Potter: Culture

Culturally Congruent Care

Transcultural nursing >>a comparative study of cultures to understand their similarities and differences Culturally congruent care >>Care that fits a person's life patterns, values, and system of meaning -Leininger defines 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. Patterns and meaning are generated by people themselves rather than from predetermined criteria. [Ask students: What are some examples of culturally congruent care? Discuss: For example, rather than instructing all patients to always take their medications at the same set times during a day, you learn their lifestyle patterns, eating habits, sleep habits, and beliefs about medications and then try to plan a dosage schedule that fits each patient's needs.] -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. -When you provide culturally congruent care, you bridge cultural gaps to provide meaningful and supportive care for all patients. -Do not assume that all members of a cultural group will feel the same way about a given situation. Instead, combine your knowledge about a cultural group with an attitude of helpfulness and flexibility to provide quality, patient-centered, culturally congruent care.

Cultural Knowledge—World Views

World view >>Emic >>Etic Avoid stereotyping Treat the individual See every patient encounter as cross-cultural -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 to ensure that it is safe, effective, and culturally sensitive. -In any intercultural encounter there is an insider perspective (emic world view) and an outsider perspective (etic world view). -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 the person's 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. As a nurse it is best to see every patient encounter as being cross-cultural. [Shown is Figure 9-1: How we develop our world view. (Copyright © 2011 Barnes-Jewish Hospital Center for Diversity and Cultural Competence.)]

Health Disparities

-Health disparity >A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage (USDHHS, 2015) -Social determinants of health >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 (WHO, 2013) -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 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. -Members of the disadvantaged group bear a burden of disease, injury, and violence that is disproportiate to the size of the group. -While Americans' health overall has improved during the past few decades, the health of members of marginalized groups has actually declined. [Ask students: What causes health disparities? Discuss: -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. [Ask students: What are some examples of social determinants of health? Discuss: Income and wealth, family and household structure, social support, education, occupation, discrimination, neighborhood conditions, and social institutions are some examples of social determinants of health.]

Skills and Interventions (Cont.)

-Using a cultural model during your assessment (such as the one shown here that integrates Kleinman's explanatory model with the previously discussed Iceberg Analogy) will help you develop open-ended questions that effectively reveal your patient's views on illness. -Table 9-1 summarizes and contrasts a patient's explanatory model of illness with the biomedical explanatory model of illness. [Review Table 9-1, Explanatory Model Comparison, with students.] [Shown is Figure 9-3: Cultural Model that integrates Kleinman's explanatory model with the Iceberg Analogy. (Copyright © 2011 Barnes-Jewish Hospital Center for Diversity and Cultural Competence.)]

Cultural Competency (Cont.)

1. Respecting a patient's health beliefs and understanding the effect of the patient's beliefs on health care delivery 2. Shifting a model of understanding a patient's experience from a disease happening in the patient's organ systems to that of an illness occurring in the context of culture 3. Ability to elicit a patient's explanation of an illness and its causes 4. Ability to explain to a patient 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 -In its early stages, the field of cultural competency primarily focused on the cultural barriers between health care providers educated in Western health care practices and immigrants arriving from non-Western parts of the world. -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 the patient's 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 Encounters

Are interventions that involve a nurse directly interacting with patients from culturally diverse backgrounds Have the potential for conflict Enable new forms of community and collective identity Provide the opportunity to show compassion -The use of a caring, therapeutic, and culturally congruent relationship will lessen the likelihood of conflict when you engage in such encounters. -A cultural encounter enables new forms of community and collective identity between you and your patients. -Campinha-Bacote describes two goals of a cultural encounter: to generate a wide variety of responses and to send and receive both verbal and nonverbal communication accurately and appropriately 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 Awareness

Bias: a predisposition to see people or things in a certain light, either positive or negative. Becoming more self-aware of your biases and attitudes about human behavior is the first step in providing patient-centered care. -Everyone holds biases about human behavior. A bias is a predisposition to see people or things in a certain light, either positive or negative. -You should spend time reflecting on what you learned, formally and informally, throughout your life about health, illness (physical and mental), health care system, gender roles, sexual orientation, race, ability, age, family, and many other issues as a part of your commitment to becoming a culturally competent nurse. -It is helpful to think about cultural competence as a lifelong process of learning about others and also about yourself.

