Community, Culture and Cultural Assessment in Nursing Care

What are the questions to be asked of a patient in the "4C's" assessment model?

What do you CALL your problem? What do you think CAUSED your problem? How do you COPE with your condition? What are you CONCERNS regarding the condition and/or recommended treatment?

Culturally competent

process through which the nurse finds meaningful and useful ways to provide care based on the cultural heritage, believes, attitudes, and behaviors of the individual, family, or community served. This is a process, not an endpoint

Infrastructure

provides basic necessities of life

What are some of the variations of pain from culture that impact, health, illness, and health care delivery?

reactions to pain may be culturally prescribed, but pain is also a very individual experience. Respect that in some cultures it may be expected to NOT respond outwardly to pain.

How do you cope with your condition?

1. Allows you to understand whether the patient uses alternative treatments or healers. 2. You need to know what other treatments the patient may use at home since there could be a dangerous drug interaction if they are prescribed a medication.

What are you concerns regarding the condition and/or recommended treatment?

1. Ask: How serious do you think this is? What complications do you fear? How does it interfere with your life or your ability to function? 2. You must ask this in order to address concerns or misconceptions. 3. If you ask about the patient's concerns with treatment you may be able to spot issues with potential nonadherence.

What do you call your problem?

1. Ask: What do you think is wrong? 2. You can assess how the patient perceives the problem 3. Same symptoms may have different meanings in different cultures - may result in barriers to compliance

Describe/explain the six cultural domains identified in Giger & Davidhizar's Transcultural Assessment Model. Apply each of these to the care of a patient from a different culture.

1. Communication: language, voice quality, nonverbal, silence, pronunciation. • What do you do to help others understand what you are trying to say? • Do you like communicating with friends, family, and acquaintances? 2. Space: degree of comfort observed, proximity to others, body movement, perception of space. • When you talk with family members, how close do you stand? • When you communicate with co-workers and others, how close do you stand? 3. Social orientation: culture, race, ethnicity, family roles and function, work, leisure, church, and friends. • How do you define social activities? • What is your role in the family unit? • What are your hobbies? 4. Time: use of time, measures, definition, social time, work time, time orientation (future, present, past) • What kind of timepiece do you wear daily • If you have an appointment at 2 PM, what is an acceptable arrival time? 5. Environmental control: cultural health practices, values, definition of health and illness • How do you define good health? • How often do you have visits in your home? • What home remedies do you use that work for you? 6. Biologic Variation: body structure, skin and hair color, enzymatic and genetic existence of disease, susceptibility to illness, nutritional norms, psychological characteristics, coping, and social support. • What illnesses or disease are common in your family? • Does any family member have a genetic susceptibility to a disease?

What do you think caused your problem?

1. Discover the patient's belief regarding the source of the problem. Not everyone believes in microorganisms. 2. Some believe that body imbalance, breach of taboos, or spirit possession can cause disease.

How can the importance a culture places on Gender Roles impact the delivery of health care and nursing care?

1. In many cultures the man or woman is the dominant figure and will make decisions for the family - important to know who is the dominant member when planning care. 2. Some patients may require direct care from nurses of the same gender, some may even limit speaking or making eye contact with the opposite sex 3. We must be respectful of their preference or request for a nurse of the opposite sex from the start so that we do not run into issues along the way.

What are the 4 basic elements of culture?

1. Learned: you do not biologically inherit a culture, you learn your culture. Enculturation is the process when a culture is passed from generation to generation. 2. Symbolic: language is the most important symbolic aspect of culture. Symbols help to communicate meaningful concepts among members of the culture. Symbols include signs, sounds, clothing, tools, customs, beliefs, rituals, and other items that represent meaningful concepts 3. Shared: if you are part of a culture you share values, beliefs, ideals, and expectations. 4. Integrated: 3 structural elements work together to keep a culture strong according to Haviland's Barrel Model of culture. If one part of the system changes, other parts must change as well.

Describe issues one might encounter in the area of "Communication" in work with a patient from a different cultural background. Describe appropriate nursing interventions to deal with these situations

1. Nurse and patient may misunderstand one another if they are from different cultures 2. Someone from a different culture may misinterpret the use of touch or a facial expression 3. It is important to find a medically trained interpreter to help in these situations to be sure misunderstanding does not occur 4. The physical health and well being of the patient, their communication skills, their knowledge of what you are talking about, may all influence the communication between patient and nurse.

