Week 11 culture- book

Care Plan Development

Conflicting Cultural Belief is the only nursing diagnosis that addresses cultural concerns in a unique way. Therefore, it is vitally important for the nurse to view patient ethnicity and cultural influences as significant pieces of assessment data without considering them the only cause of a problem or concern. Just as with any patient, many different nursing diagnoses may be applicable to a patient's situation depending on the health care problem being addressed. It is particularly important for nurses to avoid cultural bias when identifying potential nursing diagnoses or concerns in situations in which the patient and nurse are from dramatically different ethnic and cultural backgrounds. For example, a patient who speaks a language other than that of the nurse does not have Impaired Verbal Communication (ICNP); rather, the patient simply speaks another language. Being familiar with the actual definition of a nursing diagnosis will help prevent choosing a nursing diagnosis in a culturally insensitive manner. The culturally competent nurse develops a plan of care by analyzing the assessment data, both subjective and objective, prioritizing needs, and discussing potential goals with patients and their families or support system before formulating a plan of care. According to Andrews, Boyle, and Collins, nurses should use three major modalities, adapted from Leininger, to guide decision-making and actions to provide culturally congruent care that is beneficial, satisfying, and meaningful to patients: • Cultural maintenance: Helps people of a particular culture retain and/or preserve relevant care values so that they can maintain their sense of well-being, recover from illness, or face handicaps and/or death. • Cultural care accommodation or negotiation: Helps people of diverse cultures adapt to or negotiate with others for beneficial or satisfying health outcomes with professional health care providers. • Cultural care repatterning or restructuring: Respects patients' cultural values and beliefs while helping patients reorder, change, or modify their lives and adopt new, different, and beneficial health care patterns. Each of these strategies may be beneficial in establishing realistic goals or outcome statements for patients from ethnically and culturally diverse backgrounds. Potential interventions to be included in a plan of care for people of diverse cultures should be discussed with the patient, family, and significant others (e.g., extended family, cultural healers, identified support system) to determine their level of acceptance in advance. Interventions to relieve anxiety for a person who has recently moved to a foreign country and speaks a language other than that of the care providers include the following: • Arranging for a professional interpreter to be available by phone in challenging situations • Identifying community agencies that work specifically with people of the patient's culture • Seeking social service care from a specialist who speaks the patient's language The more a plan of care reflects patient preferences, the more likely it is to be accepted and successful. If it becomes necessary to revise the plan of care, the nurse must discuss this with the patient and redefine mutual patient-nurse goals.

Implementation And Evaluation

Spiritual care interventions are purposeful actions to promote another person's spirituality. Recognizing a spiritual need and providing spiritual interventions may happen spontaneously. When the nurse recognizes a patient's cue, it is important to first be present and actively listen to the patient in a compassionate manner, with eye contact. The nurse can further determine whether the patient requires assistance that promotes reflection, connections with others, or faith rituals. The nurse may initiate reflective interventions by stating, "This must be a difficult time for you. Much has changed. What are your thoughts (or feelings)?" In many cases, such discussions involve exploring and searching for meaningful aspects of a situation and the subsequent impact on loved ones. Such a discussion may also include life plans or health care decision-making. Promoting connectedness with others implies that family and friends are providing the spiritual care; the nurse's role is to encourage that connection and/or to eliminate barriers in the environment that are inhibiting this connectedness. Appropriate interventions can include navigating policies and procedures related to visitation and assisting families to overcome fear related to medical equipment and technology (such as ventilators or cardiac monitors). To initiate connections with others, the nurse may ask, "Is there someone with whom you would like to talk? Can I call family or friends?" If family is available, the nurse may encourage interaction by saying: "You have much to talk about. Is there anything I can do? Do you need more information? Let me give you privacy so you can talk." Nurses need to individualize their spiritual care based on careful assessment of the environment and recognition of spiritual connections among family members. To promote connection with a higher power, nurses can refer patients to the chaplain. Board-certified chaplains are sensitive to patients' cultural and faith differences, understand the dynamics of the health care system, and are fully accountable members of the health care team. Some nurses offer to pray with patients, but this is contingent on the institution's policies and procedures as well as the nurse's comfort with prayer. If the patient asks the nurse to pray and the nurse is uncomfortable participating in this practice, it is best to allow the patient to lead the prayer or offer to contact a chaplain. Spiritual care includes facilitating religious rituals. Some religious rituals may be contrary to hospital policy (e.g., lighting candles). Nurses should collaborate with chaplains and administration to maximize religious expression. A variety of nursing interventions can be implemented for patients experiencing spiritual concerns: • Allow time and opportunity for self-disclosure by the patient. • Be physically present and actively listen when the patient speaks. • Support avenues to spiritual growth that are meaningful to the patient, such as praying, meditating, listening to music, viewing or creating art, or reading or writing poetry. • Arrange for regular visits from religious advisers. • Monitor and promote supportive social contacts. • Integrate the family into spiritual practices as appropriate. • Avoid sharing personal beliefs that are in direct conflict with those of the patient. • Refer the patient to a support group or arrange for the patient to receive counseling, as appropriate.

