Nursing Chapter 5

Assuring Cultural Competence in Health Care(5-4)

(pg. 90)

family support

In many cultural and ethnic groups, people have large, extended families and consider the needs of any family member to be equal to or greater than their own. They may be unwilling to share private information about family members with those outside the family (including health care providers). Other cultural groups have great respect for the elders in the family and would never consider institutional care for them.

biological sex roles

In some cultures, the man is the dominant figure and generally makes decisions for all family members. - For example, if approval for medical care is needed, the man may give it regardless of which family member is involved. In male-dominant cultures, women are often passive. -On the other hand, there are cultures in which women are dominant. Knowing who is dominant in the family is important when planning nursing care. - For example, if the dominant member is ill and can no longer make decisions, the whole family may be anxious and confused. - If a nondominant family member is ill, the person may need help in verbalizing needs, particularly if the needs differ from those the dominant member perceives as being important.

The increasing population of older people has also raised problems associated with poverty

any older people live on fixed incomes that often do not keep up with inflation, and many (particularly widows) are on the borderline of poverty or have already slipped below the poverty level.

Mental Health

many ethnic groups have their own norms and acceptable patterns of behavior for psychological well-being, as well as different normal psychological reactions to certain situations. For example, many Hispanic people deal with problems within the family and consider it inappropriate to tell problems to a stranger. -Some traditional Chinese people consider mental illness a stigma and seeking psychiatric help a disgrace to the family. -In times of high stress or anxiety, some -Puerto Ricans may demonstrate a hyperkinetic seizure-like activity known as ataques; this behavior is a culturally accepted reaction. ~Be aware of these variations and accept them as culturally appropriate.

When a minority group lives within a dominant group: Cultural assimilation or acculturation

many members may lose the cultural characteristics that once made them different, and they may take on the values of the dominant culture. For example, when people immigrate and encounter a new dominant culture as they work, go to school, and learn the dominant language, they often move closer to the dominant culture.

Culture

may be defined as a shared system of beliefs, values, and behavioral expectations that provides social structure for daily living The *NIH* defines culture as the combination of a body of knowledge, a body of belief, and a body of behavior. -Elements include personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are specific to ethnic, racial, religious, geographic, or social groups.

Orientation to space and time

*Personal space* is the area around a person regarded as part of the person. -This area, individualized to each person and to different cultures and ethnic groups, is the area into which others should not intrude during personal interactions. -When providing nursing care that involves physical contact, you should know the patient's cultural personal space preferences. For example, people of Arabic and African origin commonly sit and stand close to one another when talking, whereas people of Asian and European descent are more comfortable with more distance between themselves and others. arriving early and getting the job done is viewed as important. This is not true in some other cultures. - For example, in some South Asian cultures, being late is considered a sign of respect. In addition, while some cultures are future oriented (including activities that promote future good health), other cultures are more concerned with the present or the past. Understanding the patient's orientation to time is important as you communicate, for example, the need to be on time for appointments for health care procedures and when taking medications

Factors Inhibiting Sensitivity to Diversity

*Stereotyping* : When one assumes that all members of a culture, ethnic group, or race act alike-stereotyping Stereotyping may be positive or negative: Negative stereotyping includes racism, ageism, and sexism. These are mistaken beliefs that certain races, an age group, or one biological sex is inherently superior to others, leading to discrimination against those considered inferior. *cultural imposition* : which is the belief that everyone else should conform to your own belief system *cultural blindness* : which occurs when one ignores differences and proceeds as though they do not exist. ~*Cultural imposition* and *cultural blindness* can be observed within the health care system, especially in regard to nontraditional methods of care *Cultural conflict* : when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values

Guidelines for nursing care: Transcultural nursing

*Transcultural nursing* , now both a specialty and a formal area of practice, originated from work by Dr. Leininger (1991), a nurse-anthropologist. -Her Theory of Cultural Care Diversity and Universality provides the foundation for providing culturally respectful care for patients of all ages, as well as families, groups, and communities. -A nurse who is culturally respectful has the knowledge and skills to adapt nursing care to cultural similarities and differences. Cultural competence takes time. It involves developing awareness, acquiring knowledge, and practicing skills. Each patient must be considered a unique person. What is true of one person may not be true of another, even if they are from the same cultural background.

