Delivery of Culturally Competent Care to Children With Cancer and Their Families—The Latino Experience

Experiences with Childhood Cancer among Latinx Families: Identification of Informational and Support Needs

Latinx children with cancer generally have poorer health outcomes than their non-Latinx White counterparts. The purpose of this study was to examine the experience of Latinx mothers whose children have been diagnosed with cancer at the onset of symptoms, the barriers surrounding the diagnostic process, and the resources families identify are needed post-diagnosis. The researchers conducted two focus groups (one in Spanish, one in English) with Latina mothers of children who have or experienced pediatric cancer in the United States. Two researchers conducted constant comparative analysis of the transcribed focus group audio recordings to identify themes. Themes included a sense of community support at the onset of symptoms, feelings of disbelief, helplessness, overload of information, and a need for advocacy in medical settings. Needs included more palatable and simplified information, financial assistance and resources, increased parental social support, accessible Spanish-speaking providers, and culturally informed care. Latina mothers indicated a range of challenges pertaining to childhood cancer diagnosis and treatment that may impact child and family outcomes. Implications for social work practitioners to reduce disparities and develop intervention programs for Latinx families of children with cancer are discussed.

The evolution of parents' beliefs about childhood cancer during diagnostic communication: a qualitative study in Guatemala

INTRODUCTION

Fatalistic cancer beliefs may contribute to delayed diagnosis and poor outcomes, including treatment abandonment, for children with cancer. This study explored Guatemalan parents' cancer beliefs during initial paediatric cancer communication, and the sociocultural and contextual factors that influence these beliefs.

METHODS

Twenty families of children with cancer were included in this study. We audio-recorded psychosocial conversations with psychologists and diagnostic conversations with oncologists, then conducted semi-structured interviews with parents to explore the evolution of their cancer beliefs. Audio-recordings were transcribed and translated from Spanish into English, with additional review in both languages by bilingual team members. All 60 transcripts were thematically analysed using a priori and novel codes.

RESULTS

Guatemalan parents' beliefs evolve as they learn about cancer through various sources. Sources of information external to the cancer centre, including prior experiences with cancer, media exposure, community discussion and clinical encounters, contribute to pre-existing beliefs. Many parents' pre-existing cancer beliefs are fatalistic; some are influenced by Mayan spirituality. Sources internal to the cancer centre include psychologists and oncologists, other providers, other patients and families. Psychologists acknowledge pre-existing beliefs and deliver cancer education using verbal explanations and hand-drawings. Oncologists provide diagnostic information and outline treatment plans. Both support hope by providing a path toward cure. Parents' lived experience is a culmination of sources and simultaneously independent. Ultimately most parents arrive at an understanding of cancer that is consistent with an allopathic medical model and offers optimism about outcomes.

CONCLUSION

An interdisciplinary communication process that includes cancer education, is attentive to pre-existing beliefs, and supports hope may encourage acceptance of the allopathic medical model and need for treatment. Providers in settings of all resource levels may be able to use these techniques to support cross-cultural cancer communication, reduce treatment abandonment and improve therapy adherence.

Exploring Differences in Perceived Satisfaction, Resilience, and Achievement Between Hispanic and Non-Hispanic White Childhood Cancer Survivors

INTRODUCTION

To address gaps in understanding disparities of posttraumatic growth among childhood cancer survivors, the aims of this study were to (1) compare satisfaction, resilience, and achievement among Hispanic and non-Hispanic White survivors; and (2) examine relationships between sociodemographic and clinical factors with satisfaction, resilience, and achievement.

METHOD

Survivors (N = 116) at Children's Hospital of Orange County After Cancer Treatment Survivorship Program completed the Child Health and Illness Profile-Adolescent Edition.

RESULTS

Resilience (p = .003) and achievement (p = .005) were lower among Hispanic survivors. Resilience was positively associated with satisfaction (p < .01) and achievement (p < .01) and achievement was positively associated with years of schooling (p < .01). No differences were found between Hispanic and non-Hispanic White satisfaction scores (p = .95).

DISCUSSION

Our findings suggest ethnic disparities in posttraumatic growth in childhood cancer survivors. Interventions aimed at promoting posttraumatic growth are vital to address these differences.