Cultural Competency (Cont.) 3

Campinha-Bacote >>Cultural awareness >>Cultural knowledge >>Cultural skills >>Cultural encounters >>Cultural desire Blanchet and Pepin >>Building a relationship with the other >>Working outside the usual practice framework Reinventing practice in action -A variety of models for acquiring cultural competency exist. 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 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. -Blanchet and Pepin have recently described the processes involved in the development of cultural competence among registered nurses and undergraduate student nurses. Clinical experience and interactions with patients and fellow clinicians help to build cultural competency. -When you compare features of the models and the universal skills associated with cultural competence, 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 from the individual, and unique, lively individuals become static objects of your assessment. You do not form the important relationship that is needed to provide patient-centered care. You may be tempted to categorize people according to simplistic differences if you approach understanding all patients in the same way. By describing people only in terms of how they differ from the majority, you unintentionally reinforce the dominant culture and lose the details of each individual's character and behavior. -As a nurse you are responsible for assessing patients' health issues within their world view.

Skills and Interventions

Cultural assessment >>Cultural assessment model >>Open-ended, focused, and contrasted questions >>Explanatory model >>Trust -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. -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. -Using a cultural assessment model will help you focus on the information that is most relevant to your patient's problems. -You need to assess and interpret a patient's perspective during your assessment. Use open-ended, focused, and contrasted questions. -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 and treatment for an illness episode. -Cultural assessment is intrusive and may take more time to conduct because it requires building a trusting relationship between participants.

Culture

Culture >>Norms, values, and traditions >>Ethnicity, race, nationality, and language >>Gender, sexual orientation, location, class, and immigration status Intersectionality >>Belonging simultaneously to multiple social groups Oppression >>A system of advantages and disadvantages tied to our membership in social groups -Culture is associated with norms, values, and traditions passed down through generations. It also has been perceived to be the same as ethnicity, race, nationality, and language. -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. [Review Box 9-1, Key Concepts of Intersectionality, with students.] -According to this framework our memberships in social groups are not neutral. 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. It impacts an individual's access to resources such as health care, housing, education, employment, and legal services. Whether we live in a disadvantaged community or a community with access to social power and resources, we are all affected by the system of oppression. Understanding the dynamics of oppression that operate on various levels while simultaneously affecting you and your patients helps you engage in the process of becoming more culturally competent. -The many categories that comprise culture are not isolated from each other—they stand alone, interact, and are interdependent and mutually reinforcing. Although both groups and individuals within cultural groups may share commonalties in their experiences of oppression, there are also differences in these experiences. Including oppression in our definition of culture helps us recognize the profound effect it has on the individual and group experiences of all of us. -Understanding culture requires you to adopt an intersectional perspective. This allows you to consider the multitude of different experiences of your patients so that you can provide effective, evidence-based, culturally competent care.

Meaning of Disease and Illness

Culture affects how an individual defines the meaning of illness Illness >>The way that individuals and families react to disease Disease >>Malfunctioning biological or psychological processes -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. -People tend to react differently to diseases on the basis of their unique cultural perspective. Most health care providers in the United States are primarily educated to treat disease, whereas most individuals seek health care because of their experience with illness. In addition, there is a lack of cultural diversity among health care providers. This often frustrates patients and providers, fostering a lack of trust, lack of adherence, and poor health outcomes. -Providing safe, quality care to all patients means taking into consideration both disease and illness.

Cultural Competency

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. Culturally competent organizations: >>Value diversity >>Conduct a cultural self-assessment >>Manage the dynamics of difference >>Institutionalize cultural knowledge >>Adapt to diversity -Developing cultural competency allows systems, agencies, and groups of professionals to function effectively to understand the needs of groups accessing health information and health care and thus help eliminate health care disparities and ultimately health disparities. -A culturally competent organization integrates these principles and capabilities into all aspects of the organization and systematically involves consumers, key stakeholders, and communities. -In 2000 the Office of Minority Health (OMH) developed the Culturally and Linguistically Appropriate Standards (CLAS). In 2013, after 10 years of successful implementation, the OMH updated the standards to reflect the tremendous growth in the field and the increasing diversity of the nation. The enhanced national CLAS are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint to help individuals and health care organizations implement culturally and linguistically appropriate services. [Review Box 9-2, National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, with students.]

