Creating cross-racial primary care relationships in a nurse-managed center

Journal of Cultural Diversity, Fall, 2004 by Ramona Benkert, Joanne M. Pohl, Patricia Coleman-Burns

Abstract: Culturally incompetent communication patterns with providers influence the health disparities of African Americans. Limited knowledge exists on cross-racial nurse practitioner nurse-patient relationships (NP-NPRs). The purpose of this paper is to describe how NPs and patients in cross-racial relationships developed primary care relationships in one nurse managed center (NMC).

A qualitative design incorporated a social constructivist paradigm and the methodology of Interpretive Interactionism. Twenty cross-racial NP-patient dyads (White NPs and Black patients)participated in individual 1 to 3-hour audiotaped interviews regarding their ongoing relationships and the impact of the NMC.

The analysis uncovered a rich description of the relationship processes from the initial meeting to its current state. Multiple themes for each phase, as well as, four typologies of primary care cross-racial NP-NPRs are described.

Significant relationship work was needed by both partners to overcome communication misunderstandings, contextual aspects of cross-racial interactions and other overt and covert perceptions.

Key Words: Cross-Cultural, Primary Care Relationships, Nurse-Managed Center

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Racial and ethnic biases have been implicated as a factor in the health disparities of persons of color (Smedley, Stith, & Nelson, 2002). Racial biases are critical to understanding community-based primary care because mutual patient-provider decision-making and planning are dependent on a complex interactive process that is hampered by these biases (van Ryn & Burke, 2000). Numerous studies have suggested that racial differences influence communication resulting in inadequate diagnostic testing (Canto, Allison, & Kiefe, 2000), miscommunications about etiologies, insufficient treatment plans (Abreu, 1999) and discounting of patient's ideas (Helms & Cook, 1999). Most studies focus on physician providers. Yet, nurse practitioners (NPs) and patients from diverse backgrounds have created relationships in primary care for over 30 years. Despite the considerable research about NPs, few studies focus on the nurse practitioner-nurse patient relationships (NP-NPRs) (Fisher, 1995; Johnson, 1993) and none were found that provide an understanding of cross-racial relationships.

Cross-racial communication during primary care NP-NPRs in a nurse-managed center (NMC) has received little to no attention. Assumptions about care in NMCs are based on the work of non-NP nurses (Morse, DeLuca-Havens, & Wilson, 1997), nursing philosophical tenets (Lowenberg, 1994) and studies of NPs in other settings (Brykczynski, 1989). Few studies have explored the perspectives of patients (Scott & Moneyham, 1995), and no study described the perspectives of persons of color. The purpose of the present study was to reconstruct the process of cross-racial primary care relationships between African American patients' and White nurse practitioners from one urban nurse-managed center.

Background

The NP profession has focused most of its research toward professional validation (Bullough, 1995), instead of discovering the source of their successes. Seminal qualitative studies have reported that NPs creatively develop the NP-NPR utilizing a variety of contextually complex relationship skills (Brykczynski, 1989; Fisher, 1995; Johnson, 1993). These researchers argued that to fully understand NP care, and consequently their NP-NPRs, the care must be studied in context and with more depth about the participants and the relationships. Although NPs have been found to excel in nurse-patient interactions, the patients in these studies have been predominately White middle-class women (Johnson) or remain undocumented (Taylor, Pickens, & Geden, 1989). Few studies have provided information on the practice site or other setting specific influences (Campbell, Mauksch, Neikirk, & Hosokawa, 1990). Given that NPs in NMCs service a large proportion of culturally diverse and disenfranchised clients (Reisch, 1992), these NPs, like most nurses, are likely confronting the complexities of cross-cultural relationships. Yet, few studies of these relationships exist.

With the exception of the community health nursing literature, most of the non-NP nurse patient relationship literature is limited in its applicability to NP research due to role distinctions (Morse, et al., 1997), context (May & Purkis, 1995) and autonomy over practice (Lowenberg, 1994). The community health nursing literature suggests that nurses struggle with cross-cultural relationships finding them difficult (Chalmers, 1994), challenging (DeLaCuesta, 1994), and at times mutually dissatisfying (Murphy & Macleod-Clark, 1993). Community health nurses also find that the shift in context from hospital to community settings accentuates the complexities of cross-cultural relationships (Clarke, & Cody, 1994).

A report by the Commonwealth Fund (2001) suggested that cross-racial communication in health care settings have the greatest potential for misinterpretations between providers and patients. Persons of color report cross-racial discrimination as one cause for their service under-utilization and unmet health care needs, but report different views about their private physician and contrast him/her with the systemic discrimination in health care. In contrast, White providers often cite discriminatory behaviors in co-workers, but not in themselves (Kaiser, 1999). A wealth of physician-patient communication literature exists, but there has been no study of the concept of a sustained cross-racial partnership as advocated in the Institute of Medicine report on primary care (1996). Most studies focus on deficits in these relationships (Cooper & Roter, 2002). These reports substantiate that a problem exists in cross-racial communication but there is limited descriptions about how to sustain cross-racial primary care relationships.