culturally respecting nursing care

*cultural competence* Providing culturally respectful nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse populations within society

Culture influences roles and interactions with others as well as within families and communities, and is apparent in the attitudes and institutions unique to particular groups

-Culture helps shape what is acceptable behavior for people in a specific group. It is shared by, and provides an identity for, members of the same cultural group. -Culture is learned by each new generation through both formal and informal life experiences. Language is the primary means of transmitting culture. -The practices of a particular culture often arise because of the group's social and physical environment. -Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. -Culture influences the way people of a group view themselves, have expectations, and behave in response to certain situations. Because a culture is made up of people, there are differences both within cultures and among cultures.

cultural competence

-Developing an awareness of one's own existence, sensations, thoughts, and environment to prevent them from having an undue influence on those from other backgrounds -Demonstrating knowledge and understanding of the patient's culture, health-related needs, and culturally specific meanings of health and illness -Accepting and respecting cultural differences in a manner that facilitates the patient's and family's abilities to make decisions to meet their needs and beliefs -Not assuming that the health care provider's beliefs and values are the same as the patient's -Resisting judgmental attitudes such as "different is not as good" -Being open to and comfortable with cultural encounters -Accepting responsibility for one's own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices

Nursing care for a patient in pain is always individualized but important culture-sensitive considerations include the following:

-Recognize that culture is an important component of individuality, and that each person holds (and has the right to hold) various beliefs about pain. -Respect the patient's right to respond to pain in his or her own manner. -Never stereotype a patient's perceptions of or responses to pain based on the person's culture.

Cultural Diversity

-can be defined as the coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit -people of varying religion, language, physical size, sexual orientation, age, disability, occupational status, and geographic location.

Develop Cultural Self-Awareness (5-3) -pg.92

Before you can provide culturally competent care to patients from diverse backgrounds, you'll need to become aware of the role of cultural influences in your own life. Objectively examine your own beliefs, values, practices, and family experiences. As you become more sensitive to the importance of these factors, you'll also become more sensitive to cultural influences in others' lives. Identify your biases. How do they affect your feelings about others? How could they affect your nursing care of others?

Respect Culturally Based Family Roles

Consider the cultural role of the family member who makes most of the important decisions. In some cultures, it is the husband or father, whereas in others it may be a grandmother or another respected elder. To disregard this person's role or to proceed with nursing care that is not approved by this person can result in conflict or in disregard for the patient's and family's values. Be careful to involve this person in the nursing care planning

Concepts of cultural diversity and respect

Culture is an integral component of both health and illness because of the cultural values and beliefs that we learn in our families and communities. Nurses and other health care providers must be familiar with the concepts of cultural diversity in order to understand characteristics common to certain populations. ~also need to respect cultural backgrounds The concept of *cultural respect* enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. -Moreover, cultural respect is critical to reducing health disparities and improving access to high-quality health care -It is also vital to remember that each person may be a member of multiple cultural, ethnic, and racial groups at one time. Therefore, different cultural values may guide a person in different situations based on what is most important to that person at the time. - In addition, any person should be viewed foremost as an individual, not as a representative of a cultural group.

food and nutrition

Food preferences and preparation methods often are culturally influenced. Certain food groups serve as staples of the diet based on culture and remain so even when members of that culture are living in a different country. Patients in a hospital or long-term care setting often do not have much choice of foods. This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition. When assessing the possible causes of a patient's decreased appetite, try to determine whether the problem may be related to culture. It may be possible for family or friends to bring in foods that satisfy the patient's nutritional needs while still meeting dietary restrictions

Mutual cultural assimilation also occurs with both groups taking on some characteristics of the other.

For example, many Hispanic immigrants to the United States learn to speak English, and many Americans learn to cook and enjoy traditional Hispanic foods. We all gain from the many cultures with which we live. Although we seldom think about it, the clothes we wear, the foods we eat, the music we enjoy, many of the words we use, and the leisure activities we practice are all influenced by acculturation.

