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Journal of Transcultural Nursing 24(3) 313 –318 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659613481809 tcn.sagepub.com

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Two important aspects of providing culturally competent care are the ability to reflect on one’s own beliefs, values, and perspectives and the ability to understand the perspec- tive of the other, often the patient or family (Jeffreys, 2010; Leininger & McFarland, 2002; Purnell & Paulanka, 2003; Spector, 2009). These are not concrete tasks that can be learned through memorization or following a set of direc- tions. They are skills that require that the nurse be directly involved in the learning process and that result in competen- cies that are adaptable to individual patient needs.

The creation of a learning environment that encourages self-reflection and direct interaction with the learning pro- cess can often be challenging for educators and others charged with staff or student training. Transformational learning theory (Mezirow, 1997) supports an active learning approach and enables nurse educators and trainers to create an environment in which the nurse can self-reflect and con- sider how his/her own perspective affects patient care, espe- cially when the patient’s needs, beliefs, and values do not match his/her own. This article describes event analysis, a methodology that can be used in multiple settings, to identify the individual nurse’s perspective and how it can have an impact on the provision of quality patient care.

Event analysis is an effective way to incorporate impor- tant concepts such as empathy, self-awareness, and reflection into learning through the exploration of events that already have meaning to the nurse. In event analysis, the nurse’s own practice offers a rich source of information and examples

that are used to enhance both clinical and emotional intelli- gence. The use of the nurse’s own experience is advanta- geous in that there is already a direct emotional and cognitive connection with the material to which the nurse has already applied personal or professional meaning. This is a key con- cept in transformational learning theory (Mezirow, 1997) where “frames of reference” or the “structures of assump- tions through which we understand our experiences” (p. 7) provide the context for the learning process. A distinct advantage to this approach is that the use of the nurse’s own assumptions and understandings has the potential to hold each individual nurse’s interest in learning and to provide the context of immediate relevance to each individual’s nursing practice, in addition to prompting free discussion and sup- port for a variety of concerns and topics. The objectives of this article are to discuss the usefulness of event analysis in the development of the nurse’s self-awareness and awareness of the perspectives, needs, values, and culture of others; to describe how to perform event analysis; and to discuss ways this method can be used and adapted for multiple settings.

481809TCNXXX10.1177/1043659613481809Journal of Transcultural Nursing 24(3)Kozub research-article2013

1Xavier University, Cincinnati, OH, USA

Corresponding Author: Mary L. Kozub, Department of Nursing, Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207, USA. Email: [email protected]

Through the Eyes of the Other: Using Event Analysis to Build Cultural Competence

Mary L. Kozub, PhD, RN1

Abstract Cultural competence requires more than the accumulation of information about cultural groups. An awareness of the nurse’s own culture, beliefs, and values is considered by several transcultural nursing theorists to be essential to the development of cultural competence and the provision of quality patient care. Using Transformational Learning Theory, this article describes event analysis, an active learning tool that uses the nurse’s own practice to explore multiple perspectives of an experience, with the goal of transforming the nurse’s approach to diversity from an ethnocentric stance, to one of tolerance and consideration for the patient’s needs, values, and beliefs with regard to quality of care. Furthermore, the application of the event analysis to multiple settings, including inpatient, educational, and administrative environments, is discussed.

Keywords cultural competence, self, reflection, transformational learning

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The Value of Self-Awareness: The Role of Reflection

Awareness of the nurse’s own culture, beliefs, and values and how they contribute to the quality of care provided to a diverse population of patients is a key step to attaining cul- tural competence that is noted frequently in transcultural nursing theory. Self-awareness and reflection provide both a baseline for culturally competent practice and an understand- ing of the nurse’s responses to diverse patient needs and motivations to provide quality individualized care.

