Transcultural Nursing

The five levels of experience of the Dreyfus model of skill acquisition.

How to conduct a detailed cultural assessment = nurses pass through five distinct stages before they become experts. The following five levels of experience are based on the modified version of the Dreyfus model of skill acquisition. Nurses' cultural skills vary from level to level going from novice to expert.

participate as observer

Nurses can refine their knowledge and skills by spending a great deal of time in the participant role. They can now apply the cultural rules of communication behavior when interacting with and caring for patients.

observer as participant

Observation and interviewing constitute most of this phase. _ - Nurses continue to observe the RSS (repetitive social situations).

complete observer

Observes without becoming a participant - Obtain basic background information about multiple dimensions of a group's cultural beliefs and practices. - Example= watch films, TV, videos, plays, or read novels that deal with cultural groups. Foreign language media is best.

The 4 phases of a therapeutic relationship

(1) the pre -interaction phase (2) the orientation phase (3) the working phase (4) and the termination phase.

Briefly define the importance of cultural competence in the nurse-patient relationship

- Because culture and communication are strongly linked, and the population needing health care services has become increasingly diverse, nurses need to demonstrate core knowledge and skills in providing care for clients - so they can respond with respect and sensitivity with clients and families from different cultural and linguistic backgrounds.

Briefly define the values for the following groups: Hispanic

- Hispanic is a broad term that refers to Caribbean, Mexico, and central/ South America and people who trace their ancestry back to Spain. - Latino = cultural ties to South America rather than Spain. - Hispanics will be the nation's largest minority group. - value family and often place the needs of family members above the needs of individuals, respectful and affectionate and traditionally value religion especially Catholicism.

Define Knowledge Deficit

- Nurses suffer from knowledge deficit when they lack information and knowledge concerning the cultural groups with whom they work. - A nurse who was not knowledgeable about patients cultural values, health beliefs, and patterns of seeking help would not be able to provide the culturally sensitive care that all patients deserve

Give an example of a cultural competence in the nurse-patient relationship

- Recognizing differences, integrating cultural knowledge, and acting in a culturally appropriate manner will facilitate cultural competence. - Positive outcomes of cultural competency improve the quality of health care services, increase client satisfaction, decrease errors in practice, increase client's compliance to prescribe treatment regimens, and reduce liability and malpractice suits.

Why should people not be stereotyped simply because they are members of a broad, statistically defined, racial or ethnic category?

- because they are first and foremost an individual. - Within each broad, statistical categories there are numerous cultural groups of various lifestyles, values, beliefs, health, and illness related practices, preferences for care, and family member patterns of interaction.

Holistic belief system

- belief system upheld by Asian cultures and some Native American cultures. -Emphasis on health promotion, illness prevention, and health maintenance -. Develops when one does not properly care for the body and the body becomes imbalanced. To restore health the person must restore equilibrium to the body. (Ex. Yin Yang, hot / cold)

Supernatural Belief System

- common among traditional Hispanic, Caribbean, African, and other cultures. -They view illness as a sign of weakness, punishment for evil doing, retribution for shameful behavior, or as possession from evil spirits. - To diagnose illness, Hispanics may turn to a healer, and Caribbeans' to a voodoo priest or priestess, and natives traditionally rely on dreams or divination.

what does culturally competent care mean?

- defined by the American Academy of Nursing as a complex integration of knowledge, attitude, and skills that enhance cross cultural communication and appropriate and effective interactions.

Define the biomedical belief system

- derived from Descartes; -Mind- body dichotomy that is the mind and body are separate from each other. -Disease is caused by physiological disturbances. Traditional treatment = medications, surgery. -Majority belief system of United States and western physicians spread this belief elsewhere.

To achieve culturally competent care nurses...

- need to commit themselves to enhancing their knowledge of different cultures and developing their skills. - Achieve this by reading about cultures, seeing films about different cultures, talking with patients or coworkers about their cultural backgrounds. - or acting as a participant - observer in a cultural setting such as an ethnic neighborhood.

(2) questions you might ask during a participant-observation interview and describe why these questions were selected.

-"How did this affect your family" a good question to use in PO when your start with interviews rather than observations. -A good way to end interviewing is to ask is "what else should I know about (whatever the topic is)?"

Briefly define the values for the following groups: Asian/Pacific

-Asian values are firmly rooted in traditional religious beliefs and family oriented. - Chinese, Vietnamese, and Korean beliefs are greatly influenced by Buddhism, Taoism, Christianity, and Confucianism. - Japanese religious values are based on Zen Buddhism and Shintoism, and east Indians on Hinduism.

Describe a potential conflict a practitioner of the biomedical belief system may have when treating a patient that practice a holistic belief system.

