FD- Culturally Competent Nursing Care + Culture
Every nurse brings two cultures into a relationship with patients.
1- First culture is that of the personal self. The qualities and characteristics of the nurse's personal culture are key determinants of personal and professional behavior. 2- Second culture, equally important, is that of the health care delivery system. The nurse represents the health care system and helps the patient and family acquire access to this system, which has its own separate and unique culture. Both of these cultures must strike a balance with a third culture, that of the patient.
1- Cultural Knowledge? 2- Cultural Sensitivity 3- Cultural Skill 4- Cultural Humility 5- Cultural Proficiency 6- Cultural Awareness
1- The basis for cultural understanding. It is a constant process of acquiring information about other cultures. 2- Having value, admiration, and respect for cultures that are different from one's own. 3- Having the ability to effectively communicate with individuals of other cultures that includes their beliefs and values when planning and providing care. 4- Recognizing one's own limitations in knowledge and understanding of another individual's culture and perspectives. 5- Maintaining and acquiring new cultural knowledge along with sharing that information with others to encourage a culturally competent organization. 6- Understanding one's own culture and being mindful of preconceived biases when interacting with different cultures.
The term cultural competence was first described in
1989 by Cross
Which patient would the nurse recognize as having the highest risk for low health literacy?
A 25-year-old undocumented migrant worker This patient is at high risk for low health literacy. The patient may be in a minority group and in a lower socioeconomic class; in addition, the patient may have limited formal education because of status as an undocumented migrant worker.
Which patient would the nurse identify as someone who is ready to learn new information?
A patient with dilated cardiomyopathy who asked for more information on heart failure A patient who is requesting information about the disease process is showing emotional readiness, so this patient would be the best one to begin teaching.
Using the following mnemonic during patient encounters can help:
ETHNIC: Explanation Ask if the patient has identified any causes for his or her symptoms and what concerns the patient most about the symptoms. Treatment Ask if the patient has tried any medications, herbal supplements, or other forms of treatment to address the symptoms. Healers Ask if the patient has sought advice or treatment from alternative health care providers or friends without a medical background. Negotiate Identify treatment options that will be acceptable to both the nurse and the patient based on the patient's beliefs/cultures and the medical treatment that has been offered. Intervention Decide which interventions are appropriate including those that may include alternative treatments, spirituality, and healers. Collaboration Ensure that medical decisions and the plan of care have been collaborated with the patient, the patient's family, the health care team, and any other community members who may be involved.
Which statement about ethnicity is correct?
Ethnicity describes people who share common ancestry. Ethnicity is the identity of a group of people who share common ancestry, customs, language, and culture.
Which action by the nurse indicates cultural awareness?
Respecting the cultural request of a patient for a same-gender caregiver Fulfilling a culturally based patient request demonstrates knowledge of cultural awareness.
Which nursing action exemplifies cultural awareness?
Questioning one's own religious beliefs Cultural awareness is an understanding of one's own culture and being mindful of preconceived biases when interacting with different cultures. Questioning one's own religious beliefs would be gaining more understanding of a person's culture.
The nurse would be aware that a patient's cultural worldview is influenced by which variables?
The patient is agnostic. A patient's choice of religion or spirituality (or lack of) would influence his or her cultural worldview. The patient is of male gender. A patient's cultural worldview is shaped by gender, so being male does affect the patient's view of life and experiences. The patient was raised in Italy. Being raised in another country would affect a patient's cultural worldview because of the influences imparted on the patient during youth. The patient identifies as homosexual. Homosexuality is a variable that influences a patient's cultural worldview.