This simple act of reflection is a stepping stone to the ful- fillment of the Standards of Practice for Culturally Competent Nursing Care (Douglas et al., 2011). The knowledge and understanding nurses can gain through reflection and per- spective taking are applicable to multiple practice standards, specifically Standards 1, 2, 3, 6, and 9. Standard 1, Social Justice, refers to the provision of equitable care for all peo- ple, regardless of their differences from others and includes fairness, dignity, and respect in the provision of care. Standard 2, Critical Reflection, is at the core of the event analysis and involves awareness and analysis of one’s own perspective and the role it has in the provision of culturally congruent care. Standard 3, Knowledge of Cultures, involves not only the awareness of cultural information but also the understanding of how this information relates to the patient and his or her well-being. Standard 6, Patient Advocacy and Empowerment, is a positive outcome of the nurse’s engage- ment in the role that self-understanding and the awareness of the patient perspective can play in the provision of care. Through the acts of advocacy and empowerment, the nurse can ensure that care is culturally appropriate, safe, and mean- ingful and the patient can become an active participant in his or her own care. Standard 9, Cross Cultural Communication, is key to providing culturally congruent and meaningful care and is not limited to merely a linguistic interpretation. Communication is also a nonverbal and a behavioral process, and in addition to allowing nurses to learn about their own and their patients’ cultural values, perspectives, and needs, it provides an avenue for the expression of respect and caring between nurse and patient.

Transcultural nursing theorists identify self-awareness as an integral step in the development of culturally congruent care. Leininger and McFarland (2002) clarify the role of self- reflection when she stresses the value in having an awareness of one’s own cultural biases, which can interfere with effec- tiveness in caring for patients when they do not share a com- mon cultural background or values with the nurse, or when patients come from different racial backgrounds than the nurses who care for them. Leininger explains that ethnocen- trism, the belief that an individual’s own culture, beliefs, or life ways are superior to any others, is not the nurse’s charac- ter flaw, rather a universally held principle in the human community, but she adds that strong adherence to ethnocen- tric attitudes, which can result in nonacceptance of the

values, culture, and needs of patients, can impair nursing practice, and even cause harm. Spector (2009) affirms that rigid adherence to one’s own culture as superior can be harm- ful in the caring relationship. Furthermore, professional eth- nocentrism can be expressed as part of the nurse’s professional identity when prescribed Western medical- and technology- based treatments are the preferred approach to care, and the health care provider is seen as the authority on what is best for the patient without consideration for the patient’s views that might contradict medical authority. The rigid nature of pro- fessional ethnocentrism is evident when the health provider adheres strictly to Western medicine’s technological approach to health and healing and the patient’s beliefs, cultural prac- tices, and values are, at best, ignored. This approach leaves the patient, the health care consumer, at a significant disad- vantage, without the benefit of a meaningful healing experi- ence and without the possibility of active participation in the restoration of either health or healing. The development of a professional ethnocentrism may begin in nursing education (Jeffreys, 2010) where traditional nursing beliefs and values are taught and supported. Jeffreys challenges nurse educators to increase their sensitivity to the rapidly changing cultural climate and its effect on quality care and to accommodate these into the education of future generations of nurses.

How does awareness of one’s own cultural beliefs and values contribute to quality in nursing practice? Purnell and Paulanka (2003) believe that the nurse’s own cultural expe- riences, once understood, can have a positive impact on the care of individuals from diverse cultural backgrounds. Self- awareness is a tool that allows the nurse to understand per- sonal reactions, feel confident as a professional, and create a context where the patient’s needs can be understood and prioritized appropriately. When nurses acknowledge their feelings, beliefs, and values, they are better able to separate them from the feelings, beliefs, and values of their patients and remove them from a context of personal bias. This frees the nurse to interact with patients and others in a culturally respectful manner and challenges him/her to go beyond pure awareness of cultural beliefs, values, and biases into the cognitive and emotional realms of culture and use it to con- sciously integrate cultural competence into professional practice.