-The biomedical belief system believes in administering medications and performing surgery as sources of treatment. - The holistic belief system believes a person must remain in harmony with the natural laws and be willing to continually adjust and adapt to changes in the environment to be healthy. -A patient of the holistic belief system may believe that their fever or infection was caused by a hot agent and should be treated with cold foods, such as fresh veggies, and cold medicines like milk of magnesia to restore balance to the body. - This could be a potential conflict for a practitioner of the biomedical belief system when they would rather treat the physiological disturbance alone and give their patient antibiotics or westernized medicine to treat their fever or infection.

Briefly define the values for the following groups: Black

-The term black also lumps together highly diverse group of people. -Currently the largest minority group in the United States. - Black Americans traditionally value family bonding, matrifocus, present oriented, and spiritual orientation

Briefly define the values for the following groups: White

-The value system for many mainstream white Americans is based on white, ango-saxon, Protestant (WASP) ethinc. -Values include independence, individuality, wealth, comfort, cleanliness, achievement, punctuality, hard work, aggression, assertiveness, rationality. - orientation towards future, and a mastery of one's own fate. - Tend to act as an individual rather than a group leading to competition.

Why are language barriers the most difficult barrier to overcome?

-They make it difficult/ impossible to obtain a patient's history, assess the patient's symptoms, and it interferes with explaining hospital policies and medical procedures, and it severely impedes the vital processes of teaching and counseling the patient and family. Language barriers = misunderstandings and resentments between nurses and patients. Need professional medical interpreter

How to overcome knowledge deficit

-To learn more about specific cultures. -Attend classes/ seminars about transcultural nursing. - Textbooks about history, beliefs, and practices of major American cultural groups. - Read novels and autobiographies and watch documentaries, and foreign films that are written and directed by diverse cultures.

1. Why should people not be stereotyped simply because they are members of a broad, statistically defined, racial or ethnic category? (Please share a personal experience or an observed example)

-U.S. and Canadian governments have created population categories for the purpose of statistics. - Such as white, black, Hispanic, Asian, and Native American. - These categories are used in various healthcare settings and businesses. - These five categories tend to diminish quality health care as the broad categories blur or even extinguished the crucial cultural differences between individuals. -We should always treat coworkers and patients as individuals with unique experience and expectations. -While someone may be Asian, they could be Japanese, Chinese, Indochinese, Korean, Vietnamese, Filipino, or of an Indian population with numerous, diverse subcultures

eight (8) potential barriers to communication

1) Lack of Knowledge 2) Fear and Distrust 3) Racism 4) Bias and ethnocentrism 5) stereotyping 6) Ritualistic behavior 7) language barriers 8) differences in perceptions and expectations.

If a facility does not have the resource, name two (2) guidelines a health care professional should considered when an interpreter is not available.

1) When a patient speaks little to no English and a medically trained interpreter is not available, the healthcare professional must find someone to interpret. Unfortunately, they may be forced to rely on a family member to interpret for the patient. This can cause complications and confusion and there are certain guidelines to follow to avoid language barriers. (2) a healthcare professional should off so to see if the health care facility has access to a telephone interpretation service. Some health care facilities have an account with a language line which provides 24-hour service to interpreters for approximately 140 languages. However, this can be expensive and not all telephone interpreters understand medical terminology.

What are 2 consequences a health care professional may encounter if their cultural competence is lacking in the nurse-patient relationship?

1. A consequence could develop from a lack of cultural knowledge in the nurse - patient relationship, if the nurse did not recognize that there are specific ethnic and cultural differences in drug response as well as variations in clinical significance of certain laboratory tests such as glucose levels, levels of hemoglobin, and hematocrit. 2. A consequence could develop from lack of cultural skill to collect relevant cultural data through interviews to obtain client's health history and presenting a problem. It is extremely important to recognize the potential problem with a non-English speaking client. There could be several languages and dialects that the clients and their families speak and is best for the health care provider to obtain a formally trained, preferably certified, interpreter.

What are the four (4) phases of Participant Observation.

1. Complete observer 2. Observer as participant 3. participate as observer 4. complete participant

According to the Dreyfus Model of Skill Acquisition, what is skill level of a Level 5 HCP?

A level 5 expert nurse is so experienced in performing cultural assessments that they no longer need to rely on specific rules/ assessment tools. Expert nurses use their intuition to seek information in a sensitive matter. - must dedicate many years to learning the art of listening cultural information from patients and developing accurate cultural profiles.

What is ritualistic behavior?

A ritual is a set procedure for performing a task.

What is a therapeutic relationship?

A therapeutic relationship is an interaction that is directed towards helping a patient heal both physically and emotionally. - Unlike a social relationship a therapeutic relationship implements the five steps of nursing process assessing and has 4 phases

What is Active Listening?

Active listening is used to build trust and show respect. Combined of verbal and nonverbal cues to communicate you're interested in the patient. The acronym SOLAR is used to describe the techniques to promote active listening.

Define racism as a barrier to communication and provide a scenario where this barrier may produce a problem.