Accommodate Cultural Practices in Health Care

Incorporate factors from the patient's cultural background into health care whenever possible if the practices would not be harmful to the patient's health. To ignore or contradict the patient's background may result in the patient refusing care or failing to follow prescribed therapy. Accommodate the cultural dietary practices of patients as much as possible. Dietary departments in many hospitals and long-term care facilities can provide meals that are consistent with special dietary practices

Avoid Mandating Change

Keep in mind that health practices are part of the overall culture and that changing them may have widespread implications for the person. Provide support and reinforcement for the patient if it is necessary to change a health practice with a cultural basis. Do not force patients to participate in care that conflicts with their values. If a patient is forced to accept such care, resulting feelings of guilt and alienation from a religious or cultural group are likely to threaten that patient's well-being.

Develop Cultural Knowledge

Learn as much as possible about the belief system and practices of people in your community and of patients in the area in which you work. Practice techniques of observation and listening to acquire knowledge of the beliefs and values of patients for whom you provide care. Some people, especially those of minority cultures, may have been belittled or ridiculed and may be hesitant to discuss their beliefs and practices. Approach this topic with patients carefully. If you are motivated by sincerity, respect, and concern, your attitude will convey this, and most patients will respond positively. On the other hand, if you are motivated merely by curiosity and have a condescending attitude, most patients will respond negatively.

The ESFT Model

National standards issued by the Office of Minority Health (2001): were developed to ensure that all people entering the health care system be provided equitable and effective treatment in a culturally and linguistically appropriate manner.

In some cultures, the power to heal is thought to be a gift from God bestowed on certain people: cultural influences on health

People in these cultures believe that these folk or traditional healers know what is wrong with them through divine intervention and experience. A patient accustomed to traditional healers may think that health care providers are incompetent because they have to ask many questions before they can treat an illness. Traditional healers speak the patient's language, often are more accessible, and are usually more understanding of the patient's cultural and personal needs.

cultural influences on health and illness

People's values and beliefs about health, illness, and health care are influenced by cultural and ethnic groups. For example, in some groups, illnesses are classified as either natural or unnatural. "Natural illnesses" are caused by dangerous agents, such as cold air or impurities in the air, water, or food. "Unnatural illnesses" are punishments for failing to follow God's rules, resulting in evil forces or witchcraft causing physical or mental health problems.

Race

Racial categories are typically based on specific physical characteristics such as skin pigmentation, body stature, facial features, and hair texture. -Because of the significant blending of physical characteristics through the centuries, however, race is becoming harder to define using simple classifications, and physical characteristics are not considered a reliable way to determine a person's race. *Federal standards for race classification* provide five categories including: ~American Indian or Alaska Native ~Asian ~ Black or African American ~Native Hawaiian or Other Pacific Islander ~White ~ provide the opportunity for people to identify themselves in multiple categories.

seek cultural assistance

Seek assistance from a respected family member, member of the clergy, or traditional healer, as appropriate, so that the patient is more likely to accept health care services. Acknowledging the role of the person's traditional healer can be an important way of building trust. Folk medicine practitioners can work closely with professional health practitioners in the interest of the patient and family. Such efforts promote mutual understanding, respect, and cooperation.

Reactions to pain

Some cultures allow or even encourage the open expression of emotions related to pain, whereas other cultures encourage suppression of such emotions. -You should not assume that a patient who does not complain of pain is not having pain. If you make this assumption, you may overlook the pain-reduction needs of a patient who deals with pain quietly and stoically. -To avoid this error, be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area, avoiding activities that intensify the pain, and uncontrollable, spontaneous expressions of discomfort, such as facial grimacing and moaning. -You also should not consider patients who freely express their discomfort as constant complainers with excessive requests for pain relief. Pain is a warning from the body that something is wrong.