An essential aspect of planning interventions for patients from culturally diverse backgrounds is language and literacy. Addressing literacy is important when planning care for a patient. Often, patients who are illiterate may try to hide their inability to read or write because of shame. Asking what is the patient's preferred way of receiving information is a nonjudgmental way of assessing literacy. A patient who cannot read may choose audiovisual materials to learn information. Interventions the nurse can take when the patient and nurse speak different languages include:
Using a professional interpreter Avoiding the use of abbreviations and acronyms Using a slower speech pattern to enhance the patient's ability to comprehend Avoiding speaking loudly to the patient Limiting the use of jargon, slang, and humor Providing written or audiovisual materials
The Giger and Davidhizar Transcultural Assessment Model found 6 cultural phenomena that are evident in all cultures and must be taken into account for a culturally appropriate assessment:
communication space social orientation environmental control time biologic variation
What is cultural competence?
it is a dynamic process that requires a lifelong commitment to being aware of one's own cultural biases in addition to constantly expanding one's own knowledge about the traditions, beliefs, and rituals of other cultures.
cultural competence can be achieved through
learning to ask the questions that will help provide understanding from the patient's perspective
Cultural awareness is
the understanding, acknowledgment, and appreciation that different cultures exist. It is a specific way of thinking that allows the individual not only to see the differences and similarities among various ethnic groups but appreciate the differences as well. For nurses to be culturally aware, they must first recognize their own ethnic and cultural beliefs and also recognize any bias (either conscious or subconscious) toward other cultures or ethnicities. This open-mindedness allows for the individual to be culturally sensitive and ultimately more understanding thus providing better nursing care. When nurses understand how a patient's culture shapes his or her life experiences, health care issues, and perception of the health care issues, it allows for better assessment of the patient's health care needs. Improved cultural awareness in nursing care allows for the development of a trusting nurse-patient relationship leading to improved medication adherence, treatment compliance, and ultimately improved health outcomes.
Which aspects of cultural identity can be influenced by outside factors?
Religion Cultural identity is dynamic and ever-changing and can be influenced by outside factors. Examples of cultural identity that can be influenced include geographic location, religion, socioeconomic status, and education. Socioeconomic status Cultural identity is dynamic and ever-changing. Although certain aspects of cultural identity cannot be changed such as age, race, and ethnicity, other aspects of cultural identity can be influenced by geographic location, religion, socioeconomic status, and education.
Which statement indicates that the nurse needs additional education about teaching and learning styles?
"When teaching, I will include the three distinct styles of learning: visual, auditory, and reading and writing." There are four learning styles, not three, because the nurse did not include kinesthetic/tactile as the fourth learning style. This statement indicates the nurse would benefit from learning more about teaching styles.
cultural competence is defined as
"a set of appropriate behaviors, attitudes, and policies in an organization or among professionals and enables the organization or the professionals to work in cross-cultural situations".
Resources for Enhancing Culturally Competent Care
- Contacting specific culturally focused resource centers - Calling on immigration or refugee centers to become better aware of available resources for specific cultures - Sharing pertinent cultural information with all members of the health care team - Working or volunteering at community outreach centers to increase awareness of needs in the community - Sharing with patients and families information about community programs specific to their culture
Communication is vital throughout the nursing process but even more important when interacting with patients of different cultural backgrounds. Research has shown that many factors influence communication including:
- Overall physical health and emotional well-being of the patient - Intent or reason for the communication (Is the patient hearing bad news or outcomes?) - The nurse's and the patient's skill at communication - The nurse's and the patient's philosophical beliefs and cultural backgrounds - The attitudes of the individuals in the communication (Does the culture value one gender over another?) - Personal tendencies and judgmental behaviors of individuals involved in the communication - Past experiences that relate to the current situation
Which rationales for asking specific questions during a cultural assessment are accurate?
Allows the nurse to see the health concerns from the patient's perspective Asking the right questions allows the nurse to see the health concerns from the patient's point of view. Although sometimes it may seem intrusive and time-consuming, completing a thorough cultural assessment is a necessary component of providing holistic patient-centered care. Helps eliminate miscommunication between the nurse and the patient Asking the right questions decreases the risk for miscommunication. Miscommunication is often seen in transcultural relationship interactions. Strengthens the nurse-patient relationship Asking the right questions strengthens the nurse-patient relationship by increasing the trust level between the patient and the nurse.