Time Orientation

Time orientation varies by culture. Cultures tend to be oriented to time in the context of past, present, or future events. Cultures that are oriented to the past tend to look to traditional approaches to health and healing rather than to new approaches, procedures, and medications. People of these cultures tend to believe that if certain solutions worked for their ancestors, those solutions will work for them. Cultures oriented to the present are less likely to embrace preventive health care. The orientation of these cultures is focused on the "here and now"—people in these cultures often use the way they are feeling at the moment to dictate future health practices. For example, if people from present-oriented cultures are diagnosed with a specific disorder but still "feel good," they may reason that prescribed medication is an unnecessary expenditure because they are not having symptoms. Their orientation is not geared toward preventing the long-term effects of the disorder; rather, they adopt a wait-and-see approach. Nurses also need to be mindful that certain economic pressures can force patients into a present-time orientation. When finances dictate that day-to-day survival takes priority over future needs, patients often make choices that conflict with the recommendations of nurses and other health care professionals. According to Giger and Haddad, African American and Hispanic cultures tend to think of time in a linear fashion. People in these cultures tend to believe that a particular task or spending time with another must be accomplished in the "here and now" because that opportunity can never be regained. Some people in these cultures also share the belief that time is flexible and events will begin when they arrive at a destination. This belief has led to a more lenient perception of time so that arriving 30 minutes to an hour late is considered acceptable behavior. Middle-class Americans, regardless of ethnic or cultural origin, tend to be future oriented. People in the middle class tend to delay immediate personal gratification if a purchase interferes with their ability to pursue plans such as buying a home, planning a family, or pursuing higher education. Middle-class people tend to structure time rigidly, adhering to a time-structured schedule as a way of life. The nurse providing care to such patients should be reminded to speak of events in relationship to the future and stick to a schedule of planned events. To give culturally competent care, nurses need to understand time as it applies to diverse cultural groups. Time orientation and punctuality vary from group to group and from place to place. It is important for the nurse to identify the time orientation of the patient (past, present, future) and realize that nursing care may have to be adapted to the patient's time orientation. This adjustment may seem cumbersome and unnecessary; however, the nurse needs to keep in mind that time orientation dictates many activities in patients' lives and that intolerance of a patient's cultural time perception may have a negative impact on the nurse-patient relationship and affect patient care.

Interprofessional Collaboration and Delegation Chaplains as Members of the Health Care Team-table

• Nurses should make chaplaincy referrals when a patient demonstrates or verbalizes a need for spiritual care, and they should follow up to make sure that the patient's spiritual needs are being met. Research indicates that nurses make more patient referrals to chaplains than any other members of the health care team. • In health care facilities with well-functioning departments of spiritual ministry, frequent communication takes place within the interdisciplinary team, consisting of nurses, chaplains, physicians, social workers, case managers, and other care providers. • Chaplains should be asked to attend care conferences at which they can provide spiritual insight and participate in planning holistic health care for patients. • Hospital chaplains provide pastoral care for staff faced with difficult situations and serve as a resource when complex ethical issues affect health care decisions. Studies show that the role of chaplains in providing support to nurses and other health care staff is becoming more important. • Research indicates that spiritual care provided by chaplains contributes to positive emotional and spiritual patient outcomes and patient satisfaction.

Culturally Congruent Care

A culturally competent clinician realizes the importance of caring for patients as people with unique experiences, beliefs, values, and language. How people perceive health care delivery and respond to diagnoses and treatment depends on a variety of cultural factors. Culturally congruent care uses culturally based knowledge in sensitive, creative, safe, and meaningful ways to promote the health and well-being of individual people or groups and improve their ability to face death, disability, or difficult human life conditions. Culturally congruent care and culturally competent care are terms that often are used interchangeably.

