Nurses need to recognise and overcome negative attitudes towards Gypsy Travellers to help address the health needs of this community
In this article…
- Developing and implementing a project to explore nurses’ attitudes towards Gypsy Traveller
- Dealing with negative attitudes and overcoming bias
- How personal views can affect professional practice
Gill Francis is health inclusion worker for Travellers and Gypsies at Homerton University Hosptial, NHS Foundation Trust, London
Francis G (2011) Attitudes towards Gypsy Travellers. Nursing Times; 107: 39, early online publication.
Gypsy Travellers often experience wide-ranging inequalities, associated with poor access to health services and education, discrimination, and health professionals’ lack of understanding of the cultural identity and health needs of their community. This article explores nurses’ attitudes to Gypsy Travellers, and discusses how overcoming bias and negativity can help address the health needs of this community.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- Gypsy Travellers experience inequalities, and have poorer health than other English-speaking black and minority ethnic groups in the UK
- Nurses often have a limited understanding of Gypsy Travellers’ culture and issues affecting them; perceptions can be influenced by media stereotypes
- Bias is a normal survival mechanism; recognising this can make it easier to discuss negative views about a particular group
- In accordance with the Nursing and midwifery Council’s code of conduct, nurses must demonstrate a professional and personal commitment to equality and diversity
- Training can help nurses to challenge negative attitudes, and explore how such views can lead to discriminatory practices
The health of Gypsy Travellers is considerably poorer than that of other English-speaking minority ethnic groups (Van Cleemput et al, 2007). According to Cemlyn et al (2009), Gypsy and Traveller communities in Britain experience wide-ranging inequalities, and their life expectancy is shorter than that of the general population.
These disparities are associated with poor accommodation, poor access to health services and education, discrimination, and health professionals’ lack of understanding of the cultural identity and health needs of the Gypsy Traveller community. However, evidence suggests that receiving cultural competence training can increase confidence and awareness of the care requirements of ethnic minority patients (Beach et al, 2007; Pearson et al, 2007).
The Mary Seacole Development Awards provide an opportunity to undertake a project, or other educational activity, which benefits the health needs of people from black and minority ethnic (BME) communities. This article describes an award project that aimed to support the development of cultural competence in health professionals working with Gypsy Travellers. The project explored staff attitudes, as well as knowledge and understanding of the cultural identity and health needs of this community.
Forty staff from local community nursing services took part in the study. They varied in seniority and included school nurses, health visitors, community matrons, health care support workers and nursery nurses.
Access to staff was negotiated through team managers and by attending team meetings to explain the purpose of the project. Staff who agreed to participate were made aware they were under no obligation to take part, and that all responses would remain anonymous.
Participants were asked to write down:
- Things, words or statements that came to mind when they heard the term “Gypsy” or “Traveller”; and
- Two questions they wanted answered by the community.
The exercise was carried out in various settings, including team meetings, both in groups and on a one-to-one basis. Participants submitted their responses anonymously to a group collection envelope; anonymity was further maintained by keeping all responses together until completion of the data collection. Staff members’ questions and comments were then used to inform training and the content of a booklet for staff on the cultural identity and health needs of Gypsy Travellers.
The data suggested many participants had limited understanding of Gypsy Traveller culture or the issues affecting this community. It also suggested that perceptions of Gypsies and Travellers were largely informed by negative media stereotypes (see Table 1 for examples).
Participants were given examples of some of the comments written by staff on hearing the term “Gypsy” or “Traveller”, and asked to consider the following questions:
- If you were from a community about whom these views were held, and you knew you were viewed in this way, how might it affect the way you accessed a service?
- If we (health professionals) hold these views, do we need to challenge them?
- If you were a professional who held these views, what would need to happen to make you change your mind?
The discussions that followed demonstrated the benefits of honest, non- judgemental, open discussion within professional forums about the existence and impact of bias and prejudice on practice. The creation of a safe environment, where staff felt able to express their views openly without fear of alienation, was essential in allowing staff to feel able to challenge themselves, and allow themselves to be challenged. Table 2 shows some of the staff responses to the questions.
Bias and discrimination
Staff were invited to take part in feedback sessions where they were presented with the data. To facilitate a reflective process, they were given a brief introduction to the work of Kandola (2009), which explores the concept of bias as an intrinsic part of the human condition and an essential human survival mechanism.
Having a negative bias against a particular group makes it difficult to take a balanced view, or make even-handed judgements about that group; this can lead to discrimination and behaviours that impact negatively on the group. Although bias and discrimination are components of typical human behaviour, what we
do about the negative effect these can have on others needs to be addressed (Kandola, 2009).
Recognising that bias is part of a spectrum of human behaviour made it easier to have a discussion about the negative views we may hold about a particular group or community. According to Kandola (2009), recognition of our behaviour, and having increased awareness, are essential in addressing the possible effects of bias, such as discriminatory practice.
Although the existence of “respectable racism” is acknowledged, within professional circles it may still be considered unwise to divulge such views (Commission for Racial Equality, 2006). “Respectable racism” is a term that explains how racism towards the Gypsy Traveller community remains largely acceptable.
This is evidenced by the discriminatory way the community are dealt with, with regards to planning law and the way they are reported on and represented in the media. It is still not uncommon to see “No Traveller” or “Travellers by appointment only” in public houses; outrage would likely ensue if this was leveled at any other BME community.
