ANS: Advances in Nursing Science Blog

The concept that one’s morally transgressive behavior may result in lasting harm to the individual’s well-being is thoroughly documented in historical literature, as ancient cultures struggled to explain and cope with warrior reintegration. In more modern times, Civil War soldiers were diagnosed with “soldiers’ heart” or profound melancholy. In WWI, the condition was described as “shell shock.” WWII introduced the term “battle fatigue,” and the Vietnam Veterans were diagnosed with Post Traumatic Stress Disorder (PTSD). However, mental health professionals are beginning to understand that these terms do not fully capture war’s moral and ethical implications. As a result, they fail to fully capture the soldiers’ challenges as they transition into civil society.

Shortly after the start of the wars in Afghanistan and Iraq, my military colleagues and I began to recognize the harmful effects of deployment. The concerns about our comrades’ psychological well-being escalated as current treatment modalities proved to be ineffective. The inability to explain our observations prompted us to refer to these soldiers “as broken.” Currently, 22 veterans commit suicide each day in the United States, and the rate of suicide among veterans 18 to 34 years of age has risen 80% compared to the civilian population.

Acknowledgment that the suffering of these soldiers does not resolve upon exiting the military; prompted our team to explore the concept of moral injury (MI) in relation to veteran suicide. MI is the damage done to one’s conscience or moral compass when the person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical code of conduct. Our study describes the struggles veterans face as they try to reassemble their lives post-war.

Breaching moral boundaries has created dissonance between the veterans’ conscience and subconscious thoughts regarding right and wrong, resetting the individual’s fundamental identity and impeding their ability to develop relationships and maintain group identity. This inner struggle helps explain the previously determined feelings of betrayal, guilt, and irredeemablity frequently seen in veterans with MI. Unfortunately, I feel like I am reliving the past as the trauma experienced by our health care providers due to Covid-19 is manifesting in the same manner that we witnessed in those returning from deployment. It creates an environment where clinicians, similar to our veterans, struggle to reconcile the incongruence between their perceived ethical standards and those they are witnessing daily. Exploring the implications of this moral discord may be necessary to avert a similar crisis in our healthcare professionals. 

Throughout nursing history, we, nurses, have been on the frontline of the battles against health disparities, and have strived to provide culturally competent care for racial/ethnic minorities who are frequently discriminated and underserved in our health care systems.  Culturally tailored interventions are one of the products from the battles to have us equipped with necessary competence to provide better health care for all human beings regardless of their race/ethnicity. Considering the recent rise of racially motivated violence and discrimination against racial/ethnic minorities, it would be meaningful for us to reflect on culturally tailored interventions that have been our instruments in the battles against health disparities.

To start this blog, I am including a picture of a modern high-rise building with a Buddhist temple entrance. This is a typical scene of our daily life with a mixture of cultures that supports ourselves as cultural beings. As a researcher working on cross-cultural women’s health issues, from the beginning of my career as a nurse researcher/scientist, I have been frequently involved in the discussions on human beings as cultural beings, the complexity of culture, and culturally appropriate and sound approaches to culturally diverse populations. Many nurse researchers and scholars have talked about how to ensure cultural equivalence of wordings used in the questionnaires, how to ensure the accuracy of translations in research process, and if cultural matching would be needed, etc.  Also, nurse researchers and scholars have talked about inherent post-modern dilemmas in cross-cultural research (e.g., generalizability, etc.). However, it is very recent that our nursing community begins to talk about what makes an intervention be a “culturally tailored” intervention.In recent years, “cultural tailoring” became a buzz word among nurse researchers/scientists who are working with racial/ethnic minorities. With a recent high funding priority on health disparity research, an increasing number of nurse researchers/scientists began to develop and test culturally tailored interventions among specific cultural groups of racial/ethnic minorities.  Cultural tailoring sounds very simple in a way, but it requires researchers/scientists to give their special attention to many complex and various aspects of the interventions.  However, very little is still clearly known about the principles and processes of cultural tailoring although there have been some advances in the tailoring methods (e.g., surface tailoring, deep tailoring).

In this paper, we proposed suggestions for what would be essential in culturally tailored interventions based on our experience in multiple culturally tailored intervention studies, especially technology-based interventions.  Thus, the components that we are proposing might not be easily generalizable to the interventions that are not technology-based.  However, we made an assumption that cultural tailoring in both technology-based interventions and non-technology-based interventions would be similar in most aspects except the intervention medium.  Yet, technology-based interventions do not require physical transportation of the users and may not provide tangible in-person interactions.  Also, there are many unique characteristics of technology-based interventions that traditional interventions might not have (e.g., 24 hour access, required computer literacy, etc.). Thus, I hope that readers would be careful about the interpretation of the findings and suggestions.

Despite the limitations of the findings and suggestions that we made in this paper, most of our suggestions could be easily applicable to any culturally tailored interventions.  For instance, the suggestion to consider if their interventions specifically meet culturally unique needs of target populations could be applicable to any culturally tailored interventions using various different intervention media.  Cultural tailoring definitely needs to address culturally unique needs of the specific population. Otherwise, the intervention would not be easily accepted by the target group, and the intervention would be useless without the acceptance by the actual users. Also, the suggestion on the use of multiple languages and culturally matched bilingual research team members would be applicable to any culturally tailored interventions in a different medium.  For surface tailoring, the use of multiple languages and culturally matched bilingual research team members has been frequently emphasized in any culturally tailored interventions although it is new to find that they are essential even for non-face-to-face technology-based interventions.  Indeed, at the beginning era of the Internet usages, researchers thought that non-face-to-face interactions would eliminate the influences of race/ethnicity on human interactions. However, the findings reported in this paper support that culturally tailoring is necessary even for technology-based interventions, and the impact of race/ethnicity on human interactions still remain even in non-face-to-face interventions using computers and mobile devices.

All the suggestions, however, need researchers’ careful reflections on the benefits and costs involved.  For instance, we suggested researchers’ flexibility in intervention process (e.g., timing, intervention medium) to accommodate special and unique needs of their target populations. This flexibility will definitely increase the recruitment rate of potential research participants and will be helpful in retaining the participation throughout the intervention period.  However, at the same time, this could be a source of biases in determining the effects of the intervention on targeted outcomes of the research participants. Thus, researchers who are thinking of adopting flexible arrangements/strategies for their research participants need to consider possible biases that would be brought up by the arrangements/strategies and need to balance the losses and gains from adopting the arrangements/strategies.

We really appreciate this opportunity to discuss about the essential components in culturally tailored interventions, which would be pivotal for future nursing care and practice with racial/ethnic minority populations.  Hope that this article would urge nurses to further reflect on and discuss about future directions of culturally tailored interventions in nursing and contribute to advances in practical knowledge that is needed for development, implementation, evaluation, and refinement of culturally tailored interventions for racial/ethnic minority populations who are in great needs.  These efforts would definitely strengthen our instruments for future usages in our battles against health disparities.