Nurs. 120 - Ch. 9 Cultural Awareness

Cultural Competency 1

Cultural competency is defined as the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. It is a developmental process that evolves over time. According to the NCCC framework, culturally competent organizations: • Value diversity • Conduct a cultural self-assessment • Manage the dynamics of difference • Institutionalize cultural knowledge • Adapt to diversity Expanding the original focus on interpersonal skills, many of the current approaches to cultural competency now also focus on: (1) all marginalized groups and not just immigrants; (2) prejudice, stereotyping, and social determinants of health; and (3) the health system, communities, and institutions.

Box 9-1 Key Concepts of Intersectionality

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Box 9-2 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care

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Box 9-3 Patient-Centered Care for LGBT Patients

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Core Measures

To improve health outcomes, TJC and the CMS developed a set of evidence-based, scientifically researched standards of care called core measures. The core measures are key quality indicators that help health care institutions improve performance, increase accountability, and reduce costs. All of the core measures such as screening for depression and controlling high blood pressure are consistent with national health priorities. They represent clinical conditions such as heart failure, acute myocardial infarction, pneumonia, and surgical-site infections. Following these standards of care on a nationwide scale is expected to reduce mortality, complications, and inpatient readmissions. In addition, core measures are intended to reduce health disparities. When policies impede the delivery of effective care, you and your colleagues must advocate for policy change.

Skills and Interventions.

To provide patient-centered culturally competent care, you must know how to collect relevant cultural data about a patient's presenting health problem(s) and how to then use it. Critical to success is your ability to conduct a systematic cultural assessment, communicate effectively), and have the skills to successfully manage world view differences with others.

Cultural Encounters.

A cultural encounter is an intervention that involves a nurse directly interacting with patients from culturally diverse backgrounds. The use of a caring, therapeutic, and culturally congruent relationship will lessen the likelihood of conflict. Campinha-Bacote (2011) describes two goals of a cultural encounter: (1) to generate a wide variety of responses and to send and receive both verbal and nonverbal communication accurately and appropriately, and (2) to continuously interact with patients from culturally diverse backgrounds in order to validate, refine, or modify existing values, beliefs, and practices and to develop cultural desire, awareness, skill, and knowledge. The challenge is being able to show compassion, especially if cross-cultural conflict develops.

Cultural Knowledge—World Views 2

A young female patient who has willingly agreed to be admitted to the hospital for a serious medical condition requiring surgery may refuse the surgery for religious reasons. In the patient's view she came to the hospital for help to eliminate the pain and infection from her illness. At the same time she believes that she needs to seek God's will for a decision that entails removing a body part. The patient's health care provider assumes that the patient is in the hospital to receive care for a serious illness and is willing to accept any and all treatments to cure the illness. The patient's deeply held religious beliefs about removing a body part are not obvious by assessing for a religious preference. Thus you would need to conduct a comprehensive cultural assessment (Box 9-4) to understand the patient's world view, including how her religious values affected her willingness to receive care. Conflict arises when health care providers interpret the behaviors of patients through their own world view lens instead of trying to uncover the world view that guides this behavior. Most important, remember that the core of this negotiation is compassionate care. During these encounters participants not only exchange information but also acknowledgment, presence, and affirmation

General

African-Americans have the highest mortality rate of any racial and ethnic group for all cancers combined, contributing in part to a lower life expectancy for both African-American men and women. Asian Americans generally have lower cancer rates than the non-Hispanic white population, but they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Whites, or non-Hispanic Blacks. Hispanic youths ages 2 to 19 are more likely to be overweight or obese than the non-Hispanic White or Black youths of the same age, which places them at a greater risk of developing a number of chronic diseases such as type 2 diabetes, high blood pressure, and asthma. Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, and substance use disorders and are four times as likely as their straight peers to make suicide attempts that require medical attention. Transgender individuals are more likely to postpone medical care because of lack of insurance and encounters with discrimination than people who do not identify as transgender. In American Indian and Alaska Native populations, the infant mortality rate is 60% higher than in non-Hispanic Whites. In 2008 the infant mortality rate for African-American infants was more than twice the rate for non-Hispanic white infants. The infant mortality rate among children born to college-educated African-American women is significantly higher than among babies born to white women who are similarly educated.