What are the 12 cultural domains of the Purnell Model

1. Overview/Heritage: origins, residence, economics, politics, education, occupation 2. Communication: dominant language, dialects, contextual use, volume/tone, spatial distancing, eye contact, facial expression, greetings, temporality, time, names, touch 3. Family roles and organization: head of household, gender roles, goals and priorities, developmental tasks, roles of aged, extended family, social status, alternative lifestyles 4. Workforce issues: acculturation, autonomy, language barriers 5. Bicultural ecology: biological variations, skin color, heredity, genetics, ecology, drug metabolism 6. High-risk behaviors: tobacco, alcohol, recreational drugs, physical activity, safety 7. Nutrition: meaning of food, common food rituals, deficiencies, limitations, health promotion 8. Pregnancy and childbearing: fertility practices, views towards pregnancy, pregnancy beliefs, birthing, postpartum 9. Death rituals: death rituals and bereavement 10. Spirituality: religious practices, use of prayer, meaning of life, individual strength, spirituality and health 11. Health care practices: traditional practices, religious beliefs, who is responsible for health, self-medication, pain/sick role, mental health barriers 12. Health care practitioner: perceptions of practitioners, folk practitioners, gender and health care

Describe issues one might encounter in the areas of "Space" and "Time" in work with a patient from a different cultural background. Describe appropriate nursing interventions to deal with these situations

1. Some cultures emphasize the past, and may look to traditional approaches to health and healing rather than wanting to try new approaches, procedures or medications 2. Cultures oriented to the present are less likely to embrace preventive health care - focused on here and now 3. Some cultures may view time as flexible and may not arrive on time to appointments 4. As nurses we may need to adapt care to the patient's time orientation 5. Personal space is area around a person regarded as part of the person - this may depend on the person's culture 6. Intimate zone, personal distance, social distance, and public distance

Balancing 3 cultures

1. The qualities and characteristics of the nurse's personal culture are key determinants of personal and professional behavior. 2. The second culture, which is equally important, is that of the health care delivery system, to which the nurse helps the patient and family to acquire access. 3. Both of these cultures, that of the nurse and of the health care system, must strike a balance with a third culture, that of the patient.

Race

1. classification of humans primarily based on biologically determined physical characteristics such as skin color, hair texture, bone structure, and height. 2. socially constructed concept that tends to group people by common descent, heredity, or physical characteristics.

How does culture influence attitudes related to health and illness?

All cultures have systems of health beliefs to explain what causes illness, how it can be cured or treated, and who should be involved in the process. The extent to which patients perceive patient education as having cultural relevance for them can have a profound effect on their reception to information provided and their willingness to use it. Cultural values determine how one will behave as a patient and what it means to be ill and especially to be a hospital patient. They affect decisions about a patient's treatment and who makes the decisions.

Culture shock

Condition that occurs when one is suddenly immersed in a culture that is very different from their own.

What are the 3 structural elements in Haviland's Barrel Model of culture?

Infrastructure Social Structure Superstructure

Xenophobia

Fear of strangers or foreigners, especially those with a different cultural or political viewpoint.

What is the importance of "self-reflection" in the provision of nursing care to persons from other ethnic and/or racial groups?

If it is your first experience with a patient from a different racial or ethnic group you should take time to reflect on areas where you may have been culturally incompetent. Developing culture competency takes time to develop, so we must consistently reflect on what we learn in order to grow.

Social Structure

determines how people interact with one another

Health care disparities

Racial or ethnic differences in the quality of health care Includes discrimination, biases and stereotyping

Purnell Model of transcultural care

The Purnell model provides a framework for all healthcare providers to learn concepts and characteristics of a culture. You can be unconsciously incompetent, consciously incompetent, consciously competent, or unconsciously competent according to Purnell. There are 12 cultural domains that affect one another and are organized in a circle surrounded by global society, community, family, and person.

Explain culture shock in health care/nursing delivery

This happens to patients when they come into the hospital. Being in a hospital is VERY different than taking care of yourself at home and this can be shocking and difficult to adjust to.

How is culture expressed through members of an ethnic and/or racial group?

Through symbols, norms, values, traditions, rituals

What is the danger of making generalizations about persons who are members of a particular ethnic group?

When you make generalizations you are often assuming facts or statistics about a patient, and they could be COMPLETELY wrong. You must confirm by asking questions and conducting a thorough assessment. If you just generalize you may be providing inadequate care to the patient.

What are some of the psychological characteristics of culture that impact, health, illness, and health care delivery?

a person interprets the behaviors of another person in terms of her or his own culture.

Rule of descent

arbitrarily assigns a race to a person based on a societal dictate that associates social identity with ancestry. Divides society and perpetuates disparities in health care.

How do cultural rites and rituals affect health care delivery?

assess the patient's spirituality or religious beliefs, because these beliefs will affect health-related challenges

What are some of the physiologic characteristics of culture that impact, health, illness, and health care delivery?

certain racial groups are more prone to specific diseases and conditions (sickle cell anemia, lactose intolerance, keloids)

5 components of cultural competence

cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire.

Continuum of cultural competence

cultural destructiveness -> cultural incapacity -> cultural blindness -> cultural pre-competence -> cultural competence -> cultural proficiency

What is the relation of culture to health and health behaviors?

culture involves unconscious thoughts and actions that have a dramatic influence on health and illness. If culture is ignored, patients are at risk of not getting the support that they need or receive care that may do harm to them.