Generalization

A generalization is a statement, idea, or principle that has a broad application. Generalizations typically infer or draw conclusions from many factors. Generalizations tend to be applied broadly regarding common beliefs, behaviors, and patterns shared by a particular culture. Generalities occur in certain times and places but not in all cultures. They may be widespread, but they are not universal. Generalizations may be applied when traits that are fairly consistent across cultures can be identified within a particular group while keeping the importance of individual differences in mind. Certain behaviors may be anticipated and understood by using generalizations. However, differences are invariably present among individuals within cultures; nurses need to consider these differences when providing care.

Individualized Care

A patient's inclusion in care-planning activities is extremely important in the managed care climate, in which patient outcomes and satisfaction with the care provided by nurses and others are used as indicators of the provision of quality health care. Nurses need to ensure that the instruments and processes used by health care organizations are culturally appropriate. The feedback obtained from patients from diverse cultures should be used to improve nursing care for people of all cultural backgrounds. Nursing care plans that blend diverse cultural values, beliefs, and health care practices will increase adherence and patient satisfaction. This is clinically essential to avoid nontherapeutic outcomes. Understanding the underlying principles of culturally competent care gives the nurse the ability to see more than one way to achieve the same outcome. For many people of culturally diverse backgrounds, working with community agencies that provide interpretive services and government support is essential.

School

A school is the official place where generational transmission of a society's accumulated knowledge and skills occurs. Schools are places where a society's cultural values, traditions, and official heritage are taught. The school curriculum can reinforce what is learned in the family, but it also can challenge family socialization. A curriculum is geared toward learning social behaviors that are appropriate for peer groups that are not necessarily friendship groups but become the model for secondary group interactions. In this setting, people learn to communicate or negotiate with, or dominate, peers who are outside their immediate social circle and often are from diverse social backgrounds. In many ways, a social curriculum reinforces and deepens the gender role socialization that starts in the family and continues into the peer group.

Stereotypes

A stereotype is an unreliable generalization about all members of a group that does not recognize individual differences within the group. The dominant or majority group creates these stereotypes through the process of racial formation. For example, consider the assumption that all single-parent households are in lower socioeconomic communities. If the patient is a single parent and the nurse thinks that the patient must come from a lower socioeconomic community, this is stereotyping. However, if the nurse thinks that a patient is single parent and may come from a lower socioeconomic community, this is a generalization. The acceptance of stereotypes ignores the individuality of people within a cultural group. Stereotyping ignores the fact that people belong to many cultural groups, including those based on ethnicity, religion, generational status, educational level, gender, sexual orientation, and socioeconomic level. In the patient-nurse relationship, there is no place for stereotypes because they are detrimental to providing patients with necessary care. False opinions, perceptions, or beliefs are developed because of an unwillingness to obtain all the information necessary to make fair judgments about particular people or situations. In the absence of confirmed knowledge, stereotypes allow people to make unfounded assumptions. Stereotyping can have negative results in health care when nurses and other health care professionals assume that all people of a specific culture or ethnicity act in similar ways. For example, if a nurse previously encountered an Asian patient who requested care only from Asian nurses and a new Asian patient is admitted to the unit when no Asian nurses are available to provide care, stereotyping may lead to neglect of the newly admitted patient. In all cases, stereotyping of individual patients should be avoided. Race and ethnicity do not, in and of themselves, make persons "resident experts" on the beliefs and value systems of other persons. The nurse needs to interview and assess each patient with an open mind to obtain accurate information for planning patient-centered care.

Acculturation

Acculturation is a mechanism of cultural change achieved through the exchange of cultural features resulting from firsthand contact between groups. The culture of one or both groups may be changed over the course of time; however, each group remains distinct. Firsthand contact between groups may bring about cultural changes in language, technology, food, clothing, music, and other aspects.

Evaluation

After each intervention designed to help patients meet their spiritual goals, evaluation of the outcome criteria must be completed. Evaluation of goals to address spiritual needs may be difficult to quantify. Nurses should be attentive to physical indications of patient improvement, nonverbal cues, and statements regarding patients' spiritual well-being. Congruency between objective and subjective evaluation data is important to discuss with the patient to help validate goal attainment. After determining the degree to which the patient's spiritual goals were met, the nurse works with the patient to continue, modify, or discontinue the plan of care. The importance of providing holistic patient care that includes spiritual care cannot be overstated. Nurses must recognize the impact of spirituality on personal health and facilitate the ability of patients to stay connected to their sources of spiritual support during illness or crises.