According to Jones (2010), having prejudice is normal, but admitting to it is certainly not a career-enhancing move. This can lead to a culture of denial, which perpetuates failure to explore attitudes and raise awareness of our unconscious biases. He argues that awareness of bias is therefore pivotal to achieving sustainable and authentic behaviour change and suggests we develop control over our natural prejudicial instincts by accessing our ability to prevent innate reactions becoming behaviour. As with muscles, which have memory for repeated actions, we can develop this ability by increasing our awareness of our own prejudices through practice (Jones, 2010).
Personal versus professional views
When asked for responses to the terms “Gypsy” or “Traveller”, some staff members queried whether they were being asked for their personal or professional views. This suggested a perceived ability to compartmentalise professional and personal views. Whether this is possible, or to what degree it may be done, is questionable. In addition, it should be noted that the Nursing and Midwifery Council’s professional code of conduct states that individuals must demonstrate both “a personal and professional commitment to equality and diversity” (NMC, 2008).
Although nurses and midwives must abide by the NMC code of conduct, they are inevitably influenced by, and reflect, the wider society in which they live. Within the caring professions, motivation to express professional group norms that reflect the NMC code is likely to be high. However, health professionals may also be influenced by negative and racist societal views, which could impact on their behaviour and practice.
Within professional groups, the expression of negative views may be suppressed to fit with what is seen as the group norm. It could therefore be difficult to conclude whether professionals are genuinely culturally competent, or whether they are just expressing views that support the group norm. Dowden and Robinson (1993) said the suppression of prejudice is not always motivated by personal or professional integrity, or an inner hunger for
justice or equality, but by an attempt to conform to perceived social or group norms regarding the appropriateness of expressing prejudice.
A number of key messages emerged from the project. First, there is often a gap between our personally held views and our public voice and professional practice. Although we may think we compartmentalise these well, we may be overestimating our ability to do so. This means that the way we view particular groups or communities may “leak” and impact negatively on our practice.
Second, there needs to be an acknowledgement that bias is a normal human survival mechanism and that we are “hardwired” this way. In the course of human development we have had to be able to make quick decisions about whether another person should be considered “friend” or “foe”; to do this we take short cuts based on our own past experience or the views and experiences of others. We don’t reserve judgement until after we’ve established how safe an encounter might be; we learn to prejudge both situations and people quickly in order to remain safe. Because our judgements are often based on negative stereotypes perpetuated in much of the media, it may be inevitable that we develop negative bias against particular groups or communities. Although forming bias is a normal part of human behaviour, how this affects our attitudes and behaviours is what matters.
The third key message concerns training, which must be robust enough to challenge us to examine our attitudes closely and look at how negative opinions and discriminatory attitudes can lead to discriminatory practices.
Self-awareness is an integral part of many cultural competence frameworks, and is fundamental to the reflective processes within nursing practice.
The pervasive nature of bias, prejudice and discrimination, and the negative impact these can have on practice and the delivery of equitable service, must be acknowledged. Only then will we have a safe environment in which to discuss and unpack the issues that inform professional practice when working with Gypsy Travellers.
Box 1. considerations for health professionals working with Gypsy Travellers
- Engagement often takes time. Professionals must allow Gypsy Travellers time to develop trust
- Cultural competence – both organisational and individual – needs to be developed
- Avoid “parachuting in” expertise. Developing partnerships with Gypsy Travellers can help to find “quick wins” as well as achieving long-term goals. An example of a quick win is when the London Ambulance Service delivered a parent and baby first-aid course at a local children’s centre; by using it as a venue, the women began to see the centre as a “safe” place to go
- Don’t reinvent the wheel. Partner with organisations already working with the community to understand local need
- Understand the need to incorporate community development approaches to the long-term work plan and remember that there is a fine line between being an advocate and creating dependency
- Understand the impact of poor literacy. This can lead to poor health literacy, increased use of emergency departments, poor follow-up, non-attendance of appointments and reduced uptake of preventive interventions. Give simple, jargon-free information
- Targeted services are often critical in increasing engagement, but you should still try to engage clients with mainstream services
- Dispel the inaccurate perceptions Gypsy Travellers may have of services, particularly relating to mental health, psychological, and social services
Beach MC et al (2007) Can patient-centred attitudes reduce racial and ethnic disparities in care? Academic Medicine; 82: 2, 193-198.
Commission for Racial Equality (2006) Common Ground: Equality, Good Relations and Sites for Gypsies and Irish Travellers. London: CRE.
Dowden S, Robinson JP (1993) Age and cohort differences in American racial attitudes. In: Sniderman P et al (eds) Prejudice, Politics and the American Dilemma. Stanford, CA: Stanford University Press, 86-103.
Jones P (2010) 10 Things You Didn’t Know About Prejudice.
Kandola B (2009) The Value of Difference: Eliminating Bias in Organisations. Oxford: Pearn Kandola Publishing.
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
Pearson A et al (2007) Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. International Journal of Evidence Based Healthcare; 5: 54-91.
Van Cleemput P et al (2007) Health-related beliefs and experiences of Gypsies and Travellers: a qualitative study. Journal of Epidemiology and Community Health; 61: 205-210.