Differing interpretations of health care encounters: A qualitative study of non-Latinx health care providers' perceptions of Latinx patient behaviors

INTRODUCTION

Due to provider shortages, it is probable that non-Latinx health care providers (HCPs) will treat Latinx patients. Because of this discrepancy, both providers and patients are likely to experience barriers and cultural differences during medical encounters. This article discusses select cultural factors and behaviors such as language, communication styles, and health care practices of Latinx families through the lens of their non-Latinx HCPs. The purpose of this study was to examine how non-Latinx HCPs perceive and describe certain behaviors they observe during healthcare visits with Latinx patients and families, and to illustrate how those behaviors can alternatively be interpreted as representing Latinx cultural norms.

METHODS

This qualitative study used a template coding approach to examine narrative interviews conducted with 18 non-Latinx HCPs to report how they described interactions with and the behaviors of their Latinx patients. Template codes were based on well-established Latinx cultural norms (e.g., familismo, respeto, personalismo, simpatía, confianza).

RESULTS

Many HCP descriptions of Latinx patient behaviors were coded into the Latinx cultural values categories (familismo, personalismo, simpatía, respeto, and confianza) by the research team. Results suggest that HCPs were not aware of how several of their patients' behaviors may be culturally grounded, and that cultural differences between HCPs and their Latinx patients may exist.

DISCUSSION

Understanding how Latinx-specific cultural norms may be exhibited by Latinx patients and their families during healthcare encounters has potential to improve providers' understanding of patient behavior, helping to promote culturally congruent care for Latinxs.

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

Towards culturally competent paediatric oncology care. A qualitative study from the perspective of care providers

In order to gain more insight on the influence of ethnic diversity in paediatric cancer care, the perspectives of care providers were explored. Semi-structured interviews were conducted among 12 paediatric oncologists and 13 nurses of two different paediatric oncology wards and were analysed using a framework method. We found that care providers described the contact with Turkish and Moroccan parents as more difficult. They offered two reasons for this: (1) language barriers between care provider and parents hindered the exchange of information; (2) cultural barriers between care provider and parents about sharing the diagnosis and palliative perspective hindered communication. Care providers reported different solutions to deal with these barriers, such as using an interpreter and improving their cultural knowledge about their patients. They, however, were not using interpreters sufficiently and were unaware of the importance of eliciting parents' perspectives. Communication techniques to overcome dilemmas between parents and care providers were not used and care providers were unaware of stereotypes and prejudice. Care providers should be offered insight in cultural barriers they are unaware of. Training in cultural competence might be a possibility to overcome manifest barriers.

The impact of language barriers and immigration status on the care experience for Spanish-speaking caregivers of patients with pediatric cancer

BACKGROUND

An increasing proportion of pediatric cancer patients in the United States are Latino and many have Spanish-speaking immigrant parents with limited English proficiency (LEP). Little is known about how language or undocumented immigration status impacts their care experience.

PROCEDURE

A cross-sectional survey was administered to English (N = 310) and Spanish-speaking LEP (N = 56) caregivers of pediatric cancer patients. To assess differences in healthcare experiences between the language groups, t-tests and chi-square statistics were used. Multivariable logistic regression evaluated associations between primary language and knowledge of clinical trial status.

RESULTS

Spanish-speaking caregivers were more likely to report higher rates of quitting or changing jobs as a direct result of their child's cancer, and their children were more likely to experience a delay in education. Although Spanish-speaking caregivers reported higher satisfaction with care, 32% reported feeling that their child would have received better care if English was their primary language. Spanish-speaking caregivers were more likely to incorrectly identify whether their child was on a clinical trial compared with English-speaking caregivers. The majority of Spanish-speaking caregivers reported at least one undocumented caregiver in the household and 11% of them avoided or delayed medical care for their child due to concerns over their undocumented immigration status.

CONCLUSIONS

Language barriers and undocumented immigration status may negatively impact the quality of informed decision-making and the care experience for Spanish-speaking LEP caregivers of pediatric cancer patients. These families may benefit from culturally appropriate Spanish language resources to improve communication and open a dialogue regarding undocumented immigration status.

Obstacles to Transcultural Caring Relationships: Experiences of Health Care Staff in Pediatric Oncology

This qualitative study explores the caring situation of families with an immigrant background within the context of pediatric oncology care from the perspective of health care staff. Five focus group interviews and 5 complementary individual interviews were conducted after purposive and theoretical sampling, respectively. Grounded theory methodology revealed that obstacles to transcultural caring relationships are a main concern of the health care staff. These obstacles are divided into 4 main categories: linguistic, cultural and religious, social, and organizational. When health care staff fail to recognize obstacles to transcultural caring relationships, the result is inequity in care of families with an immigrant background. Equity in care for all does not mean identical treatment but, rather, care adjusted to the needs of the individual family regardless of background.