Transforming Nurses’ Thinking As Jeffreys (2010) suggests, active learning is a useful tool to help individuals develop cultural competence. Active learning, which occurs when the individual interacts directly with the information rather than passively absorb- ing it as would occur in a lecture, involves a commitment, by the learner, to relate directly with the concepts and con- tent being taught. Many learning theories use an active learning approach, but transformational learning theory (Mezirow, 1997) provides the learner with a strongly reflec- tive approach, which incorporates the individual’s own

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perspective into learning and explores the meaning the individual ascribes to the concepts being presented.

One way to illustrate transformational learning theory (Mezirow, 1997) in a culture care context is by considering the concept of ethnocentrism. As stated above, ethnocentric thinking in nursing creates a limited context whereby the nurse functions from the perspective that his/her own beliefs, values, or perspectives, or those of nursing culture, which include the Western medical model, are superior (Jeffreys, 2010; Spector, 2009). Additionally, in this perspective, the medical practitioner, in this case the nurse, has authority over the patient’s treatment. In this example, ethnocentrism pro- vides the nurse with a frame of reference, or a set of assump- tions, which informs his/her nursing care, one assumption being that the nurse knows what the patient needs and the patient should be a passive recipient of nursing care.

In transformational learning (Mezirow, 1997), the learner becomes aware of his frame of reference and the underlying assumptions and reflects on them critically, with the goals of becoming aware of what they are and understanding them. In our example, the nurse would become aware of ethnocentric attitudes and how they affect the care of the patient and then consider whether this approach results in care that meets the patient’s needs.

The applicability of transformational learning (Mezirow, 1997) has been demonstrated successfully in a wide variety of studies across multiple disciplines and using various methodologies. Ruth-Sahd, Beck, and McCall (2010) used survey and focus group methodologies to examine outcomes of professional externship experiences for nursing students prior to entering their senior year. They found that, although not all students reported the same level of change in their perspectives of nursing as a career, most found that the externship was transformative, with many experiencing changes in their assumptions and beliefs about nursing as a profession and gains in confidence in their ability to fulfill their roles and become professional nurses. Sandlin and Bey (2006) used a case study methodology to document the trans- formative changes experienced by archaeologists as they considered the basic assumptions of their profession and began to place it in a context that retained the purely scien- tific approach to archaeology and also began to incorporate concepts such as environmental preservation and social con- sciousness. In this study, they chronicled the development of an archaeological project in the Yucatan Peninsula and the experiences of the participants as they acted on their newly transformed perspectives and began to incorporate environ- mentally sound and socially conscious methods into their work. Their reflections on the impact this may have on their profession as a whole also demonstrated a transformative experience. Finally, Ntseane (2011) applied transformational theory within a cultural context in Botswana and found that transformation in thinking is not limited to the Western per- spective. It can take place in other cultural contexts using a culturally sensitive approach, and change can be expressed

within the context of the individual’s cultural understand- ings, broadening the applicability of Mezirow’s (1997) model. Discourse, an important tool in the process of reflec- tion, is a dialogue and occurs in the context of a group. The group of learners works together with the information, nego- tiating, validating, and supporting each other’s learning (Mezirow, 1997). During discourse, group members learn through working directly with the content, interpreting it, understanding it, negotiating, and problem solving with each other. The goal, throughout this process, is not to memorize pieces of information but to transform the way the learner understands and uses his/her frame of reference to impact, in this case, on patient care. In the case of ethnocentrism, a nurse who has experienced a transformation in his/her think- ing may recognize his/her own biases or the biases of nursing culture, resulting in a better understanding of the patient’s needs, values, and perspectives, incorporating them into his/ her care, or he/she may use this awareness to seek informa- tion to learn about the patient’s culture in order to understand how the patient views and experiences illness or healing.

Event Analysis

An event analysis is the exploration of an occurrence or inci- dent from multiple perspectives with the intention of describ- ing what happened, understanding its impact, and exploring the meaning it holds. There are three phases of the analysis, each an observation of the same event from the perspective of a different stakeholder. The event that forms the focal point of the analysis is unique to each participant and is derived from his or her professional nursing experiences.

