Romani, the adjective; Romani, plural noun; or Roma,
singular noun, are the preferred terms when referring to people
and incorrectly known as Gypsies. Gadje (or gazho) is the plural
term referring to non-Roma. An individual Romani household is
a familia consisting usually of three generations of six to fifteen
relatives. Families are male dominated, with a group of male
elders within the familia being the major decision makers. Romani
women are often not included in the decision making process and
generally have a much more subordinate role.
The Roma originated in India and migrated to Europe by the 15th
century. A large Romani migration to the United States occurred,
from Russia via Argentina in the 19th and 20th centuries. The
Romani language is derived primarily from Sanskrit. Education
and technology have not traditionally been considered important.
Many older Roma are not literate.
Roma are generally a nomadic people. They have traditionally
adopted the dominant religion of the area in which they live.
They also maintain beliefs in the supernatural, omens and curses
and may carry charms, amulets and talismans in their pockets
for safety, good luck and to prevent illness. Romani female healers,
called drabarni or drabenhgi, prescribe traditional healing rituals
and cures. The Romani people tend to use the Gadje health care
system only in crisis situations when there is an acute and/or
unresolved condition for which folk medicine has failed.
Most Roma make a concerted effort to remain socially isolated
and invisible. In the United States Roma often present themselves
as members of one of the other minority groups in the U.S., due
to concerns about the “impurity” of outside cultures
and to the long history of prejudice and misconceptions about
The Roma have a strict taboo code that classifies all outsiders
as soiled or unclean. "Wuzho" (pure) and "marimé" (pollution
or impurity) are important Romani concepts. To maintain purity,
Roma are required to follow strict sexual mores. They must wash
their hands after touching the lower body before touching the
upper body. Separate soap and towels are used on the upper and
lower parts of the body and they must not be allowed to mix.
Dishes may not be washed in a sink used to wash clothing. Roma
believe that polluting actions will result in illness. To return
to a state of purity, cure, and good health one must conform
to or correct the marimé social behavior.
This case story discusses how a Nurse Manager begins
to approach helping the hospital in which she worked and the nursing
staff become more culturally competent.
Challenges of a New Mandate
By 7:00 am, Jacqueline Strong is already in her office,
preparing for the day to come. As a Clinical Nurse Manager on a busy
pediatric unit at Kendrick Hospital, she is in charge of patient care
and training. She also chairs a hospital committee for Cultural Competence.
Last month, the Board of Trustees unveiled its 10-year Strategic Plan.
Objective #3 mandates that the entire hospital, from an individual
to an organizational level, must demonstrate the ability to provide
culturally competent care. Helping achieve this goal has become another
one of Jacqueline’s responsibilities.
Prior to the Board’s development of the Strategic Plan, Kendrick
Hospital conducted an organizational self-assessment of cultural competence.
Staff in different departments were asked to complete anonymous self-assessments
in cultural competence. Jacqueline was quite concerned when she looked
at the nursing responses. She knows that the department has a long
way to go.
For many years, Kendrick Hospital has served a blue collar, Irish Catholic
neighborhood on the edge of Chicago. Many of the nurses are from this
neighborhood (many of them grew up here) and hospital staff and patients
have enjoyed a feeling of close camaraderie. They have also taken particular
pride in Dr. Jamieson, a nationally known oncologist who was recruited
to develop a satellite oncology program to be affiliated with the larger
Metro Healthcare Center. Recently, a number of Romani patients have
been coming to Kendrick. They frequently ask for Dr. Jamieson, even
problem for which they are seeking help is not cancer. While perceived
by some as loud and demanding, the Romani patients seem to have an
admirable ability to negotiate the system, obtaining the information
and getting appointments with the physicians they wish to see.
Jacqueline is concerned, however,
because the nurses have little to no experience with members of other
cultures. Just yesterday, for example, Christy Fitzgerald, a young,
enthusiastic, usually cheery nurse came into her office, her voice
filled with frustration. She protested that she “could not get
her work done with that Gypsy girl.” Christy said that least
10 of the girl’s relatives were in her room at all times, while
many others “camped out” in the hall and waiting room.
When Christy entered the room, one of the older men “demanded” to
know why they hadn’t seen Dr. Jamieson. When Christy attempted
to give the child a sponge bath, several of the women insisted in staying
and watching her. As she proceeded, they clearly became angry. Christy
couldn’t understand what they were saying, but their loud and
agitated voices made it clear they wanted her to stop. Later, she tried
to butter some of the girl’s toast, and again she was stopped.
Christy thinks she saw one of the girl’s relatives pocketing
some of her medications. She told Jacqueline that she has heard that
Romani patients have a reputation for stealing, though she can’t
imagine why they’d be stealing antibiotics. She thinks just being
at the hospital is stealing, in a way, because they clearly have no
insurance. Christy thinks the Gypsies lie, too. After all, one of the
family members told another nurse that they were Hispanic and that’s
clearly not true. And it’s been hard to get anything done. When
the doctor told the girl’s mother that, with her permission,
he’d like to use a new medication on her daughter, the mother
just wouldn’t make up her mind. Christy also thinks the family
is at fault because they waited so long before bringing the girl into
the hospital. The girl wouldn’t have gotten this sick if they’d
brought her in right away. As Christy talked, it became clear to Jacqueline
that Christy has been approaching this Romani patient and her family
entirely from her own perspective, without attempting to understand
the family’s views and beliefs.
Jacqueline knows that she will need to have a long talk with Christy.
As chair of the Cultural Competence Committee she will have to provide
training for all of the nurses. While the Romani patients present the
most immediate need, Jacqueline wants the nurses to learn more generally
about how to work with people from diverse cultures. In addition, she
is coming to realize that the hospital is not a welcoming place for
Romani patients. She recognizes that changes will need to be made at
the institutional level, to allow Romani patients to feel more comfortable
Interventions at all levels
Jacqueline decides to approach the problem at two
levels. First, she holds a series of in-services for the nurses, using
Christy’s experiences with her Romani patient as a starting place
for the first one. Jacqueline knows that developing a culturally competent
staff will take more than these seminars, and that knowledge does not
immediately translate into attitude and behavior change. But she feels
this will be a start. She plans also to consider the possibility of
asking the Romani elders whether they would be willing to act as “faculty”,
talking with the nurses about their culture and beliefs. She would
ideally like this to happen in their homes, but knows that she will
have to approach this idea gently, as members of the “gadje” community
are generally seen as presenting an impure and potentially dangerous
influence on the Romani community.
Simultaneously, Jacqueline and other members of the Cultural Competence
Committee writes a proposal that she presents to the hospital’s
executive committee. They would like to develop a special program for
Romani patients. This program would involve providing rooming-in accommodations
for the larger family groups, special sanitary precautions (disposable
plateware and eating utensils; two washcloths and bars of soap; careful
attention to Romani concerns); and training to physicians and nurses
regarding the importance of communicating with elders and refraining
from touching surfaces in the rooms of Roma; sensitivity to the fact
that Romani elders may not read and accommodations for this; flexible
billing programs to allow Romani patients to pay their bills over time;
and appropriate mores for communicating with members of the opposite
Things to consider about this case
There are several issues to consider about this case.
You will explore these issues more fully in the learning activities.
- What challenges do medical facilities face when trying to become
more culturally competent?
- What kinds of assumptions do providers sometimes make about people
from other cultures?
- What factors may cause providers to relate to patients in a biased
What to do next
Now that you have read the case, go to the lecture
section to gain a better conceptual understanding of the issues related