Cultural Influence on Family Management of Children With Cancer

A family's cultural context directly influences how they define and manage their child's cancer. Knowing this dynamic can guide nurses in delivering holistic, culturally competent care. This literature review examines the international and domestic pediatric oncology research as it relates to the inclusion of family and cultural variables. Most international studies and comparative studies have investigated Asian cultures and found that health beliefs, communication beliefs, religious practice, and family structure are common themes of cultural influences on families. Additional studies within the United States are needed to explore cultural beliefs through carefully tailored family assessments. Implications for practice include the possibility of providing evidence-based culturally competent care to families of children with cancer.

Exploring Factors Influencing Transcultural Caring Relationships in the Pediatric Stem Cell Transplant Setting: An Explorative Study

In the literature, there is evidence about the importance of ensuring a Family-Centered approach for foreign patients to provide culturally competent care. The Italian context shows a lack of studies concerning nurses' perceptions regarding factors that influence foreign patients' daily care. In addition, the number of pediatric patients coming to Italian hospitals to be cured has increased dramatically in the last few years. This study aims to investigate the pediatric nurses' perception of the factors influencing nursing care for foreign pediatric patients who have undergone a stem cell transplant (SCT) and their families. A qualitative approach is used. Semi-structured interviews were recorded, transcribed verbatim, and analyzed using qualitative techniques for recurrent themes. Italian SCT pediatric nurses were interviewed until data saturation was achieved. Four themes emerged from the analysis: "Respect for other cultural traditions," "Different roles," "Communication," "Equal treatment and different opportunities." Communication was seen as a barrier in caring for foreign patients. Nurses perceived a lack in their training and knowledge when caring for foreign patients. The hospital supports nurses when caring for foreign patients. We found that pediatric nurses do not feel they are caring for foreign patients in the same way as they do for Italians, but adopt strategies to improve their relationships with them. Semi-structured interviews proved to be useful in highlighting the nurses' perceptions. These data were confirmed by the results of the audit conducted with the "Children and Young People's Audit Policy Tool," The tool suggests specific interventions when foreign patients are admitted.

The shared experience of adolescent and young adult cancer patients and their caregivers

OBJECTIVE

We examined the interdependent, dyadic, mental health of adolescent and young adult (AYA) cancer patients and their caregivers. Our aims were as follows: (1) to investigate the degree to which patients' and caregivers' subjective perceptions of illness severity are congruent with objective severity (i.e., medical indicators), (2) to compare patients' and caregivers' subjective perceptions of illness severity and cancer-related posttraumatic stress symptoms (PTSS), and (3) to evaluate whether subjective perceptions of illness severity are linked to patients' and caregivers' cancer-related PTSS.

METHODS

The AYA cancer patients (n = 110; ages 12-24 years; 52% male) undergoing active treatment at an outpatient clinic and their caregivers (n = 110; 97% parents; ages 24-68 years; 89% female) independently reported their PTSS and subjective illness severity.

RESULTS

Overall, neither patients' nor caregivers' reports of subjective illness severity were associated with objective illness severity. Caregivers reported higher PTSS than did patients and higher illness severity than younger, but not older, patients. Actor-partner interdependence model analyses indicated that AYA patients' subjective illness severity is the strongest predictor of their own PTSS and is a significant correlate of their caregivers' PTSS. Caregivers' subjective illness severity is associated with their own PTSS only. Results remained robust after controlling for demographic and illness characteristics.

CONCLUSIONS

The AYA patients' and caregivers' illness perceptions are distinct from each other and from objective medical indicators of illness severity. Patients' reports of subjective illness severity may be a marker for their own and their caregivers' mental health. Patient care and efficacious psychosocial interventions may require consideration of both patients' and caregivers' subjective perceptions of illness severity.

Cultural Influences in Pediatric Cancer

Objective: To review the literature on cultural factors influencing clinical care and family management of pediatric cancer. Methods: A literature review including 72 articles related to cultural issues in pediatric cancer was conducted. Information was organized around several clinically driven themes. Results: Cultural factors influenced many aspects of the cancer experience including illness representations, reaction to diagnosis, illness disclosure patterns, complementary and alternative medicine use, management of medical procedures, coping strategies, and end of life issues. Conclusion: Increased awareness of cultural factors is needed to improve clinical care and reduce health disparities. Specific strategies to approach cultural differences are provided to enhance patient and family care from diagnosis to cure/end of life.

