and Crawford (1995). 1. Please identify any specific challenges that you have in managing a culturally diverse workforce: 2. Does the ethnic diversity of your staff closely reflect your patient population? e.g. If 20% of your patient population are of Chinese descent, 20% of your staff are also of Chinese descent. Yes No Please elaborate on the proportion of ethnic staff/patient mix: 3. List 3 (or more) skills/resources that would help you manage better in your culturally diverse environment. 106 Appendix B: Interview Guide The purpose of this focus group interview is to get your perceptions, as a first line nurse manager, of managing in a culturally diverse environment. Before we begin this focus group interview, it would be helpful to define the term "culture". Culture represents a system of values and beliefs shared by a group. For the purposes of this focus group interview, I am using the term culture to include differences in race, religion, national origin, and language. Please keep this definition in mind throughout the interview. Focus Group Trigger Questions: 1. I would like to begin this interview by discussing the cultural differences represented in your nursing staff and patient population. Can you tell me about the cultural differences represented in your staff. Probe: Could you elaborate on what basis your staff are unicultural or homogeneous? How do these cultural differences compare to those represented in your patient population? Probe: Are your staff and patient population approximately the same or different. If they are different, how so? 2. As a FLNM, can you tell me how you accommodate these cultural differences among your staff? 3. Thinking back over the past few months, could you give me some examples of challenges that you have encountered managing in a culturally diverse environment. 107 Probes: Differing role expectations among culturally diverse nurses was identified as a challenge in the survey data. Is this a challenge for you? Language and communication problems can lead to misunderstanding. Is this a challenge for you? Hospitals are not immune to racial discrimination. Could you provide an example where discrimination was an issue (i.e., language proficiency, performance evaluations)? Conflict among staff often arises as a result of cultural differences. Is this a challenge for you? Conflict may also arise as a result of cultural differences among members of the multidisciplinary team of health care professionals. Is this a challenge for you? Please tell me how you deal with the challenges that you have described. 4. Can you tell me about any exposure you have had to the topic of managing a culturally diverse staff? Can you tell me what you, as a FLNM, would find most helpful in managing a culturally diverse staff. Probe: Could you tell me more about the type of information/education/programs you would find most helpful. 5. We talked earlier about the challenges of managing in a culturally diverse environment. Now I would like to discuss some of the benefits. Can you tell me about any benefits or advantages that you've noticed working with a culturally diverse staff in this hospital. Probe: The literature identifies improved patient care by matching cultural profiles of staff to patients, improved problem-solving and decision-making, enhanced creativity as strengths associated with a culturally diverse staff. Is this the case? 108 6. Thinking back over the past few months, could you give me some examples of how you, as a FLNM have fostered an appreciation of cultural differences in your environment. 7. Are there any other points on this topic that we haven't touched on that you would like to bring up? Appendix C: Demographic Sheet Age at last birthday: Highest educational level: Nursing Diploma Nursing Diploma with additional certificate/courses Baccalaureate Degree (Nursing) Baccalaureate Degree (Other) Masters Degree (Nursing) Masters Degree (Other) Years of experience as a first line nurse manager: Completed questionnaire in Spring 1994: YES _ NO Thank you for your participation in this focus group. T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A 110 School of Nursing T206-2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Tel: (604) 822-7417 Fax: (604) 822-7466 Appendix D: Consent FOrm I understand the purposes of this study, "Decentralized Organizational Structures and First Line Nurse Managers", are to examine 1) fiscal restraint, culturally diverse environments, and technology as factors contributing to organizational complexity and 2) the relationships between decentralization and job satisfaction, organizational commitment, and professional autonomy of first line nurse managers. Data have already been collected through a self-administered questionnaire. Therefore, the focus group interviews will be conducted to explore the factors contributing to organizational complexity in further depth. I understand that I will be asked to participate in a focus group interview, conducted by Virginia Lim, to explore the issues surrounding managing in a culturally diverse environment. Six to eight first line nurse managers will participate in this focus group interview which will not exceed two hours in duration. The interview will be tape recorded for transcription into written format at a later time. Once the interviews are transcribed, the tapes will be destroyed. My name and any identifying information will not be revealed in the study. Confidentiality has been assured because a code number known only to Virginia Lim and the two co-researchers will identify the tapes and written copies of the recorded information. I am under no obligation to participate in this study and refusal to participate will not affect my employment in any way. I understand that if I participate, I can withdraw at any time, refuse to answer any questions or ask to have part or all of the tape erased. I will receive a copy of this form. All my questions have been answered and if I have any further questions, I can contact Virginia Lim at XXX-XXXX or the co-researchers: Dr. Sonia Acorn, XXX-XXXX; Ms. Marilyn Crawford, XXX-XXXX. Date: Signature: I understand the nature of this study and give my consent to participate. Date: Signature: I acknowledge receipt of a copy of this consent form. 

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