The First Perspective

To begin, participants are asked to describe an incident that occurred while they were working as a nurse and which stands out in their minds. This request potentially results in a wide variety of scenarios encompassing patient care, advocacy, policy, and administrative events, with some of their incidents being pleasant and others traumatic. This variety of subject matter contributes to the richness of the discussion and allows for multiple topics to be discussed. It is important to note here that the moderator of the activity may require additional criteria, such as that the event must be linked to cultural care or may limit the topic to direct patient care experiences. It may also be helpful to put a limit on the length of each perspective, such as no more than two, double spaced, typewritten pages. This will become impor- tant when the group meets and the experiences are shared with the other group members. It is also advisable to assign one perspective at a time, so that the participants’ focus is on letting the process unfold rather than just getting all the work done ahead of time.

When describing their selected event, participants are asked to explain the situation, or event, in terms of what

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happened, describing their thoughts and reactions, the context, the action, and the people involved. They are also asked to describe the results of what happened and interpret the impact of the situation, including what it meant to them or how they feel it reflected on them as nurses or on their nursing practice.

I didn’t know what to do, I kept asking her questions, some of them very personal, and her husband insisted on answering every time. All she did was sit and look at her lap, with her hands folded. I could see she was in pain, but she didn’t make a sound. I couldn’t help thinking that I should have insisted more strongly that he leave but when he refused the first time I asked him I didn’t know what else to do. He almost looked at me as if he was going to be angry when I first suggested it, and there I was alone in the room with them. I was beginning to get angry myself, I had a lot of work to do besides this admission, and I was getting nowhere. I knew that we had a large Asian population here, and I had heard that the husbands pushed their way in, but I thought those were just stories. I thought “he is not going to get out of my way and let me care for is wife the right way.”

The power of this exercise comes from the group context in which it is held. Once the first description is written, par- ticipants meet in a group with a moderator and each, in turn, shares his/her chosen scenario with the group. Once read, the audience is encouraged to comment on what they have just heard, asking questions, interpreting, and offering their thoughts. This process is repeated as each individual offers his/her story and receives feedback from the group. At this point, the role of the moderator is to listen, encourage the group to provide constructive comments and to help clarify if needed. Presentation of each perspective to the group is an essential component of this exercise and is consistent with Mezirow’s (1997) discourse phase. In transformational learning theory, group interaction and negotiation is vital to the process of learning, beginning with the awareness of one’s frames of reference, to creative problem solving to validate a newly learned perspective.

The Second Perspective

After the completion of the first description, participants are asked to retell their same stories from the perspective of a different stakeholder. This person is another person, not the nurse, who is directly involved in the incident. It may, for example, be the patient in a patient to nurse interaction, or a colleague, in a disagreement in a work-related context. In the case of cultural care, this may require some research on the part of the nurse to gain an understanding of the values, beliefs, and other cultural aspects of the individual’s cultural group in order to represent the individual’s perspective more accurately.

Identifying a second perspective allows the individual, and the group, to redefine the problem, to break out of their comfort zones, and consider that there may be another per- spective outside of their own frame of reference. According

to Mezirow (1997), the introduction of challenges to previ- ously held assumptions creates learning as the group process begins. This second assignment is often met with anxiety, which is expected and is described by Mezirow, but once completed, the second perspective most often results in an insightful description of the event, providing rich data not found in the nurse’s perspective and affords further opportu- nity for group discussion and analysis.

The nurse was so disrespectful. She expected me to leave! If I left, who would speak for my wife? Who would protect her? Her English is not good. I stood my ground, I am the husband, it is my job to speak for her, I know what she needs. She is a woman, she does not know how to get what she needs. Those questions were so personal! Why do they need to know when she went to the bathroom last? She is in PAIN! Can’t they see that? Why do they make her ask for relief? Aren’t they supposed to care? They should know. I really have to watch them to make sure they take good care of my wife! I will stay by her side, they cannot make me leave.