Low-income cancer patients in depression treatment: dropouts and completers

This study aims to explore reasons for depression treatment dropout among low-income, minority women with depression and cancer. Semi-structured telephone interviews are conducted with 20, predominately Latina, patients who dropped out of depression treatment and 10 who completed. Transcripts analyzed using techniques rooted in grounded theory. Treatment completion barriers cluster according to Meichenbaum and Turk's (Facilitating treatment adherence: A practitioner's guidebook, Plenum Press, New York, 1987) five adherence dimensions: (a) Barriers to Treatment (informational, instrumental, cultural [language, discrimination]); (b) Disease Features (emotional burden of cancer/depression); (c) Cancer/Depression Treatment Regimens; (d) Provider-Patient Relationship (depression treatment dissatisfaction); and (e) Clinical Setting (hospital organizational issues). Although both groups describe multiple overlapping dimensions of barriers, completers seem more motivated and satisfied with treatment, possibly due to completers experiencing the positive treatment effects after the first several sessions. More research should be conducted to determine the most effective clinical treatment methods for this population.

Cultural and religious considerations in pediatric palliative care

OBJECTIVE

A growing multicultural society presents healthcare providers with a difficult task of providing appropriate care for individuals who have different life experiences, beliefs, value systems, religions, languages, and notions of healthcare. This is especially vital when end-of-life care is needed during childhood. There is a dearth of literature addressing cultural considerations in the pediatric palliative care field. As members of a specific culture often do not ascribe to the same religious traditions, the purpose of this article was to explore and review how culture and religion informs and shapes pediatric palliative care.

METHOD

Comprehensive literature searches were completed through an online search of nine databases for articles published between 1980 and 2011: PsychINFO, MEDLINE®, Journal of Citation Reports-Science Edition, Embase, Scopus, CINAHL®, Social Sciences Citation Index (SSCI), EBSCO, and Ovid. Key terms included: culture, transcultural, spiritual, international, ethnic, customs or religion AND end-of-life, palliative care, death, dying, cancer, or hospice, and children, pediatrics, or pediatric oncology. Reference lists in the retrieved articles were examined for additional studies that fit the inclusion criteria, and relevant articles were included for review. In addition, web-based searches of specific journals were conducted. These included, but were not limited to: Qualitative Health Research, Psycho-Oncology, Journal of Psychosocial Oncology, Journal of Pediatric Psychology, Journal of Pediatric Health Care, Journal of Pediatric Oncology Nursing, Omega, Social Work in Health Care, and Journal of Palliative Medicine.

RESULTS

Thirty-seven articles met eligibility criteria. From these, seven distinct themes emerged that have implications for pediatric palliative care. These include the role of culture in decision-making, faith and the involvement of clergy, communication (spoken and unspoken language), communicating to children about death (truth telling), the meaning of pain and suffering, the meaning of death and dying, and location of end-of-life care.

SIGNIFICANCE OF RESULTS

The review of the literature provides insight into the influence of religion and how culture informs lifestyle and shapes the experiences of illness, pain, and end-of-life care. Recommendations for providing culturally sensitive end-of-life care are offered through the framework outlined in the Initiative for Pediatric Palliative Care Quality Improvement Project of 2002. Cultural traditions are dynamic, never static, and cannot be generalized to all families. Guidelines to aid in approaches to palliative care are provided, and providers are encouraged to define these important differences for each family under their care.

Childhood cancer-parenting work for British Bangladeshi families during treatment: an ethnographic study

OBJECTIVE

To detail the day to day management experiences of a specific group of parents from a minority ethnic group who lack representation in many studies.

BACKGROUND

Studies of parental experiences during their child's treatment for cancer have revealed a considerable burden of care related to intensive treatment regimens and the uncertainty of prognosis. In the context of UK paediatric cancer services there is limited research on how parents manage their daily lives and no published studies detailing the experiences of parents from minority ethnic groups.

DESIGN, SETTING AND PARTICIPANTS

This ethnographic study used participant observation in the home, community and clinical settings, to follow eight families of British Bangladeshi children undergoing cancer treatment over an extended time period (22 months). Focused interviews with parents (7) were conducted. Data were analysed concurrently during fieldwork with themes identified, defined and refined, maintaining context whilst comparing within and across data sets.