Cultural Competency 3

Blanchet and Pepin (2015) have recently described the processes involved in the development of cultural competence among registered nurses and undergraduate student nurses. The researchers describe three dimensions of cultural competence: • Building a relationship with the other • Working outside the usual practice framework • Reinventing practice in action A central theme is being able to know patients through their eyes and learning their stories. Failing to understand a person's world view may result in your being very impersonal and detached. As a nurse you are responsible for assessing patients' health issues within their world view. For example, are their issues simply the effects of their illness, or are they associated with underlying societal conditions such as poverty, lack of transportation, or an unsafe neighborhood?

Health Literacy.

Choosing a healthy lifestyle, knowing how to seek medical care, and taking advantage of preventive health care measures requires people to understand and use health information. Health literacy is the ability to obtain, process, and understand health information needed to make informed health decisions. Lower health literacy has been associated with higher risk of mortality for seniors, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and poorer overall health status among seniors. Patients who are especially vulnerable are the elderly (age 65+), immigrants, people with low incomes, people who do not have a high-school diploma or GED, and people with chronic mental and/or physical health conditions. Commonly used measures of health literacy include literacy measures such as the Rapid Estimate of Adult Literacy in Medicine (REALM), which is a word recognition test; and the Test of Functional Health Literacy in Adults (TOFHLA), which measures reading skills and numeracy.

Teach Back 1

Clear communication is essential for effective delivery of quality and safe health care, but most patients experience significant challenges when communicating with their health care providers. The Teach Back method is an intervention that helps you to confirm that you have explained what a patient needs to know in a manner that the patient understands. The Teach Back technique is an ongoing process of asking patients for feedback through explanation or demonstration and presenting information in a new way until you feel confident that you communicated clearly and that your patient has a full understanding of the information presented. You also use Teach Back to help you identify explanations and communication strategies that your patients most commonly understand. Ask open-ended questions to verify his or her understanding. You can ask the question in the following ways: • "I've given you a lot of information to remember. Please explain it back to me so I can be sure that I gave you the information you need to take good care of yourself." • "What will you tell your wife (or husband/partner/child) about the changes we made to your medications today?" • "We've gone over a lot of information today about how you might change your diet, and I want to make sure that I explained everything clearly. In your own words, please review what we talked about. How will you make it work at home?"

Cultural Awareness.

Curiosity about other ways of being in the world is an important attitude for cultural competence; however, it is also important for you to understand the forces that influence your own world view. A bias is a predisposition to see people or things in a certain light, either positive or negative. Becoming more self-aware of your biases and attitudes is important. It is helpful to think about cultural competence as a lifelong process of learning.

Cultural Desire.

Cultural desire is the motivation of a health care professional to "want to"—not "have to"—engage in the process of becoming culturally competent. An ethically responsible professional nurse must embrace the importance of cultural competency and apply principles in daily patient encounters. Examples of such organizational policies and practices include: • Instituting a requirement for all staff to be trained in cultural competence. • Embedding a broad description of family in written policies. • Expanding visitation policies and practices to include a patient's preferences. • Requiring nursing staff to conduct and document a cultural assessment on all patients within the clinical documentation system. • Ensuring that people who are deaf or speak limited English have access to an interpreter. • Embedding health literacy principles in written and verbal communication. • Collecting race, ethnicity, and language information from patients on admission and stratifying outcomes data by these and other demographic indicators to identify disparities in care. • Using stratified outcomes data to improve the health of populations.

Meaning of Disease and Illness

Culture and life experiences shape a person's world view about health, illness, and health care. To provide culturally congruent care, you need to understand the difference between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. People tend to react differently to diseases on the basis of their unique cultural perspective.