Match the following:
Assuming a person who is homeless is lazy and does not want a job (Generalizing) Assuming someone is an undocumented immigrant because they are Hispanic (Stereotyping) Refusing a patient assignment due to the ethnicity of the patient (Discrimination) Assuming a teenager is sexually active based on choice of clothing (Prejudice)
Additional Ways to Improve Cultural Awareness
Be self-aware of your own biases. Learn from others and appreciate the differences. Take classes about other cultures and their history. Visit cultural gatherings in your community such as museums or parades. Eat at different ethnic restaurants. Encourage cross-cultural relationships. Learn to say "hello" in other languages.
Developing Cultural Awareness
C Consider your own cultural biases and how these affect your nursing care. U Understand the need to recognize cultural implications in planning and implementing nursing care. L Learn how to use cultural assessment tools. T Treat patients with dignity and respect. U Use sensitivity in providing culturally competent care. R Recognize opportunities to provide specific culturally based nursing care. E Evaluate your own previous encounters with patients from other cultures and backgrounds.
broad generalizations but can be used as guidelines during times of cross-cultural communication
Chinese Americans Soft tone Slow speech Silence is valued Avoid eye contact Avoid excessive touch Hispanic Americans Faster speech Loud tone Maintain eye contact Touch is acceptable Native Americans Soft tone Slow speech with silence Respect is shown by avoiding eye contact Light touch is acceptable African Americans Loud tone Faster speech Maintain eye contact but avoid prolonged eye contact Touch is acceptable Orthodox Jews No tone or speech cadence preferred Touch is acceptable Eye contact can be interpreted as sexual
6 cultural phenomena explained:
Communication Language(s) spoken Do you have a preference about vocal quality? Do you like a softer tone or do you prefer a strong tone? How do you feel about eye contact with conversation? Space Degree of comfort with space and physical touch Is physical touch from a stranger acceptable? What distance during conversation is comfortable or acceptable? Social Orientation Race, ethnicity Do you have specific religious or spiritual beliefs? What is your role in your family dynamic? Do you have any hobbies? Time Importance of "time" in the culture If the appointment is scheduled for 9:00 a.m., what time would you normally think is acceptable to arrive for the appointment? What is the normal sleep-wake pattern for you and your family? Environmental Control Cultural health practices What home remedies have you used in the past? What do you consider being of good health or poor health? Biologic Variations Hair color, skin color, physical size Have you ever been told of genetic susceptibility to a specific disease? What diseases are common in your extended family?
Leininger's Modes for Guiding Nursing Actions and Decision Making
Cultural Maintenance Helps patients preserve important values or beliefs while recovering from illness or maintaining their health Example: Encouraging an Islamic patient to continue his or her daily prayers even though hospitalized Cultural Accommodation or Negotiation Helps patients become accepting of health interventions that may initially be difficult to accept Example: Allowing a patient to continue using garlic in attempt to lower blood pressure while informing him that he also must take the antihypertensive medication. Cultural Care Repatterning or Restructuring Mutual intervention that encourages patients to make a change they can adhere to while still incorporating some traditions of old Example: Encouraging the Jehovah's Witness patient to complete an advance directive about blood products instead of refusing a needed surgery altogether because of fear of a transfusion
Which term describes a process in which individuals or groups merge with another group and part or all of the aspects of the minority group's culture is lost to that of the majority group?
Cultural assimilation Cultural assimilation is the process in which individuals or groups of individuals from one cultural group merge with another group, and aspects of the smaller minority group are often lost or changed.
Which statements about culturally competent nursing care are true?
Cultural competence begins with cultural awareness. R: There is no single definition of cultural competence; however, most agree that cultural competence begins with cultural awareness. Cultural competence incorporates the patient's culture into his or her health care plan. R: Culturally competent nursing care provides the patient with actions or decisions that are congruent with the patient's cultural beliefs, ultimately promoting his or her health and well-being.