RESULTS

Parental roles and responsibilities are reconceptualised in this study as a form of 'work' that parents (and children) undertook to achieve and manage cancer treatment. Five themes describing parental work were identified: Managing Competing Knowledge, Vigilance, Advocacy, Balancing Parental Work and the Burdens of Treatment. Analysis revealed that cancer-specific knowledge was more highly valued by professionals than child-specific knowledge. A good deal of their 'work' related to being vigilant about their child's condition and care and treatment, including acting as advocates. Whilst undertaking caring work for their child, parents had to balance this with a range of other responsibilities. The range of responsibilities placed on parents throughout treatment were acknowledged only rarely by professionals and as a result, parents experienced their input as a burden that lacked recognition and increased a vulnerability, already present through minority ethnic status.

CONCLUSIONS

The taken for granted and often unseen aspects of parenting during childhood cancer treatment constituted a considerable workload for this group of parents. The relentless nature of treatment was also a burden, since this took place in the context of on-going uncertainty about their child's recovery. Clinical staff should consider the impact of service organisation and treatments on specific groups of parents including minority ethnic groups in order to recognise and mitigate against burdensome work.

Individual adjustment, parental functioning, and perceived social support in Hispanic and non-Hispanic white mothers and fathers of children with spina bifida

OBJECTIVE

To compare Hispanic and non-Hispanic White mothers and fathers of children with spina bifida on measures of individual adjustment, parental functioning, and perceived social support.

METHOD

Mothers (29 Hispanic, 79 non-Hispanic white) and fathers (26 Hispanic, 68 non-Hispanic white) completed questionnaires regarding psychological distress, parental functioning, and perceived social support.

RESULTS

Mothers and fathers reported similar individual adjustment across groups. Hispanic mothers reported lower levels of parenting satisfaction, competence as a parent, and social support, as well as higher perceptions of child vulnerability. Hispanic fathers reported lower levels of parenting satisfaction and higher perceptions of child vulnerability. Effect sizes were reduced when socioeconomic status was included as a covariate.

CONCLUSIONS

Hispanic parents, particularly mothers, are at risk for lower feelings of satisfaction and competence as parents. More research is needed to understand cultural factors related to these differences.

The meaning of surviving cancer for Latino adolescents and emerging young adults

Adolescent and young adult (AYA) survivors of cancer are an understudied population with unique developmental and medical needs that extend well beyond their active treatment. Survivors diagnosed as AYAs may experience both physical and emotional late effects. In particular, the experiences of Latino cancer survivors have not been explored. The purpose of this study was to conduct interviews with AYA Latino cancer survivors to inform professionals working with these survivors. A hermeneutic phenomenological approach was selected based on the focus on experiences and meanings of Latino adolescents' cancer survivorship. Phenomenology allows for understanding the subjective meaning and lived experience of populations that are understudied or marginalized. In-depth interviews were conducted with participants. Enrolled in the study were Latino AYAs between the ages of 14 and 21 years, after treatment. Interviews revealed 7 themes regarding the experience and meaning of survivorship for this population: gratitude, humor/positive attitude, empathy for younger children with cancer, God and faith, cancer happens for a reason/cancer changed my life, familial support, and staff relationships. Latino AYA cancer survivors develop meaning out of unique cancer experiences. Programs need to be developed specifically to address Latino adolescents and young adult survivors of cancer.

Toward a new definition of health disparity: a concept analysis

In response to federal requests for investigation into measures to eradicate health disparities, a concept analysis of the term health disparity was conducted. Health-related and multidisciplinary literature was reviewed. Multiple terms were explored alone and in combination with no limitations on search date parameters. Findings indicated several definitions of the concept,with the term health care disparity being used interchangeably with the term health disparity. New theoretical and operational definitions, antecedents, characteristics, and consequences of the concept are proffered. Model, borderline, and contrary cases are developed to illustrate the concept. Nursing implications and recommendations for future research are discussed.

Measuring psychosocial risk in families caring for a child with cancer: the Psychosocial Assessment Tool (PAT2.0)

BACKGROUND

The Psychosocial Assessment Tool 2.0 (PAT2.0) is a recently developed screening measure for assessing psychosocial risk in families caring for a child with cancer. This study aimed to assess the external validity of the PAT2.0 in an Australian pediatric oncology sample. Further aims included examining mothers' and fathers' PAT2.0 scores, change in psychosocial risk over time, and the relationship between treatment intensity and psychosocial risk.