Community

Community is defined as a group of people having a common interest or identity. This concept goes beyond the physical environment and includes the physical, social, and symbolic characteristics that connect people within a group. Therefore, the nurse must be cognizant of the cultural influences within a specific community that can affect the delivery of care. Delivery of care in the community setting requires that the nurse be comfortable with patients from diverse cultures and socioeconomic levels. Acquiring knowledge about a community's culture begins by conducting a careful assessment of patients and their families in their own environment. Once the assessment is complete, the nurse, patient, and other members of the health care team should develop mutual goals, make clinical decisions, plan care, implement the plan, and evaluate the care.

Impact on The Nurse

Although the purpose of providing spiritual care is to promote the patient's spiritual health, this process can also affect the nurse. Nurses frequently encounter spiritually upsetting situations that may place them at risk for spiritual distress themselves. Nurses who are in spiritual distress may not have the energy to provide spiritual care to their patients. Research has indicated that poor spiritual well-being is associated with burnout and that a healthier spiritual climate can be protective of this. To avoid the long-term negative effects of spiritual distress, nurses must attend to their own spiritual health by engaging in spiritual practices that promote their own personal reflection. Because reflection is a time of searching for meaning in a past experience, it can be facilitated by journaling, quiet time, gardening, music, artwork, exercise, or prayer and meditation. Reflecting on a patient-nurse encounter can transform a sad, spiritually distressing situation (e.g., death of a patient) into a positive spiritual memory, thereby facilitating spiritual growth. Many hospitals intervene to provide support for staff after extremely stressful situations, such as patient deaths. These interventions include support from chaplains, employee assistance representatives, and/or ethics professionals. Providing spiritual care along with reflective practice can help the nurse to grow spiritually. Nurses who work in specialties that require frequent spiritual care (e.g., hospice, oncology) typically report that upon reflection, they are able to find meaning and a sense of privilege in their work. Without reflective practice, providing frequent spiritual care in distressing situations can lead to spiritual distress and an inability to provide spiritual care in the future. Nurses must attend to their own spiritual health if they are to provide spiritual care to others. Spiritual care is central to nursing practice, is fulfilling, and is one of the reasons that nurses stay in the profession.

Language and Linguistics

An essential aspect of planning interventions for patients from culturally diverse backgrounds involves language and literacy. When the nurse and patient speak different primary languages, the use of abbreviations and acronyms in speech should be avoided. The nurse should use a slower speech pattern to enhance the patient's ability to comprehend what is being said. Speaking more slowly gives the patient additional time for processing information. The nurse should avoid speaking loudly to the patient. Yelling does not increase a person's ability to understand what is being said. The use of humor, slang, and jargon should be limited. Puns, sarcasm, and colloquialisms are not easily comprehended or interpreted by those who speak a different primary language. Providing written or audiovisual materials that can be comprehended by patients is essential to culturally competent care. Nurses must assess the ability of patients to read and write regardless of their native language. Often, illiterate patients try to hide their inability to read or write by asking others to read to them or by simply agreeing to "read" the pamphlet after the nurse has left the room.

Cultural Competence And The Nursing Process

An understanding of patients from diverse backgrounds begins with a cultural assessment and continues with the development of culturally sensitive individualized care plans. Nurses must understand the specific factors that influence health and illness behaviors within a culture to provide culturally competent care.

Patient Education and Health Literacy-table

Assessment Before Teaching Nurses should consider language barriers, the ability of patients to read and write, and their education level when planning patient education interventions. • Can the patient read and write English or is another language preferred? • Are health-related materials available in the patient's primary language? • What is the patient's highest education level? • What learning style best suits the patient: Written? Oral? Videos? • Does the patient's education level affect health behaviors? • Does the patient's education level affect the patient's knowledge level concerning health literacy? • Does the patient need an interpreter?