Physiologic Variations (table 5-1) pg. 84

Studies have shown that certain racial and ethnic groups are more prone to certain diseases and conditions. For example, a hereditary disorder, Tay-Sachs' disease, is associated with people of Eastern European Jewish descent. Although the incidence of this disorder has declined over the years owing to improved and earlier testing, it is still a concern. -Use knowledge of such risk factors when interviewing a patient to complete a health history

One of the most culturally variable forms of nonverbal communication is eye contact

The American-dominant culture emphasizes eye contact while speaking, but many other cultures regard this behavior in different ways. For example, direct eye contact may be considered impolite or aggressive by many Asians, Native Americans, Indochinese, Arabs, and Appalachians; these groups of people tend to avert their eyes while speaking. Hispanics may look downward in deference to age, biological sex, social position, economic status, or authority. Muslim-Arab women often indicate modesty by avoiding eye contact with men, and Hasidic Jewish men may avoid direct eye contact with women ~Although the above examples are not true of all members of a group, they provide some general guidelines.

Cultural Assessment

The National Center for Cultural Competence urges health care professionals who value cultural competence to enhance their understanding of the following: -Beliefs, values, traditions, and practices of a culture -Culturally defined, health-related needs of individuals, families, and communities -Culturally based belief systems of the etiology of illness and disease and those related to health and healing -Attitudes toward seeking help from health care providers ~When caring for patients from a different culture, it is important to first ask how they want to be treated based on their values and beliefs. An effective way to identify specific factors that influence a patient's behavior is to perform a cultural assessment.

Most societies include both dominant culture groups and minority culture groups

The dominant group has the most ability to control the values and sanctions of the society. It usually is (but does not have to be) the largest group in the society. Minority groups usually have some physical or cultural characteristic (such as race, religious beliefs, or occupation) different from those of the dominant group.

some common cultural norms of the health care system.

The health care system is itself a culture with customs, rules, values, and a language of its own, with nursing as its largest subculture. As you progress through your education, you will be acculturated into the culture of the health care system and will develop values related to health and health care.

phases of cultural shock

The resident having difficulty adapting to the long-term care environment is experiencing culture shock but has progressed to the stage of beginning resolution of being a part of the new environment. In the honeymoon phase, the client idealizes the new culture and is highly positive about it. In the disenchantment phase, the client recognizes and is frustrated by the differences between the old and new cultures. In the effective functioning phase, the client can participate fully and comfortably in the new culture.

health disperities

The term health disparities refers to health differences between groups of people; they can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death Many different populations are affected by disparities, including racial and ethnic minorities; residents of rural areas; women, children, and the older adult; and persons with disabilities.

Socioeconomic Factors

There has been much debate about how to define poverty. In terms of economics, a person or family whose income falls below an established poverty line is considered poor. The U.S. Census Bureau defines poverty according to money or income guidelines that vary by family size and composition. If the family's total income is less than a set threshold, all members of the family are considered poo Such standards vary at different times and in different places; what is judged to be poverty in one community might be regarded as wealth in another No matter how poverty is defined, it is an increasingly devastating epidemic, fueled by real estate foreclosures and credit debt that has evolved into a culture of its own. At highest risk are children, older people, families headed by single mothers, and the future generations of those now living in poverty. Access to financial resources affects how individuals and families meet their basic needs and maintain their health. Poverty often leads to problems such as lack of health insurance, inadequate care of infants and children, lack of access to basic health care services, and homelessness. All these are of concern to nursing.

the culture of poverty is passed from generation to generation

This appears to be especially true in such groups as migrant farm workers, families living on public assistance, and people who live in isolated areas such as Appalachia. Poverty cultures often have the following characteristics: -Feelings of despair, resignation, and fatalism -"Day-to-day" attitude toward life, with no hope for the future -Unemployment and need for financial or government aid -Unstable family structure, possibly characterized by abusiveness and abandonment -Decline in self-respect and retreat from community involvement

When caring for a patient from a cultural or ethnic group different from your own, it is important to perform a transcultural assessment of communication

What language does the patient speak during usual activities of daily living? How well does the patient speak and write in English? Does the patient need an interpreter? Are family members or friends available? Are there people the patient would not want to serve as an interpreter? How does the patient prefer to be addressed? What cultural values and beliefs of the patient (such as eye contact, personal space, or social taboos) may change your techniques of communication and care? How does the patient's nonverbal behavior affect the responses of members of the health care team? What are the cultural characteristics of the patient's communications with others?