Five Characteristics of Culture:
Culture Is Learned: Culture is not inherited. Instead, it is learned from traditions and exposures to ideas from a previous generation or group of people. This learned process comes through interactions with family members, teachers, friends, and community members. It can be taught directly through family traditions, or it can be learned subconsciously from watching the behavior of family members. The process of learning culture is known as enculturation. Culture is introduced initially in the home and then broadened as individuals grow with influences from churches, schools, peers, and work environments. Culture Is Shared: The sharing of cultural beliefs is what binds individuals together as a specific group or identity. Sharing of cultures enables individuals of a larger group of a particular culture to predict how others will behave and to identify socially appropriate behaviors. Parenting styles and behaviors exemplify how behaviors are shared in cultural groups. For instance, generally speaking, "Eastern parenting" (Chinese, Indian) is more likely to be authoritarian in style, which is an "adult-centered parenting style with a clear set of expectations and rules that are expected to be obeyed and achieved with no explanation." "Western parenting" (American, European) is more likely to be authoritative in style, which is "a child-centered pattern characterized by a clear setting of rules and expectations which allows reasoning and discussion to achieve adherence to the rules" Culture Is Symbolic: Cultures have symbols. Flags, money, songs, and languages are all symbols of a culture. Symbols are objects that stand for something else, and their meaning can vary across different cultures. For example, the Confederate flag may cause distress in some cultures but in other cultures could be a source of pride in their heritage. The song "God Bless the USA" may invoke a sense of pride in someone born in the United States but would most likely not have any emotional response for someone born in Japan. Language is one of the most important symbols of a culture as it is the basic element that binds groups of people. It allows for the sharing of ideas and values. Culture Is Integrated: Culture possesses an order and a system. To understand a culture, it is important to understand how the different parts of the culture are intertwined. Culture will have an infrastructure of the basic necessities of life, a social structure of patterns of accepted behaviors, and a superstructure, or worldview, to identify their own culture as compared with the world around them. Culture Is Dynamic: Culture is not static; it is a dynamic, always changing process. Individuals can move between cultures, for example, transitioning from a poor to a more affluent environment. College students, whose initial learned political beliefs most likely came from their parents, may have different beliefs after going to college and being influenced by their peers and professors. Specific to the nursing culture, the nursing cap was once a mainstay of the nursing profession. But as society as a whole became less formal and more men entered the nursing profession, the nursing cap became a part of the profession's past culture.
Which characteristics are true of culture?
Culture is shared. The sharing of cultural beliefs is what binds individuals together as a specific group or identity. Culture is dynamic. Culture is a dynamic ever-changing process. It does not remain the same. Culture is symbolic. Cultures have symbols that are meaningful to that specific culture. Culture is integrated. Culture has different parts that are woven together to form an infrastructure. Culture is learned. Culture is not inherited; it is learned from family members, teachers, friends, and community members.
Implementing Culture into Nursing Interventions
Gender and Orientation: What is the gender/gender identity/sexual orientation preference? Health Beliefs and Practices: Does the patient prefer a same-gender health care provider? What about the same ethnicity or racial background?Are there restrictions imposed by modesty that must be respected? What are the patient's beliefs on health, illness, pain, and death? Does the patient have any hygiene beliefs (e.g., body odor may not be a sign of poor hygiene and instead may be common to the culture)? What are the patient's attitudes toward mental illness? Is there a main family member who is responsible for all health-related decisions? Faith-Based Influences: Is there a religion or greater being that the patient follows? Are there death-related rituals that must be implemented? Is sharing health-related information with members of the religion approved for spiritual purposes or prayer? Is fasting a part of the patient's spiritual beliefs? Communication: What is the patient's primary language? How well is English understood, both verbally and written? Would an interpreter be helpful? Role of Family Members: Who makes the decisions? What is the patient's attitude toward children? Is physical affection demonstrated to others? Community Support (Beyond the Family) Are there any cultural groups that may have an influence on the patient? Are there friends, coworkers, or others in the social community who may have an influence on the patient? Dietary Practices Are there any forbidden foods or cultural rites of preparation required for certain foods? Are there any foods that hold special meaning associated with special circumstances? Are there any foods with special healing properties? If fasting is a part of spiritual beliefs, how often does the patient practice periods of fasting?