Culture

Culture is associated with norms, values, and traditions passed down through generations. A more contemporary view of culture acknowledges its many other facets such as gender, sexual orientation, location, class, and immigration status. This more dynamic perspective recognizes that we all belong simultaneously to multiple social groups within changing social and political contexts, a framework often referred to as intersectionality. Oppression is a formal and informal system of advantages and disadvantages tied to our membership in social groups, such as those at work, at school, and in families. To better understand this more dynamic and complex way of thinking about culture, consider this example. As a nurse think about how a 27-year-old homeless woman with diabetes, an 85-year-old African-American retired nurse from rural Alabama, a 32-year-old Latina lesbian executive in San Francisco who is Catholic, and an undocumented immigrant woman from Eastern Europe who has a 3-year-old child with a developmental disability experience their womanhood. How may their experiences compare to the experiences of others as they live in America? How do their experiences compare with regard to using a health care system, managing their diabetes, or perceiving the presence or absence of opportunities to live a happy, safe, and productive life? How could age affect their perspective? How would these answers change if one looked at their lives 15 or 35 years ago? How would the experiences change if these individuals were men or transgender? Understanding culture requires you to adopt an intersectional perspective like the one in the example.

Health Disparities

Healthy People 2020 defines a health disparity as "a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage". The word parity means "equality." Health disparity is literally an inequality or difference (i.e., a gap) between the health status of a disadvantaged group such as people with low incomes and wealth and an advantaged group such as people with high incomes and wealth. People in marginalized groups are more likely to have poor health outcomes and die at an earlier age because of a complex interaction between individual genetics and behaviors; public and health policy; community and environmental factors; and quality of health care. Many organizations have developed different models incorporating social determinants of health to explain the complexity of these interactions. According to the World Health Organization (2013), social determinants of health are "the conditions in which people are born, grow, live, work and age...shaped by the distribution of money, power and resources at global, national, and local levels."

Teach Back 2

Helpful hints to consider when trying the Teach Back method follow: • Plan your approach. Think about how you will ask your patient to teach back in a shame-free way. Keep in mind that some situations are not appropriate for Teach Back. • Use handouts, pictures, and models to reinforce your teaching. • Clarify. If a patient cannot remember or accurately repeat your instructions, clarify your information and allow him or her to teach it back again. Do this until the patient is able to teach back in his or her own words without parroting back what you said. Understand Teach Back as a process of "closing the loop" • Practice. Although it takes time to get used to Teach Back, studies show that it doesn't take longer to perform once it becomes a part of your routine

Cultural Knowledge—World Views 1

Historical and social realities shape an individual's or group's world view, which determines how people perceive others, how they interact and relate to reality, and how they process information. World view refers to "the way people tend to look out upon the world or their universe to form a picture or value stance about life or the world around them". When you assess a patient's cultural background and needs, you take into account each patient's world view, then you plan and provide nursing care in partnership with each patient. In any intercultural encounter there is an insider perspective (emic world view) and an outsider perspective (etic world view). For example, a Korean woman requests seaweed soup for her first meal after giving birth. Avoid stereotypes or unwarranted generalizations about any particular group that prevents an accurate assessment of an individual's unique characteristics and world view. Instead approach each person individually and ask questions to gain a better understanding of his or her perspective and needs. Most health care providers educated in Western traditions are immersed in the culture of science and biomedicine through their course work and professional experience. Consequently they often have a world view that differs from that of their patients. When patients access the health care system, they want to: (1) see their health care provider, and (2) feel better. In return the health care providers expect patients to: (1) make and keep appointments; (2) give a medication history; (3) give informed consent; (4) follow (discharge) instructions; (5) read, understand, and use health education materials; (6) correctly complete insurance forms; (7) pay their bills; and (8) go home and manage their care by taking their medication the right way, eating the right foods, and stopping/starting/changing a variety of behaviors. This list shows how complex each patient interaction is even before the interaction begins.