Participants are again asked to read their stories to the group, one at a time, continuing to provide interpretation and meaning of the event, but this time the nurse’s perspective is suppressed and the nurse speaks as the other person. The other group members perform the same role in this second phase, asking questions, interpreting and offering comments on what they have just heard. Once the second perspective is discussed, it is helpful for the group to compare and contrast this second analysis with their previous findings. The mod- erator’s role remains stable in this phase, ensuring that the discussion continues and that comments are supportive and appropriate.

The Third Perspective

The final phase of the event analysis is achieved when the participants write a third perspective, similar to the previous one, except that this is the perspective of an individual who is not directly involved in the incident itself but who either observed it, as in a member of the patient’s family, or another nurse who was present, or someone who was marginally con- nected to it, such as a nurse manager who had to mediate a disagreement, or who met with the family to resolve a con- cern. This third perspective requires the individual partici- pants to refocus and write as if they had only observed the incident and may describe a perspective of someone who did not have a personal stake in the event or first-hand knowl- edge of what had happened.

My husband was so angry. He was not very respectful of that nurse. I wish she had just let him speak for me, he knows what is best. I am in so much pain! It hurts and I just want it to stop. I don’t know why she had to ask me all those questions, can’t she see it on my face that I am in pain? I don’t understand how they do things here, the lights are so bright and I am so tired,

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but they have so many questions and they are not happy to have my husband answer for me. What does it matter if he answers or if I do? I want to go home, I want to have some tea with my herbs and go to sleep. I know that it will help me if I am just patient, I know that I just need to take care of myself and pray for relief to come.

As with the first two perspectives, group members each present their new perspectives to the group and a discussion follows. The moderator continues to provide oversight to the group and ensures that group members participate.

Closing the Event Analysis

Completion of this exercise involves contemplation and summary of the role of each perspective in presenting the whole picture. Group members are encouraged to consider differences in the perspectives that are important to improv- ing nursing care, whether they involve the evaluation of cur- rent policies, knowledge deficit of the nurse or the development of empathy, and the ability to see the care they give from the perspective of the person receiving it, moving away from a task-oriented approach and encouraging a holis- tic perspective that leaves all who are involved feeling as though a caring act has taken place. Significant learning can take place as a result of this exercise. This learning provides the basis for future discussions, or in the case of classroom use, it can present students with topics for future assignments that are meaningful to the student, increasing direct interac- tion with class content and transforming the nurse’s thinking, both in the classroom and in his/her nursing practice.

The Moderator’s Role

This process may seem like a lengthy one in that three ses- sions are required. However, the goal is a transformational change in the nurse, leading to an advancement of skills, even empathy for others. Such a profound change will not happen in an instant, an investment in the process is required. The event analysis encourages individual partici- pation as students each share their stories and their inter- pretations of their stories, and others are invited to offer support and helpful comments. The success of the group requires that each individual have the information needed to participate fully, which occurs when each member reads his/her perspectives to the group each time. In this way, the participants’ wisdom guides the process, allowing the group to validate the nurse’s perceptions, reflect critically on the event, and use critical thinking and creative prob- lem-solving techniques to reframe the event and determine alternative responses to the event in question (Mezirow, 1997). During this process, the moderator is not confined to the authoritative role demanded by traditional teaching and lecturing. The objective of the moderator is to main- tain a free environment for learning and sustain an attitude

of acceptance, collaboration, and support. An additional benefit for nursing educators and administrators is that as this process develops, the moderator is freed to listen to the participants and learn from them, allowing for constant adjustment in the moderator’s approach to the teaching process and an in-depth insight into the participants’ obser- vations, experiences, and perspectives. This can be valu- able information for the nurse mentors and administrators who need to have their fingers on the pulse of patient care and who are preparing new nurses for practice.