Assimilation

Assimilation is the process by which individuals from one cultural group merge with or blend into a second group. The concept of assimilation originated in anthropology and generally refers to a group process, although assimilation also can be defined and examined at the individual level. Assimilation involves a transformation in which members of one group, usually the minority group, enter and become a part of a second group through continuous social interaction. Quite often during this process, the minority group may lose self-identified members of its group and/or aspects of its culture. For centuries, scholars have called the results of assimilation the melting pot process and regarded this process as a natural and necessary aspect of immigrant adaptation to life in a new country. One of the more extreme forms of assimilation involves intergroup marriage. Consider, for example, a Chinese-speaking Buddhist woman who immigrates to England and marries an English-speaking Jewish male. If the woman learns English, changes her maiden name, adopts the Jewish religion, and becomes a British citizen, she will have fully assimilated into mainstream English culture while abandoning many of her native cultural ways. Entering another cultural group may result in relinquishing important aspects of cultural identity. People who fully assimilate within a culture different from the one into which they were born undergo psychological changes in cultural orientation (beliefs, attitudes, values) and cultural behaviors (customs, traditions), as well as in personal identity, to the point of losing many of the aspects of their original native culture. Accordingly, the effect of full assimilation on the psychological and social well-being of human beings may cause concern.

Cultural Competence

Attaining cultural competence (the ability to interact with and appreciate people of different cultures and beliefs) is a lifelong process. It requires intentional effort to more fully understand individuals of different cultures and ethnicities. According to Giger & Haddad, cultural competence is a dynamic, fluid, continuous process whereby an individual, system, or health care agency finds meaningful and useful care-delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care. There is a general consensus that cultural competence can be divided conceptually into two major categories: (1) individual cultural competence, which refers to the care provided for an individual patient by one or more nurses, physicians, social worker, and so on; and (2) organizational cultural competence, which focuses on the collective competencies of the members of an organization and their effectiveness in meeting the diverse needs of their patients, staff, and community. Nurses use a variety of strategies, including cultural sensitivity and culturally congruent care, to demonstrate cultural competence in their patient care.

Body Odor

Body odor may result from poor hygiene, the inability to care for oneself, or a cultural acceptance that natural body odors are normal. In some parts of the world, the fear of offensive natural smells relates to the concept of attractiveness, and great efforts are made to prevent or mask unpleasant odors. Some cultures stress frequent bathing and may criticize others for not bathing as much as they should. Nurses need to assess a patient's norms associated with body odor and encourage healthy personal hygiene practices that promote health and wellness, but they must do so while demonstrating sensitivity to cultural implications.

Community Referrals

Collaboration among health care providers, community leaders, and health consumers is required to provide culturally relevant services in the community. A high level of nursing knowledge and skill is needed to help patients from different cultures navigate community services. Nurses need to understand how to form partnerships with community leaders and health care providers who can meet the needs of patients from culturally diverse backgrounds. Cultural factors determine whether patients from diverse cultures accept community services. Cultural traditions within a community can dictate the structure of community support systems as well as the types of resources available. Giger and Haddad suggest the following guidelines for relating to patients from different cultures: • Assess personal beliefs of persons from different cultures. • Assess communication variables from a cultural perspective. • Plan care based on communicated needs and cultural background. • Modify communication approaches to meet cultural needs. • Understand that respect for the patient and communicated needs is central to the therapeutic relationship. • Communicate in a nonthreatening manner. • Use strategies to develop trust. • Use validating techniques in communication. • Be considerate of reluctance to talk when the subject involves sexual matters. • Adopt special approaches when the patient speaks a different language. • Use interpreters to improve communication. Determining the effectiveness of interventions to address the needs of culturally diverse patient populations requires sensitivity to the norms and expectations of individual patients and their support systems. It is important to refer to mutually agreed-on goals and outcome criteria. The degree to which goals are met should be evaluated based on the patient's perception and the nurse's professional judgment. Input from both sources as well as ideas from community collaborative partners will help determine the effectiveness of a plan of care and the need to continue, modify, or discontinue treatment interventions. Nurses need to understand that culture can and does influence how they view patients as well as the quality of care that is delivered. Nurses need to avoid projecting their own cultural worldview onto their patients. To deliver culturally sensitive care, nurses must remember that individuals are unique—they are the product of experiences, beliefs, and values that have been learned and passed down from generation to generation. Therefore, the culturally competent nurse must be guided by culturally relevant information when assessing, diagnosing, planning, and implementing care for diverse patients. The nurse must carefully examine the fit between the diagnosis and the patient for whom it is intended. The culturally competent nurse is sensitive and flexible while providing outstanding professional care to all patients.