Cultural Competency (Cont.) 2

Expanding the original focus on interpersonal skills, many of the current approaches to cultural competency now also focus on: >>All marginalized groups and not just immigrants >>Prejudice, stereotyping, and social determinants of health >>The health system, communities, and institutions. -You broaden your understanding of the world by learning about other people's world views, which determines how people perceive others, how they interact and relate to reality, and how they process information. Cultural competency is dynamic and takes time to develop.

Health Disparities and Health Care

Health care disparities >>Differences among populations in the availability, accessibility, and quality of health care services Addressing health care disparities >>New standards >>>Focus on cultural competency, health literacy, and patient- and family-centered care >>>Recognize that valuing each patient's unique needs improves the overall safety and quality of care and helps to eliminate health disparities. -Health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases, and related complications. -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. [Ask students: What groups are more likely to be impacted by health care disparities? Discuss: African-Americans, Asians, Hispanics, low- and middle- income groups, the uninsured, some subgroups of the LBGT community. 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. Uninsured people ages 0 to 64 years are less likely to have a regular primary care provider than those with private or public insurance. -Research suggests that some subgroups of the LGBT community have more chronic health conditions and a higher prevalence and earlier onset of disabilities than heterosexuals.] -Poor access to health care is one social determinant of health that contributes to health disparities. A patient who regularly visits a primary care provider is more likely to receive adequate preventive care than is a patient who lacks such access. -In addition to the poor access to health care, a large body of research shows that health care systems and health care providers can contribute significantly to the problem of health disparities. 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. -Disparities in access to care, quality of care, preventive health, health education, and available resources to enable self-management when patients are outside of the health care setting contribute to poor population health. -According to the 2003 National Adult Assessment of Literacy (NAAL), only 12% of U.S. adults are proficient in obtaining, processing, and understanding basic health information and services needed to make appropriate health decisions. -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.

Cultural Knowledge—World Views (Cont.)

Iceberg analogy >>Most aspects of a person's world view are hidden Conduct a cultural assessment -The Iceberg analogy is a tool that helps you to visualize the visible and invisible aspects of your world view and recognize that the same applies to your patients. Just as most of an iceberg lies beneath the surface of the water, most aspects of a person's world view lie outside of his or her awareness and are invisible to those around the person. 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. -Conduct a comprehensive cultural assessment to understand the patient's world view, including religious values, ethnohistory, and caring beliefs and practices. [Ask students: What is a patient's ethnohistory? What are some examples of nursing assessment questions you might ask to find out more about a patient's ethnic background? -Discuss: What is your ethnic background or ancestry? For patients who are first- or second-generation immigrants: How long have you/your parents resided in this country? Tell me why you/your family left your homeland. How different is your life here from back home?] [Review Box 9-4, Nursing Assessment Questions, with students.] -Realize the need to develop your assessment skills and cultural interventions that will allow you to successfully negotiate the various world views present in encounters with patients and families (and frequently other team members). Most important, remember that the core of this negotiation is compassionate care. [Shown is Figure 9-2: Both nurse and patient act in accordance with their own world views. This model has been adapted from Campinha-Bacote et al. (2005) Iceberg Analogy. It incorporates the Kleinman (1980) explanatory model. (Copyright © 2011 Barnes-Jewish Hospital Center for Diversity and Cultural Competence.)]

Cultural Awareness

In the United States many individuals face greater obstacles to good health on the basis of racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. Culture relates to all of these factors. Research findings reveal differences in rates of cancer, diabetes, infant mortality, organ transplantation, and many other health conditions because of cultural factors.