PROCEDURE

Parents of 143 children newly diagnosed with cancer completed the PAT2.0 at diagnosis (T1) and 6-8 months later (T2). A treatment intensity measure (ITR-2) was completed by two clinical oncologists.

RESULTS

The PAT2.0 stratified families into a 3-tiered risk framework and was consistent with existing data from the authors of the scale. The majority of families were stratified into the Universal (lowest risk) category; more than one-third of families had some elevated psychosocial risk. PAT2.0 scores of mothers and fathers were correlated and psychosocial risk remained relatively stable between T1 and T2. Treatment intensity scores were not related to PAT2.0 scores at T2.

CONCLUSIONS

Findings support the external validity of the PAT2.0 as a psychosocial screener. Mothers' and fathers' ratings of risk are similar; however, multi-informant use of the PAT2.0 may be clinically useful. Psychosocial risk, as measured by the PAT2.0, is a relatively stable construct over the first months of treatment and is independent of treatment intensity.

Qualitative analysis of the role of culture in coping themes of Latina and European American mothers of children with cancer

It has been well established that mothers of children diagnosed with cancer experience high levels of distress. Latina mothers may be at risk for higher levels of distress related to language barriers, cultural factors, and economic, immigration, and acculturation stressors. Despite the increasing US Latino population, few studies have examined the role of culture within pediatric oncology, including how mothers cope with their child's cancer. This study used qualitative analysis of 24 sessions from 3 Latina and 3 European American mothers of children recently diagnosed with cancer. The session transcripts were divided into a total of 2328 thought segments that were then analyzed for themes using a collaborative iterative process. Analysis identified 9 shared coping themes that included, with some variations: gathering information, professional help-seeking, activities, problem solving, positive thinking, present orientation, reframing, avoidance, and religion. Three themes were culture specific: only European American mothers discussed compromise, whereas normalization and perspective taking were unique to the Latina mothers and suggest that the cultural value of simpatía influences coping. Clinical and research recommendations are discussed.

Beyond cultural competency: Bourdieu, patients and clinical encounters

In response to widely documented racial and ethnic disparities in health, clinicians and public health advocates have taken great strides to implement 'culturally competent' care. While laudable, this important policy and intellectual endeavour has suffered from a lack of conceptual clarity and rigour. This paper develops a more careful conceptual model for understanding the role of culture in the clinical encounter, paying particular attention to the relationship between culture, contexts and social structures. Linking Bourdieu's (1977) notion of 'habitus' and William Sewell's (1992) axioms of multiple and intersecting structures, we theorise patient culture in terms of 'hybrid habitus'. This conceptualisation of patient culture highlights three analytical dimensions: the multiplicity of schemas and resources available to patients, their specific patterns of integration and application in specific contexts, and the constitutive role of clinical encounters. The paper concludes with a discussion of directions for future research as well as reforms of cultural competency training courses.

Protecting professional composure in transcultural pediatric nursing

In this qualitative study, we used grounded theory to explore the category of "overwhelming emotional expressions" that emerged in a previous study. Using theoretical sampling, 12 individual interviews were conducted with nurses in Swedish pediatric care. Overwhelming emotional expressions have been found to override nurses' professional preparedness; they continuously resolve this by protecting professional composure. Various strategies are used to protect professional composure, including rationalizing, controlled expression, power display, escape/avoidance, distancing, sharing, and management of space. Some of these strategies are similar to coping strategies. However, they differ in that they are about managing the situation and also include protecting the professional composure of the individual as well as the whole care situation. Nurses need to gain preparedness to meet overwhelming emotional expressions in transcultural care and to be aware of strategies for protecting professional composure so as to use them consciously and positively.

What has the literature taught us about culturally competent care of women and children

This article describes what is currently in the literature about culturally competent care for women and children. With the population of the United States growing increasingly diverse, there is a developing need for cultural competency among nurses and throughout healthcare organizations. Cultural competence includes both culture-specific and culture-generic knowledge, attitudes, and skills. While databased literature on cultural competency still requires further development, we do have evidence of positive outcomes of culturally competent care. The end result of the provision of culturally competent care by culturally competent nurses and healthcare organizations can be significant improvements in the health and well-being of women and children.