Examples of cultural consideration:
Health Beliefs and Practices: Russian Americans consider mental illness to be a character defect and are ashamed of a psychiatric diagnosis. They are typically untrusting of psychologists, psychiatrists, or any type of counseling. Faith-Based Influences: An Orthodox Jew may not take medication during the holy time of Passover because the preparation of the drug does not meet religious guidelines. Communication: The Japanese culture is considered a non-eye-contact culture and can consider it disrespectful to look someone in the eye. Role of Family Members: Puerto Ricans have a strong need for family support, and decision-making usually occurs in a family context. Community Support: The Amish follow the Ordnung, which are the rules and regulations developed by the community. An Amish patient may be non-compliant because of the rules of the Ordnung. Dietary Practices: East Indian Hindus practice fasting, and it is observed on holidays and specific days of the week, depending on which god is worshipped. This may span over a month or only on a single holy day.
The following are ways to reduce disparities in health care while providing culturally competent care:
Humanize your patient. Remain conscious and aware of your own biases. Do a teach-back with the patient to confirm clarity of the conversation. Educate the patient about his or her disease process or health condition. Welcome friends and family members to be involved. Learn key words or phrases in common languages in your area. Always use a qualified medical interpreter. Consider the health literacy of the patient. Respond thoughtfully to complaints, and have empathy. Hold your institution accountable for providing culturally competent care. Encourage patients to complete patient satisfaction surveys and demographics forms. Advocate that your institution interpret and instill necessary changes based on the outcomes of the surveys. Best Practice Pearl
Which outcomes are associated with improved cultural awareness in health care?
Improved patient relationships Cultural awareness has been shown to improve nurse-patient relationships because of the increased trust that occurs between the patient and nurse with improved cultural awareness. Medication adherence Cultural awareness increases trust between the patient and nurse, leading the patient to have improved medication adherence because his or her culture was included in the treatment plan. Improved health outcomes Improved cultural awareness in nursing care allows for the development of a trusting nurse-patient relationship, leading to improved medication adherence, treatment compliance, and ultimately improved health outcomes. Treatment compliance Patients have shown improved treatment compliance when a nurse has cultural awareness and the patient's culture is included in the treatment plan.
Which strategies can the nurse use to increase the effectiveness of the education process?
Involve family members in the teaching process. It is important for family members to participate in patient education to facilitate patient-centered care. Cover only two to three key points at a time. The nurse should limit information to two to three key topics to avoid overwhelming the patient. Review previous information before starting new material. Reviewing previously taught information before advancing to new material confirms that the patient retained knowledge. Encourage the patient to ask questions. Encouraging questions allows for an interactive learning process and confirms understanding of material.
Which aspect of cultural identity is illustrated by the Korean woman's request for seaweed soup after giving birth?
Ritual Rituals are formal actions performed at special times. Eating seaweed soup after childbirth is based on the ritual/belief that seaweed promotes healing and lactation.