Core Measures

Key quality indicators that help health care institutions improve performance, increase accountability, and reduce costs Consistent with national health priorities Intended to reduce health disparities -To improve health outcomes, The Joint Commission and the Centers for Medicare and Medicaid Services developed a set of evidence-based, scientifically researched standards of care called core measures. -In addition, core measures are intended to reduce health disparities. According to the 2013 National Health Care -Disparities Report, Blacks and Hispanics received worse care than whites for about 40% of quality measures; -American Indians and Alaska Natives received worse care than whites for about 30% of core measures; Asians received worse care than whites for about 25% of core measures; poor people received worse care than high-income people for about 60% of core measures. -Although most disparities in quality are significantly worse for some populations compared to white patients, there are some improvements in these outcomes as more and more effort is focused on addressing these disparities. The 2013 National Health Care Disparities Report identified that the number of disparities that are getting smaller exceeded the number that are getting larger for Blacks, Hispanics, Asians, and individuals with lower socioeconomic status. [Review Box 9-7, Evidence-Based Practice: Equity-Focused Quality Improvement, with students.] -Nurses and other health care providers need to be familiar with how policies and institutional forces enable or inhibit their ability to provide culturally competent, patient-centered, high-quality, safe care to all patients. When policies impede the delivery of effective care, you and your colleagues must advocate for policy change.

Patient Centered Care

Landmark reports >>Crossing the Quality Chasm (IOM, 2001) Unequal Treatment (Smedley et al., 2003) Cultural competence vs. patient-centered care >>Each emphasizes different aspects of quality >>Patient-centeredness provides individualized care and restores an emphasis on personal relationships >>Cultural competence aims to increase health equity and reduce disparities by concentrating on people of color and other disadvantaged populations -Two landmark reports from the Institute of Medicine (IOM)—Crossing the Quality Chasm (IOM, 2001) and Unequal Treatment (Smedley et al., 2003)—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. -Unequal Treatment stresses the importance of developing cultural competence among health care providers to eliminate racial/ethnic health care disparities. [Review Box 9-3, Patient-Centered Care for LGBT Patients, with students.] -Campinha-Bacote views cultural competency as an expansion of patient-centered care. More specifically, cultural competence can be seen as a necessary set of skills for nurses to attain in order to render effective patient-centered care. It is important for nurses to see themselves as becoming culturally competent. Your ability to exercise cultural competence by applying the components of Campinha-Bacote's model of cultural competency will allow you to deliver patient-centered care.

Skills and Interventions (Cont.) 3

Linguistic competence Heath literacy Teach back -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. -Most health care providers and virtually all health care organizations nationwide are subject to federal civil rights laws. These laws outline requirements for the provision of language access services. -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. [Review Box 9-6, Working with Interpreters, with students.] Health literacy is the ability to obtain, process, and understand health information needed to make informed health decisions. Studies show that health literacy has direct effects on health outcomes, linking poor health outcomes to limited health literacy. 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. -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. When using the teach-back technique, do not ask a patient, "Do you understand?" or "Do you have any questions?" Instead ask open-ended questions to verify the patient's understanding. [Ask students: What are some open-ended questions you could ask a patient to confirm understanding? -Discuss: "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."] -It is important to understand that teach back is not intended to test a patient but rather to confirm the clarity of your communication. [Shown is Figure 9-4: Using Teach-Back technique to close the loop. (From the U.S. Health Resources and Services Administration.)]

Skills and Interventions (Cont.) 2

Mnemonics >>LEARN: Listen, Explain, Acknowledge, Recommend, Negotiate >>RESPECT: Rapport, Empathy, Support, Partnership, Explanations, Cultural Competence, Trust >>ETHNIC: Explanation, Treatment, Healers, Negotiate, Intervention, Collaboration >>C-LARA: Calm, Listen, Affirm, Respond, Add -You can use transcultural communication skills to better understand a patient's behavior and to behave in a culturally congruent way. -A number of authors have developed mnemonic cultural assessment and planning tools. 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. -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. -Remember that cultural assessment and care planning requires a level of negotiation. [Review Box 9-5, Communication Techniques Using Mnemonics, with students.]

Cultural Desire

The motivation of a health care professional to "want to"—not "have to"—engage in the process of becoming culturally competent Health care organizations are increasingly integrating cultural competence principles into everyday organizational processes and practices -It is easy to avoid cultural encounters with patients. Time, our personal discomfort in communicating with others who are "different," and a focus on physical care priorities are just some of the factors that may limit encounters with patients. -An ethically responsible professional nurse must embrace the importance of cultural competency and apply principles in daily patient encounters. -Health care regulatory agencies, national think tanks, and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication, patient safety and quality, and patient-centered care.