Cultural Assessment 2

In contrast to standard approaches for health assessment, cultural assessment is intrusive and may take more time to conduct because it requires building a trusting relationship between participants. Miscommunication commonly occurs in intercultural transactions. This occurs because of differences in verbal communication between participants and differences in interpreting one another's behaviors. Effective communication is a critical skill in providing quality and safe care. Mnemonics, or memory aids, offer you a different option that makes it easier to perform assessments and communicate effectively with patients about their plan of care (Box 9-5). They help you remember the steps of each communication technique. For example, if you use the LEARN mnemonic, your first step is to listen to the patient's explanation or story of the presenting problem. Then you explain your perception of the patient's problem, whether it is physiological, psychological, or cultural. Then you acknowledge the similarities and differences between the two perceptions. It is important to recognize differences but build on the similarities. The fourth step involves recommendations that require you to involve the patient and family when appropriate. The last step is to then negotiate a mutually agreeable, culturally oriented, patient-centered plan.

Linguistic Competence.

Linguistic competence is the ability of an organization and its staff to communicate effectively and convey information in a manner that is easily understood by diverse audiences. These audiences include people of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing. One important service that health care organizations must provide is an interpretive service. As a nurse, it is critical for you to know that these laws require health care organizations to do the following: • Provide language assistance services free of charge at all points of contact to all patients who speak limited English or are deaf • Notify patients, both verbally and in writing, of their right to receive language-assistance services • Take steps to provide auxiliary aids and services, including qualified interpreters, note takers, computer-aided transcription services, and written materials • Ensure that interpreters are competent in medical terminology and understand issues of confidentiality and impartiality. Do not use a patient's family members to interpret for you or other health care providers. Cultural dynamics, lack of interpreting skills, low health literacy, and bias could lead to inaccurate interpretation.

Health Disparities and Health Care

On the other hand, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g., screening, diagnostic, treatment, management and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. Poor access to health care is one social determinant of health that contributes to health disparities. Access to primary care is an important indicator of broader access to health care services. The 2013 National Healthcare Disparities Report (AHRQ, 2013a) revealed that African-Americans, Asians, and Hispanics are less likely than non-Hispanic Whites to see a primary care provider regularly. Less care is available or accessible to people in low- and middle-income groups compared with people in high-income groups. Inadequate resources, poor patient-provider communication, a lack of culturally competent care, fragmented delivery of care, and inadequate access to language services all compromise patient outcomes. As a result, many disparities in health care and health outcomes remain. Health disparities are also very costly($309 billion).

Cultural Competency 2

One model suggests that nurses see themselves as becoming rather than being culturally competent because cultural competency is developmental. Campinha-Bacote's model of cultural competency (2002) has five interrelated components: • Cultural awareness: An in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people • Cultural knowledge: Sufficient comparative knowledge of diverse groups, including the values, health beliefs, care practices, world view, and bicultural ecology commonly found within each group • Cultural skills: Ability to assess social, cultural, and biophysical factors that influence patient treatment and care • Cultural encounters: Cross-cultural interactions that provide opportunities to learn about other cultures and develop effective intercultural communication • Cultural desire: The motivation and commitment to caring that moves an individual to learn from others, accept the role as a learner, be open to and accepting of cultural differences, and build on cultural similarities.

Box 9-4 Nursing Assessment Questions

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TABLE 9-1 Explanatory Model Comparison

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Box 9-5 Communication Techniques Using Mnemonics

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Box 9-6 Working with Interpreters

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Box 9-7 Equity-Focused Quality Improvement

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Addressing Health Care Disparities

The American Community Survey reports that the number of people in poverty increased to about 48.8 million or 15.9%, with African-Americans, Hispanics, and Native Americans having the highest national poverty rates. The Joint Commission (TJC), the National Quality Forum (NQF), and the National Commission on Quality Assurance (NCQA) are a few of the influential organizations that have responded to these complexities by implementing new standards focused on cultural competency, health literacy, and patient- and family-centered care. These standards recognize that valuing each patient's unique needs improves the overall safety and quality of care and helps to eliminate health disparities.

