Meeting Patients Where They Are
Nursing Students & Refugees Teach Each Other
Growing up in an industrialized country, most of us have certain routines down pat: defrosting meat safely; using the proper amount of laundry detergent to use in the washing machine; storing vegetables in the refrigerator. But if you were an adult who had never seen a refrigerator or a washing machine before, you might have a few questions. And you would be grateful to someone answering those questions with clarity – and with compassion.
Second-semester nursing students at GCC have the opportunity do just that, as part of a program that takes them out of the classroom and into a clinic, Arizona Medical Clinic, which caters to refugees who have come to Arizona, seeking a better life. Nurse Practitioner Jill Ocano, who teaches nursing at GCC, runs the program, which is required for students in her second-semester class, Nursing Theory and Science II.
Ocano characterizes the refugee population as a vulnerable community. Coming from challenging circumstances, they need education and support in their transition. And there are a lot of people in this category. According to the United Nations High Commission for Refugees (UNHCR), there are more than 40 million uprooted people around the world today. The United States accepts the most of any other country in the world, from 40,000 to 70,000 every year. According to the U.S. State Department Bureau of Population, Refugees and Migration, 1,138 refugees settled in Arizona in 2013.
Many of the patients at Arizona Medical Clinic speak little or no English. The clinic helps them get medical help in their own language. Founded by a Cambodian doctor (who herself was once a refugee) and her Vietnamese husband, the clinic is staffed by caring nurses and doctors, aided by a team of translators speaking a range of languages. The clinic sees up to 800 patients a week.
Ocano’s GCC students serve patients by running the clinic’s annual flu clinic. She also requires them to design a teaching project centered on patients at the clinic. Students earn credit for the mandatory teaching project, which centers on delivering workshops for the refugees on hygiene, nutrition and other health-related topics.
Each semester, Ocano’s students are divided into clinical groups. Each group starts the project by investigating a culture and circumstances leading to refugee status of those from that culture here in Phoenix. Then they break into smaller groups and design and deliver a teaching project.
To help explain optimal placement of food within a refrigerator, one teaching team made a refrigerator out of poster board. When you opened the doors, you could see where the food should be stored: meat at the bottom, other items placed where they would keep best.
Students Diana Hooshmand, Kathy Quintal and Catherine Sagastume, all full-time nursing students at GCC, are typical of those who take part in Ocano’s class project. Hooshmand’s group researched and presented on the Lhotshampas from Southern Bhutan, who were excommunicated to Nepal. Quintal and Sagastume were assigned Somalia; Quintal also learned about Bhutan, Myanmar and other countries, and Sagastume learned about the Bhutanese and Burmese.
In their groups, Quintal and Sagastume focused on food and exercise. In the research phase of their project, they learned that many of the refugees have never had to choose foods; they ate what was provided to them. Whereas here in the United States, there are abundant choices and a lot of marketing that promotes processed foods. The students developed a presentation that helped to educate their refugee audience on the long-term health consequences of a poor diet and the importance of eating right and exercising.
Since income is a challenge for most of the refugees, the students stressed low-cost options, such as the benefits from walking to the store, or using water bottles or canned food as weights. They even made a jump rope out of ordinary rope, which they brought to class, demonstrated, and gave to the kids to share with their friends.
Classes for the refugees are held in a community room or clubhouse, and usually attract groups of 12 or more, mostly women and their children.
Quintal observed that, in developing the teaching project, the students had to speak at a level the refugees could understand. “The medical terms we’d been struggling to learn had to be set aside in favor of more understandable terms,” she said. “While the refugees would not understand ‘diabetic amputation,’ they would understand that when you say a leg might need to be cut off if they don’t take care of their bodies with exercise and diet.”
An interpreter aids with the presentation, so the nursing students can maintain eye contact with the audience of refugees, pausing at intervals for the interpreter to catch up. The groups also used a lot of visual aids; to help teach hygiene, they brought in toothpaste, a toothbrush, and a big model of teeth to demonstrate how to brush and floss. Proper laundry techniques were illustrated with a big poster of a washing machine and dryer and a detergent scoop to show what amount of detergent to use.