Communication

Communication practiced within and among cultural groups dictates how feelings, ideas, decision-making, and strategies for exchanging information are expressed both verbally and nonverbally. When a patient and nurse are from different cultures, the chances of misunderstanding one another are greatly increased, which can have a detrimental effect on the nurse-patient relationship and result in negative patient outcomes. An example of verbal miscommunication between a nurse and a patient is as follows. An older African American patient looks at the items on his recently delivered breakfast tray and tells his Chinese-born nurse that he has "sugar." She reaches over, removes the sugar substitute packets, and discards them in the trash. The patient becomes upset. T he nurse did not know that some older African Americans refer to diabetes as "sugar." In some cultures, facial expressions, body posture, eye behaviors, and the use of touch can have a multitude of meanings. For example, in some Asian cultures, it is considered disrespectful to make direct eye contact with individuals of authority because doing so implies equality. Some factors that influence communication include the following: • Physical health and emotional well-being • The situation being discussed and its meaning to the patient • Distractions to the communication process • Knowledge of the subject matter being discussed • Skill at communicating • Attitudes toward the person and subject being discussed • Personal needs and interest • Background, including cultural, social, and philosophical values • The senses involved and their functional ability • The environment in which the communication takes place • The personal tendency to make judgments and to be judgmental • Experiences that relate to the situation

Evidence-Based Practice and Informatics-table

Cultural Competency Resources for Nurses Many agencies or organizations provide helpful resources, including evidence-based practice research, to support cultural competency in nursing. • Culture Care Connection • http://culturecareconnection.org/index.html • Transcultural Nursing Society • http://www.tcns.org/ • Agency for Healthcare Research and Quality (AHRQ) • http://www.ahrq.gov/ • National Association of School Nurses •https://www.nasn.org/ToolsResources/CulturalCompetency • EthnoMED • https://ethnomed.org/cross-cultural-health • DiversityRX • http://www.diversityrx.org/

Health Assessment Questions-table

Cultural Domains Assessment of each cultural domain requires questions in several different categories: Communication • What do you do to help others understand what you are trying to say? • Do you like communicating with friends, family, and acquaintances? • When asked a question, do you usually respond in words, body movement, or both? • If you have something important to discuss with your family, how do you approach them? Space • When you talk with family members, how close do you stand? • When you communicate with co-workers and others, how close do you stand? • If a stranger touches you, how do you react or feel? • If a loved one touches you, how do you react or feel? • Are you comfortable with the distance between us now? Social Organization • How do you define social activities? • What are some activities you enjoy? • What are your hobbies? What do you do in your free time? • Do you believe in a supreme being? • What is your role in the family unit? • What is your function in the family unit? • When you were younger, who influenced you the most? • What does work mean to you? • Describe your past, present, and future jobs. Time • What device do you use to keep track of time? • If you have an appointment at 2 p.m., what is an acceptable arrival time? • If the nurse tells you that you will receive a medication in "about half an hour," realistically, how much time will you allow before you call the nurses' station about the medication? Environmental Control • How often do you have visitors to your home? • Is it acceptable to you for visitors to drop in unannounced? • What is your definition of good health? • What is your definition of poor health? • What home remedies have you used that worked? • Will you use these home remedies again? Biologic Variations • What illnesses or diseases are common in your family? • Have any members of your family been told they have a genetic susceptibility to a particular disease? • How do you respond when you are angry? • Who or what helps you cope during difficult times? • What foods do you and your family like? • Have you ever had any cravings for unusual things such as red or white clay? Laundry starch? • What foods are family favorites or traditional foods?

Multidimensional Cultural Competencies

Cultural competence refers to the complex integration of knowledge, attitudes, beliefs, skills, practices, and cross-cultural encounters that includes effective communication and the provision of safe, affordable, quality, accessible, evidenced-based, and efficacious nursing care for individuals, families, groups, and communities of diverse and similar cultural backgrounds. To reach cultural competence, the health care professional needs to engage in a cultural self-assessment. This self-assessment will reveal personal cultural beliefs, attitudes, values, biases, and practices that may affect the kind of care the nurse is willing and able to provide for patients from diverse backgrounds and cultures. Experts have noted that in addition to cultural competence, linguistic competence is needed to offer appropriate care and responses to patients with culturally diverse backgrounds. When health care providers and organizations are culturally and linguistically competent, they can more effectively respond to the needs of the patients and communities they serve. Nurses skilled at cross-cultural communication—including verbal and nonverbal communication, communication dialects, and communication styles within various cultural groups—constitute valuable resources for health care agencies serving highly diverse populations. National Culturally and Linguistically Appropriate Standards (CLAS) from the U.S. Department of Health and Human Services identify methods for providing culturally competent care and offer guidelines for their implementation. These standards address language access, organizational support, diverse and culturally competent staff, existing laws, data collection, and information dissemination.

