A key skill of public health nurses is the ability to observe and make sense of their surroundings. In a clinical sense, participant observation is a technique in which the nurse makes careful observations of specific processes, actions, or communications while providing care as a participant in the activity. Usually, participant
observation techniques are used as research methods in ethnographies conducted over time—often a year or more. The technique, however, can be useful to public health nurses who need to pay close attention to subtle changes in their client, family, and the population and group interactions.

Participant observation is also a key method in conducting participatory action research, which is one of the best ways to design new population-based health programs. Action research involves community stakeholders in all phases of planning programs targeting that community (Brown et al., 2008; Cashman et al., 2008). For example, a public health team wants to start a program to improve psychosocial outcomes for women in a cardiac rehabilitation program. They might interview consumers in a selected program such as the “Heart Awareness for Women Program” (Davidson et al., 2008) and conduct participant observation periods to see how women move through the program.

The literature has many examples of participant observation in research, but reviewing the technique can be helpful to students who are learning observation skills to understand culture in any setting. The techniques are particularly easy to do in public settings. The following are some examples from the research literature that demonstrate how culture can be learned by an outsider. In an ethnographic study involving both participant observation and interviews, Stevens (2006) studied 15 adolescent female parents about what “being healthy” meant to them. A key finding was that although the girls were aware of public health messages about health, their fundamental needs of safe living conditions, finding food, and paying bills took precedence over practicing health promotion. For example, the girls’ attention was focused on their own needs, and the key concepts that emerged from the data related to how the young mothers were going to meet their own basic needs and the basic needs of their infants.

An example of how participant observation is a powerful supplement to interviewing in Stevens’ study was food shopping. Although it seemed clear from interviews that adolescent mothers understood that good nutrition involved eating fruits and vegetables, the pressures of long hours at work and exhaustion at taking care of an infant made fast food a much easier choice. Participant observation demonstrates exactly how and under what conditions the mothers shopped for food rather than what they stated they should buy.

Similarly, Kaplan, Calman, Golub, Ruddock, and Billings (2006) conducted participatory action research in the Bronx to identify best practices of promoting public health by faithbased institutions. Addressing racial and ethnic disparities, a coalition of 40 community-based programs, including 14 churches, was mobilized to change community members’ attitudes about health practices and to influence health policy on behalf of racial and ethnic minorities. Although limitations to the study were identified, the team concluded that the faith-based leaders could have an enormous positive influence on the health of their communities.

In an ethnographic study of 30 rural African American women who used cocaine, Brown and Smith (2006) found that the women tended to be either child-focused or self-focused with a wide range of responses to explain their drug use. For example, through interviews and participant observation conducted over 4 years, the researchers found that living in a rural area or small town created a sense of boredom among some of the women, who did drugs for something to do. It is one thing for someone living in a small town to say they have nothing to do, but quite another for the researcher to live there and experience firsthand what it feels like to be socially isolated.

In this study, other women used their children as an excuse, saying they felt overwhelmed with the demands of mothering. Again, participant observation makes clear to the researcher what it is like to live under the conditions required of the population being studied. Imagine a working single mother who arises at 5:00 a.m., goes to work at 6:00 a.m. as a waitress in a café until 3:00 p.m., picks up her children from school, helps them do homework, and then has to fix dinner and get them to bed by 8:00 p.m. while doing laundry and getting clothes ready for the next day. At what point in this busy day does she have time to shop for healthy food, take care of her own needs, and indulge in relaxing activities such as exercise or reading?

Similarly, in public health nursing, having a client say she is bored or overwhelmed by the demands of a growing family is much more meaningful if the nurse has visited the community and sees there are no social outlets for young mothers. An example of how the public health nurse might use this information is to start a series of group meetings about health topics (with child care provided) that could also serve as a support group for women. In the case of the population of adolescent mothers, the nurse might begin a support group that involves other professionals who could teach job training skills such as computer classes, crafts classes, or gardening. The point is that any successful intervention program can be made culturally specific by focusing on the needs and interests of the population served. Complete the field exercises in Box 7-1 as part of your study.

The body of literature on cultural competence has grown since this term was determined to be the desired outcome of simple awareness of cultural differences. At its most basic level, cultural competence is a set of attitudes and behaviors by the public health nurse to take into account that the client or population has cultural beliefs, values, health practices, and ways of behaving in social interactions that may differ widely from expectations of the health providers. The public health nurse uses knowledge of the culture, which may be limited, and key informants, the client being the most important, to accomplish the goals of care without violating the rights of the client or population so as to maintain their cultural traditions.

One interpretation of cultural competence is to practice the traditions of the client population, but the danger here is that these attempts to blend into the culture are unnatural and providers might appear to be making fun of the population. Mimicry can be insulting, and so the provider inadvertently creates problems instead of preventing them. Showing respect for the other’s culture does not mean trying to be someone you are not.

The American Academy of Nursing (2008) emphasizes the importance of including cultural material in nursing education. Several theorists (Campinha-Bacote, 2002; Kim-Godwin, Clarke, & Barton, 2001; Purnell, 2000, 2002; Purnell & Paulanka, 2003) have published extensively on the topic. Wells (2000) wrote that cultural competence is not sufficient and argued for cultural proficiency to replace it as the desired goal. In an attempt to clarify the definitional confusion in the literature, a descriptive study on literature in cross-cultural psychotherapy and counseling was conducted by Whaley (2008). He analyzed the two terms—cultural sensitivity and cultural competence—in a statistical literature review and proposed that cultural sensitivity is precursor to cultural competence.

Regardless of how the concept is viewed, best practice in providing culturally competent care should involve the most fundamental characteristic of respect (de Chesnay, Peil, & Pamp, 2008). Respect for differences on the part of both provider and client population leads to open communication about customs and values, and openness in the relationship leads to problem solving about how best to meet the health needs of the population. A good rule of thumb is to be as respectful, polite, and considerate as one can under the rules of one’s own culture. In this way, most clients of diverse populations understand the nurse’s intentions as honorable and respond accordingly.