How does culture food and nutrition affect health care delivery?

different cultures have different food and nutrition traditions. Be respectful of food preferences while the patient is in your care. Must assess nutrition and then create a plan for patient's that meets their needs and respects their traditions.

Community referrals

identify community providers that will meet the patient's cultural and linguistic needs

Culture

learned, shared, and transmitted knowledge of values, beliefs and ways of life of a particular group that are generally transmitted from one generation to another and influence the individual person's thinking, decisions, and actions in patterned or certain ways complex whole encompassing of values, attitudes, and customs that are shared by a group of people and are transmitted from one generation to the next. Culture is also stable, but can adapt over time. It is a universal experience, but it is unique to each group. Culture becomes the window through which we view the world. Culture is the total, generally organized way of life, including values, norms, institutions, and artifacts passed from generation to generation.

How do socioeconomic factors affect illness, health and health care delivery?

lower socioeconomic status is linked to poorer health outcomes, and in turn poor health decreases the patient's ability to work and therefore improve their health or pay for health care services.

Acculteration

mechanism of cultural change achieved through the exchange of cultural features resulting form first-hand contact between groups. First hand contact between groups may bring about cultural changes in language, technology, food, clothing, music, and other aspects. The culture of one or both groups may change over time but both groups remain distinct.

Ethnicity

person's identification with or membership in a particular racial, national, or cultural group and observation of the group's customs, beliefs, and language. Based on cultural similarities and differences within a society or nation. 1. May include a reference to skin color because group membership is often based on national origin, which may include a particular race. May also include common geographic origin, migratory status, language and dialect, and religious faith. 2. Characteristics of ethnicity: ties that transcend kinship, neighbourhood, and community boundaries, traditions/values/symbols, literature/folklore/music, food preferences, settlement/employment patterns, and special interest with regard to politics.

Assimilation

process by which individuals from one cultural group merge with, or blend into, a second group. Typically the minority group enters into and becomes a part of a second group through continuous social interaction - over time the minority group may lose self-identified members and aspects of its culture.

Cultural sensitivity

recognition of the often-pronounced differences among cultures. Using the term older adult versus elderly. Person with a disability versus handicapped person. You have to move beyond just being aware that differences exist. You must utilize that information to create a unique health care plane.

Ethnocentrism

the belief that one's own culture is superior to that of another while using one's own cultural values as the criteria by which to judge other cultures. Example is western medical practitioners tend to believe their approach to health is superior to that of non-western practitioners.

Racism

unfound belief that race determines a person's character or ability and that one race is superior or inferior to another.

Superstructure

worldviews, provides a belief system that helps people identify themselves, their society, and the world around them.

Give examples of the provision of "culturally competent" nursing care.

• Gain knowledge of the individual or family culture being assessed • Be familiar with your own cultural heritage, patterns, and biases and factors that may interfere with an effective assessment of patients, families, or communities • Use theory to guide cultural assessment • Show respect and genuine interest in the patient and ask questions and be an active listener • Assess the literacy level of the patient

How are Ethnicity and Race related to health care quality?

• Health care professionals play a vital role in counteracting racism by providing unbiased, equal access and culturally sensitive care to people of every race and culture. • Generalizations typically infer or draw conclusions from many factors. This may be a starting point, but more information MUST be gathered to treat the individual patient. • Ethnicity and race should never be considered a reason why you would provide less than 100% quality care to a patient. Ethnicity and race may shape a patient's belief about what health is, and that MUST be part of their care plan! Have a conversation and figure out what is important to the patient. How do they define health and how can you meet their needs?

Explain what is meant by "Culturally & Linguistically Appropriate Health Care Services" (CLAS).

• Must provide free language assistance to each client with limited English proficiency. • Use an interpreter, use word boards or index cards, and work to build trust • Provide educational materials and forms in commonly encountered languages - you should assess the patient's literacy • MUST use a medically trained interpreter and not the child or partner of the patient to interpret • Staff at all levels receive continuing education in linguistically appropriate services, such as continuing education events focused on delivery of linguistic services.

Describe possible applications of xenophobia in the health care setting

• Some patients may be xenophobic, so it may be extremely difficult for them to be in the hospital. • As nurses we CANNOT be xenophobic!! We are going to be with people from so many different walks of life. We must respect everyone equally no matter their viewpoint, and even if they are scared of us!

What are some of the health care disparities?

• The life expectancy of a migrant farm worker is only 49 years old. • Death rate for all cancers is 30% higher for African Americans than Caucasians • Hispanic babies are two times more likely to die in the first year of life compared to Caucasian baby. Infant mortality for black babies is twice the rate of white babies. • Disparities still exist and are the same or increasing - minorities are less likely to be immunized or have regular check-ups • "Racial and ethnic minorities tend to receive lower quality health care than whites do, even when insurance status, income, age, and severity of conditions are comparable." • Low literacy leads to a higher likelihood of suffering from heart disease, diabetes, and cancer, and ultimately they then have health care expenses 6 times higher than adults with the average level of literacy.