Sagastume felt uncomfortable at first because, to her, the topics seemed so basic: how they should brush teeth, take a bath or use various products, including a Western oven. “I felt like I was putting them down,” she said. “But they don’t know; they’re just recently got here, and they’re still getting accustomed to the way we live. They’re not used to the things we have here.”
The students’ workshops have been well-attended and well-received. The students say the audiences have been involved and interactive, asking a lot of questions. “They were gracious, funny and quick witted. We all had a great time,” said Hooshmand. “You could tell they were appreciative,” said Sagastume. “At the end of the class, we offered to take their blood pressure for them, and if it was high, we would let them know and suggest they go to the doctor, which they appreciated.”
Ocano says the focus is on development of cultural competence for her students, and on life skills for the refugees, as much as it is on health care. From a cultural perspective, her students may have learned as much as they taught the refugees. All said participating in the program expanded their perspectives on working with people from other cultures. Hooshmand, who has always been interested in other cultures, and whose husband was born in Iran, said the project allowed her to experience a culture she had known nothing about.
Sagastume’s group presented not at the clinic, but at an apartment community where many Somali refugees live. She observed how close-knit they are. “I just knew the people who came and viewed our presentations would take the information and teach others, then those people would teach others, and it would go on from there,” she said.
Quintal said when the project was first assigned, she doubted its value. But the project opened her eyes to many things. “I had never contemplated what it would be like to leave everything you’ve known and travel to a country where you know no one, don’t speak the language and leave all that you’ve known behind. Learning about what other people have endured, and the risks they take to come to this country was inspiring,” she said.
Sagastume said her perspective on the project also changed completely after her group gave its presentation. “I no longer thought of this project as something I needed to get done for the grade,” she said. “Seeing the interest in the audience’s eyes touched my heart and I felt selfish for having those thoughts because these people truly needed our help.”
She said she learned that she’s taken many things for granted: food on the table, clean water, secure housing. She recalled her parents, who came to the United States from El Salvador, telling her as she grew up that she was very fortunate to live in this country. “Although my parents did not go through the same battles as the Somali people have gone through, their life in El Salvador were rough for them as well,” she reflected.
Now, she says, she understands what her parents have been trying to tell her all along, and she has more appreciation for even the simple things we have in the United States. “I really am thankful to have been part of this project and feel that our class made a difference and touched the lives of the refugees we taught,” she said in the required “reflective paper” at the end of the project. Diana Hooshmand agreed, saying it was a wonderful program, an educational project, and an amazing instructor. The project taught them a lot about working as a team. Equally important, they found new awareness of how they communicate and what it takes to be an effective nurse.
They are better able to relate with people of different cultures and life experience. In sharing health information, they learned they must respect others’ cultures and adapt to their patients’ existing knowledge, viewpoints and learning methods. Some patients may need a lot of formal information, whereas some learn better with a hands-on approach.
“I realized we must meet our patients where they are, and teach them at a level they understand; that will make me a better nurse going forward,” said Quintal. “This lesson applies to all patients, not just to refugees.”
All three students are due to finish the program this May, graduating with an Associate in Applied Science in Nursing. Currently in CEP (concurrent enrollment program), they will also be earning their Bachelor of Sciences in Nursing from Northern Arizona University.
Hooshmand looks forward to working eventually in hospital management; Quintal wants to focus initially on bedside nursing, and later, case management. Sagastume aims to be a nurse practitioner, maybe working in medical surgery for a few years and then specializing in oncology.
Jill Ocano, who already has a string of credentials – Masters of Nursing Sciences (MSN), Family Nurse Practitioner (FNPC) – is proud of her students. A full-time teacher at GCC since 2000, she has been working part-time at the refugee clinic since about 2010. She is now pursuing a doctorate; the nursing program at the clinic is her doctoral project, and she hopes to expand the program to other sites over time.
For more information about Arizona Medical Clinic call 602-274-2100. For more information on the GCC program, contact Jill Ocano at firstname.lastname@example.org.