Thoughts and Behaviors Impeding Cultural Awareness
Stereotyping Definition: An assumption or an opinion about an individual or groups of people based on common information that is specific to the ethnicity. Example: Assuming that a Hispanic patient is an undocumented immigrant without access to health insurance. Generalizing Definition: Assigning certain traits that may be common in a certain group to an individual within that group before obtaining the necessary information to see if it is applicable. Example: Assuming that a child with a history of cerebral palsy and physical abnormality is less intelligent and not able to follow age-appropriate instructions. Ethnocentrism Definition: The tendency to believe that one's own cultural norms are superior to others' cultural beliefs. Example: Providing end-of-life care to an agnostic patient and teaching your own religious values and beliefs. Discrimination Definition: Treating a person or group of people unfavorably because of a particular characteristic such as age, race, gender, or religion. Example: Purposely not taking a patient assignment because the patient is Muslim and has different religious beliefs from your own. Prejudice Definition: The process of devaluing an entire population based on preconceived beliefs or anticipating certain behaviors from someone based on the person's appearance. Example: Assuming that a teenager is sexually active based on her clothing choice or assuming that a morbidly obese patient is lazy.
Which outcomes are often associated with low health literacy?
Taking prescribed medications incorrectly Outcomes associated with low health literacy include medication errors. Often patients do not take medications correctly because they cannot read or they misunderstand instructions. Missing follow-up appointments Low health literacy can lead to missed follow-up appointments because patients misunderstand instructions or because they are unable to read directions to get to appointments. Higher health care costs Low health literacy can lead to poor adherence to outpatient treatment plans. This in turn leads to increased health care costs associated with more hospital admissions, more medications, and greater frequency of outpatient appointments. Poor adherence with treatment plans Poor adherence to treatment plans often correlates with low health literacy because of misunderstood instructions and lack of knowledge about the disease process.
The nurse is caring for a Puerto Rican patient who must make a decision about whether to have surgery for an advanced-stage brain tumor. Which action or characteristic would the nurse expect to see based on the patient's ethnicity?
The patient will likely consult with the family before making a decision. Puerto Ricans usually have a strong need for family support, and decision making usually occurs in a family context. Therefore the nurse would expect the patient to consult with the family before making a decision.
Which actions indicate proficiency in health literacy?
Understanding which websites are appropriate to use for health information Knowing which websites offer credible health information is an important aspect of health literacy. Understanding benefits of Medicare programs Ability to understand benefits of complex health insurance programs such as Medicare would indicate proficiency in health literacy. Being able to call and schedule follow-up appointments Being capable of calling and scheduling follow-up appointments would show health literacy proficiency. Navigating a smartphone to input a medication list into an app Being able to navigate a smartphone or computer to access health information and services demonstrates health literacy. In addition, knowing the dosages of medication also shows health literacy proficiency.
Which interventions are most appropriate when a patient speaks the predominant language but it is not his or her native language?
Use a professional interpreter. Interventions the nurse can take when the patient and nurse speak a different language include using a professional interpreter and avoiding the use of abbreviations and slang. Providing written materials can also help limit miscommunication. Provide written materials. Providing written material can help when a patient and nurse speak different languages, especially if the patient can speak the language as a second language. Other helpful interventions include limiting the use of slang, avoiding abbreviations, and using a professional interpreter. Limit the use of slang. If the patient speaks the language as a second language, it is important to avoid the use of slang and jargon terminology, as this can cause confusion because it is not the native language. The nurse should also avoid the use of humor because this can also cause confusion when the primary language is not used.
According the Giger and Davidhizar Transcultural Assessment Model, which questions might be asked when addressing the social orientation cultural phenomenon?
What is your role in the family? The social orientation phenomenon includes addressing culture, race, ethnicity, family role, leisure activities, religious beliefs, and community support. This would be a question asked when assessing the social orientation cultural phenomena. Do you attend church regularly? Asking about church addresses the support system the patient might have in the community. This would be an example of addressing social orientation. What do you consider your ethnicity? Ethnicity is a part of the social orientation phenomenon as it relates to the culture of the patient's chosen identity. This will also provide insight into some beliefs and values systems associated with the ethnicity. What do you enjoy doing if you have free time? The social orientation phenomenon includes addressing leisure activities and may provide insight to community support, which is an important component of the social orientation phenomena.