Because nursing is seen as a 'caring profession, it is hard for some nurses to acknowledge racism as a potential barrier to communication. - There are three widely recognized types of racism, as Individual, Cultural, and Institutional racism. -Institutional racism manipulates or tolerates policies that unfairly restrict opportunities for certain races, groups, or cultures. Institutional racism posed a major barrier to communication at one time, when black nurses were not allowed to join the American Nurses Association (ANA). This policy prevented black nurses from having a voice in the regulation of nursing practices and policies. At an institutional level, racism plays a factor in the low enrollment number of black students to nursing schools. Black nurses have complained about not being promoted as readily as white nurses and reported having difficulty publishing in Euro-American nursing journals. - Racism will continue to be a flaw in profession as long as nurses ignore its existence and refuse to openly discuss how its affects their workplace and nurse to patient care.

Complete participant

Being a complete participant means that nurses would be full-fledged members of the group under study; interact at all levels with all other participants. - Full immersion helps our ability to see RSS through a wide-angle lens.

What are the three health belief systems?

Biomedical Holistic Supernatural

According to the Dreyfus Model of Skill Acquisition, what is skill level of a Level 4 HCP?

During level 4, nurses are proficient and have between about five years of experience conducting cultural assessments. They evaluate information and learn from patients in a holistic manner. For example, a novice nurse might view patient noncompliance as a negative attitude that must be corrected, while a proficient (level 4) nurse would recognize that this patient is not necessarily being uncooperative but simply adhering to cultural beliefs which may differ from the biomedical healthcare system.

What is a good practice for rituals and when can it be a bad behavior?

GOOD= Students and nurses training were taught to perform their duties in a ritualistic manner. -Many nursing rituals are beneficial, such as always performing certain safety checks when preparing and administering medications. BAD= Rituals call for excluding family from the bedside during treatments, and may upset patients and their families. It's important to remember while you're taking care of patients, to think of which nursing rituals are necessary and which rituals are outdated. If there is no scientific or logical reason to follow a ritual and it could compromise your relationship with your patient, try to create a new ritual or routine that will benefit you and your patient.

What are some Western Health Care subcultures?

Professional Subculture= nurses, pharmacists, physicians, and therapists. Nursing Subculture= Bio- psycho- socio- spiritual care of patient. Values, beliefs, and practices are from the American Nurses Association Code for Professional Nurses Commercial Subculture= business managers/ administrators. Value maintaining an environment to meet the goal of delivering health care. Patient Subculture= All individuals become members to patient subculture once admitted into the hospital setting.

What does SOLAR stand for?

S- Sit facing the patient - shows you are interested, and they have your attention. O-Maintain an open posture. Sit in a relaxed non authoritative and non-threatening position to signify openness. L- Lean towards the patient throughout the conversation. this behavior conveys genuine concern and interest. E- Establish and maintain eye contact. Eye contact conveys interest, whereas avoiding eye contact can convey a lack of interest, disrespect, disapproval, or boredom. remember different cultures react differently to eye contact so this may need to change. R- Relax. Sit comfortably in your chair and smile in a friendly manner to communicate relaxed attitude and establish a comfortable nonthreatening environment.

After defining the values of these cultural groups, identify one (1) major difference between any of the two groups that may cause conflict or misunderstanding.

Some Asian nurses may accept assignments without complaint that mainstream American nurses might resent. They do not complain because Asian nurses are more likely to value the combined work of the nursing teams over the work of an individual nurse. In addition, an Asian nurse might feel that it is inappropriate for a subordinate to challenge a supervisor. American nurses who feel unfairly treated are more likely to complain to their supervisors than are Asian nurses.

What issue(s) could you face if you are health care professional using the Western biomedical perspective of efficiency, science, and technology and the patient adheres to a different medical perspective?

Western biomedical Ethnocentrism leads to a serious barrier to communication. This ethnocentrism can lead to disdain that greets patient use of alternative health practices. Even the term alternative indicates that these practices are outside the accepted biomedical practices and will only interfere with the real biomedical treatment plan. - When a patient adheres to different medical practices, the language, schedule, and activities of biomedical healthcare seem new and unique. - Signs of ethnocentric reactions of shock, anger, laughter can also arise when confronted with beliefs and behaviors that conflict with the Western biomedical view. - Although this may be a common part of contact with a different health care beliefs and practices, as a professional we need to demonstrate respect to work towards a successful and mutually acceptable treatment plan.

Is direct eye contact always good? Cite an example where eye contact could be more harmful than helpful.

Western societies = eye contact conveys interest, avoiding on contact can convey a lack of interest, disrespect, disapproval, or boredom. Some Asians and Native Americans = prolonged eye contact is rude and an invasion of privacy. Native Americans may divert their eyes to the floor when they are paying attention or thinking. Muslim women= avoid eye contact as a show of modesty. Appalachians= avoid eye contact as it expresses hostility and aggressiveness. India =the amount of eye contact depends on one social position.

The yin =? Yang =?

Yin = Cold Yang = Hot