Moderating a transformational learning exercise such as this does not only require a change in thinking from the par- ticipants, the person leading the exercise must also undergo a change in perspective (Jeffreys, 2010; Mezirow, 1997). An active learning exercise requires students to interact directly with the content and provide their own interpretations; the moderator sets the context and monitors the sessions. Since there is no lecture, the moderator is not responsible for being the authority, for providing specific content to a passive audi- ence, or for forcing students to listen. This change from the role of lecturer to moderator can be challenging but will hopefully be eased with the following suggestions.

Expect the Unexpected. Participants will identify events that the moderator may not be able to predict. It is not important what event is described, as long as it meets the overall crite- ria of coming from nursing practice, having meaning for the nurse, and any other criteria specified by the moderator. It is best, however, for a situation to be specific enough to be able to be used, a generalized event, such as “improved patient care,” does not allow for in-depth analysis.

Be Patient. This approach is new, both for students and for moderators. There may be initial discomfort for students when they realize that they are not going to be able to sit back and absorb information, but will have to interact directly with it. The moderator also has to be aware of potential dis- comfort, for example, when students are slow to start talking. Here, the temptation is to break the silence and fall back into familiar ways of teaching or training.

Look for the Wisdom in Your Participants. A key assumption in this activity is that the nurses involved are experts on their own experiences, with a subsequent goal that they will use their experiences to gain knowledge and to reflect on them- selves. This concept is key to the development of cultural competence, as described above. All the information needed to successfully achieve the objectives of this activity is pres- ent in the participants’ experiences, knowledge, and perspec- tives and is enhanced through the support of the group. In addition to the participants’ learning, an observant moderator will have the opportunity to hear and understand the perspec- tive of nurses on the front lines of patient care, discussed in a manner rarely shared behind the closed doors of an adminis- trator’s office. The insight provided can provide valuable

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information that can lead to improvements in patient care, nurse retention, and other aspects of health care.

Applications

Event analysis can be a useful tool for the development of culturally competent nurses. In addition to self-reflection and the transformational aspect of this activity, there is opportu- nity for the development of cultural knowledge as well, as participants research and seek out information that will help them understand and express the perspective of the other and the opportunity to learn about other cultural groups in the context of group discussion. Because of the variety of topics that may be described within any given group, numerous topics such as communication skills, policy, patient care con- cerns, nurse to nurse relationships, and others can be covered in a short amount of time. Also, because the participants choose the events to describe, topics that are relevant to them at the time can be easily identified and covered by the nurse educator or administrator.

Event analysis is also useful in multiple contexts. Although it was developed for use in the classroom, it can be modified to be used with new nurses during orientation, staff who work together in any setting, or during problem-solving sessions such as quality assurance investigations. Additionally, the procedure described above could be followed in an online forum, with chat capability, although mechanisms for main- taining confidentiality must be ensured when information is shared in a permanent form such as writing.

Event analysis was developed for use in an RN to BSN pro- gram. The goal was to find an activity that would fully engage all students and create a cohesive group to facilitate learning in a seminar class setting. The result of using this activity was unexpected and created a focus for the entire class, which con- tinued throughout the rest of the semester-long course. Students who participated in this activity have been found to be more involved in class work and discussions, have used their find- ings from their perspectives papers as the basis for other class assignments, and have been able to identify the relevance of course content directly to their nursing practice. As the modera- tor, this activity has the potential to improve teaching skills by allowing the instructor to become less dedicated to the role of the authority in the classroom, freeing him/her to listen and respond to the learning needs of the students.

Conclusion This article has described the uses and procedure for con- ducting an event analysis, a useful tool for developing

cultural competence in nurses. The basis for the event analysis is the ability of the nurse to become aware of his/ her own perspectives and biases through the description of an event that is meaningful and relevant to him/her, and through reflection on the impact the event has had on both patient care and the nurse’s individual nursing practice. Transformational learning theory (Mezirow, 1997) pro- vides theoretical support for the use of the event analysis as a way to focus on self-awareness and self-reflection in the production of actual change in the nurse’s perspective leading to true cultural competence.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author- ship, and/or publication of this article.

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