Language and communication

When people from another part of the world move to the United States, they may speak their own language fluently but have difficulty speaking English. Assimilation is likewise slower for people who stay at home, especially if they live in communities of their ethnic and cultural background. Children usually assimilate more rapidly and learn the language of the dominant culture quickly if they leave home each day to go to school and make new friends in the dominant culture. Consider how difficult it must be to describe symptoms or give a personal health history when you do not understand the questions being asked. -In addition, patients may forget English words or revert to their more familiar language when experiencing the stress of an injury, illness, or pain. -Imagine for a moment finding yourself in an emergency room with crushing chest pain in a foreign country where no one speaks your language

The Office of Minority Health of the U.S. Department of Human Services created "Think Cultural Health"

an online service whose goal is to advance health equity at every point of contact through the development and promotion of culturally and linguistically appropriate services. Nurses who recognize and respect cultural diversity are better equipped to exhibit cultural sensitivity and provide nursing care that accepts the significance of cultural factors in health and illness.

subcultures

is a large group of people who are members of the larger cultural group but who have certain ethnic, occupational, or physical characteristics that are not common to the larger culture. Clear definition: (values and norms distinct from those of the majority, held by a group within a wider society) For example, nursing is a subculture of the larger health care system culture, and teenagers and older adults are often regarded as subcultures of the general population in the United States.

ethnicity

is a sense of identification with a collective cultural group, largely based on the group members' common heritage. -One belongs to a specific ethnic group or groups either through birth or through adoption of characteristics of that group. - People within an ethnic group generally share unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns.

Socioeconomic status

often differs by the cultural group of the older adult. - For example, Pacific/Asian, African-American, Native American, and Hispanic elders generally have lower incomes than elders in the majority population. The work history of the cultural group, especially those who have labored all their lives as agricultural workers, often means that a person has no Social Security or Medicare benefits.

Key terms (page 81)

pg 81

Transcultural Assessment: Health-Related Beliefs and Practices (5-5)

pg.91 by Dr. Leininger (1991)

Linguistic competence: language and communication

refers to the ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter. -Nurses who work in a geographic area with a high population of residents who speak a language other than English should learn pertinent words and phrases in that language. -Many facilities also have a qualified interpreter, or one can be found in the community. To avoid misinterpretation of questions and answers, it is important to use an interpreter who understands the health care system. -Sometimes a family member or friend can translate for the nurse, but such a person may be protective and not the most reliable means of transferring information; thus, guidelines discourage using family members or friends as translators.

Ethnocentrism

the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture. -When health professionals assume that they have the right to make choices and decisions for patients of another culture, patients may respond in the same way that minority cultures often respond to such an attitude by the dominant culture: by becoming passive, resistive, angry, or resistant to treatment. -The nurse's role is to understand the patient's needs and to adapt care to respectfully meet those needs. A careful merging of modern and traditional cultural beliefs is a necessary prerequisite for safe, considerate, and successful nursing care of all patients.

feminization of poverty

threatens to increase the number of people who are living at poverty level. -The number of female-headed households is increasing as a result of divorce, abandonment, unmarried motherhood, and changes in abortion laws. -Because it is now common that two incomes are required in a household for economic survival, a single woman supporting a household is at a financial disadvantage. -The number of single-parent families headed by women is associated closely with the increasing number of children living in poverty and the number of homeless families with children.

cultural shock

when placed in a different culture he or she perceives as strange. -Culture shock may result in psychological discomfort or disturbances, because the patterns of behavior a person found acceptable and effective in his or her own culture may not be adequate or even acceptable in the new culture. The person may then feel foolish, fearful, incompetent, inadequate, or humiliated. These feelings can eventually lead to frustration, anxiety, and loss of self-esteem.