Cross-cultural medicine

The early pioneers in cross-cultural medicine outlined a set of universal skills that are still applicable for helping health care providers work effectively with patients from any culture. These skills include: 1. Respecting a patient's health beliefs as valid and understanding the effect of his or her beliefs on health care delivery 2. Shifting a model of understanding a patient's experience from a disease happening in his or her organ systems to that of an illness occurring in the context of culture (biopsychosocial context) 3. Ability to elicit a patient's explanation of an illness and its causes (patient's explanatory model) 4. Ability to explain to a patient in understandable terms the health care provider's perspective on the illness and its perceived causes 5. Being able to negotiate a mutually agreeable, safe, and effective treatment plan

Cultural Assessment 1

The goal of a cultural assessment is to obtain accurate information from a patient that allows you to formulate a mutually acceptable and culturally relevant plan of care for each health problem of a patient. sing a cultural assessment model will help you focus on the information that is most relevant to your patient's problems. It will also help you better understand the complex factors that influence your patient's cultural world view. You need to assess and interpret a patient's perspective during your assessment. Use open-ended, focused, and contrasted questions. Encourage your patients to describe the values, beliefs, and practices that are significant to their care. Culturally oriented questions are by nature broad and require learning more about the patient's personal narratives. One effective approach to assessment is to ask questions that will help you understand a patient's explanatory model—his or her views about health and illness and its treatment. There are five questions in most explanatory models: etiology, time and mode of onset of symptoms, pathophysiology, course of illness (including severity and type of sick role), and treatment for an illness episode.

Culturally Congruent Care

Transcultural nursing as a comparative study of cultures to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups). The goal of transcultural nursing is to provide culturally congruent care, or care that fits a person's life patterns, values, and system of meaning. Discovering patients' cultural values, beliefs, and practices as they relate to nursing and health care requires you to assume the role of learner and to partner with your patients and their families to determine what is needed to provide meaningful and beneficial nursing care. Effective nursing care integrates the cultural values and beliefs of individuals, families, and communities with the perspectives of a multidisciplinary team of health care providers. For example, during nursing school you are assigned to care for a female patient who observes Muslim beliefs. You notice the woman's discomfort with several of the male health care providers. You wonder if this discomfort is related to your patient's religious beliefs. While preparing for clinical, you learn that Muslims differ in their adherence to tradition but that modesty is the "overarching Islamic ethic" pertaining to interaction between the sexes.

Patient-Centered Care

Two landmark reports highlight the importance of patient-centered care and cultural competence. Crossing the Quality Chasm identifies patient-centered care as one of six "aims" for high quality health care, and Unequal Treatment stresses the importance of developing cultural competence among health care providers to eliminate racial/ethnic health care disparities. Beach and colleagues (2006) succinctly summarize the differences and similarities between these two concepts: "Both patient-centeredness and cultural competence aim to improve health care quality, but each emphasizes different aspects of quality. The primary goal of the patient-centeredness movement has been to provide individualized care and restore an emphasis on personal relationships. It aims to elevate quality for all patients. Alternatively, the primary aim of the cultural competence movement has been to increase health equity and reduce disparities by concentrating on people of color and other disadvantaged populations."

Key Points

• Disparities in the access to quality of health care, preventive health, and health education contribute to poor population health. • Health care systems and providers contribute to the problem of health disparities as a result of inadequate resources, poor patient-provider communication, lack of culturally competent care, fragmented delivery of care, and inadequate access to language services. • Culturally competent health care providers and organizations can contribute to elimination of health disparities. • Current evidence shows that addressing limited health literacy and cultural differences often reduces medical errors and improves adherence, patient-provider-family communication, and outcomes of care. • Cultural desire involves a natural inclination to engage in the cultural competence process that is characterized by passion, commitment, and caring. • A person's culture and life experiences shape his or her world view about health, illness, and health care. • An effective approach to patient assessment is to use a patient's explanatory model instead of a traditional biomedical model to reveal your patient's views on illness • Becoming culturally competent is an ongoing long-term process for a health care provider.