Cultural Sensitivity

Cultural sensitivity begins with the recognition of the often pronounced differences among cultures. These differences are reflected in the ways that different groups communicate and relate to one another, which carry over into interactions with health care providers. However, cultural sensitivity does not mean that a person need only be aware of the differences to interact effectively with people from other cultures. If health care providers and their patients are to interact effectively, they must move beyond both cultural sensitivity and cultural biases that create barriers. Developing this kind of culturally competent attitude is an ongoing process.

Culture And Ethnicity

Culture is a term that refers to a large and diverse set of mostly intangible aspects of life. It consists of the values, beliefs, systems of language, communication, and practices that people share and that can be used to define them as a collective. It also includes the material objects that are common to that group or society. Ethnicity is the person's identification with or membership in a particular racial, national, or cultural group and observation of the group's customs, beliefs, and language. According to Kottak, ethnicity means identification with and feeling part of an ethnic group and exclusion from certain other groups because of this affiliation. Ethnicity may or may not include a reference to skin color because group membership often is based on national origin, which may encompass a particular race. Ethnicity is frequently a central consideration in providing culturally appropriate nursing care. Culture involves mostly unconscious thoughts and actions that have a dramatic influence on health and illness. It is imperative that nurses and all health care providers recognize and respect patients' cultural beliefs and make every effort to incorporate these beliefs into their treatment plans. Doing so is a critical skill in providing patient-centered care.

Culture Is Shared

Culture is an attribute of essentially all members of a group, not just individuals. People who grow up in a particular culture often have shared values, beliefs, ideals, and expectations. These shared attributes are absorbed and transmitted through generations of teaching and sharing ideas, traditions, and rituals. Culture is transmitted in society by observing, listening, talking, and interacting with many people. Shared beliefs, values, memories, and expectations link people who grow up in the same culture. One shared element found in all cultures is an understanding of gender roles, the roles that a particular culture assigns to men and women. Although the world is changing, certain values and beliefs regarding gender roles remain unchanged in many cultures.

Culture Is Symbolic

Culture is based on symbols. Much of human behavior is mediated and moderated by symbols—signs, sounds, clothing, tools, customs, beliefs, rituals, and other items that represent meaningful concepts. Language is the most important symbolic aspect of culture. Language represents the most extensive use of symbols in a culture because words are used to represent objects and ideas. Language is a structure of verbal symbols used to communicate and share cultural beliefs and ideas that can be manipulated and used as tools by individuals and groups to organize their lives. Nonverbal symbols are images, such as flags of countries, that represent shared ideas or beliefs. The International Federation of Red Cross and Red Crescent Societies uses a single red cross and red crescent side by side on trucks and armbands as a symbol of its relief efforts; many religions use water as a symbol of rebirth through the process of baptism. Cultural symbols are passed on and accepted throughout generations. The mention of certain symbols automatically conjures up images and associations.

Culture Is Learned

Culture is learned and it is not biologically inherited. According to the 19th-century seminal work of Tylor, culture is passed on through attributes that a person acquires by growing up in a particular society and being exposed to traditions. Enculturation is the process by which children learn their culture. Enculturation begins at birth as parents and family members begin to teach the child what is expected in terms of familial responsibilities and contributions. This learning process occurs consciously and unconsciously through interactions with friends, schoolteachers, and a variety of community members. Culture can be taught directly, for example, when a mother teaches her child a family recipe, or indirectly, when a son observes the behavior of his father and other males in his family. By paying attention to things that happen around them, children modify their behaviors based on the actions of other family members.

Culture Is Integrated

Cultures are integrated, patterned systems, not a haphazard collection of customs and beliefs. If one part of the system changes (e.g., the economy), other parts of the system also change. For example, during the 1950s, most American women were stay-at-home mothers and wives; their career was being a housewife. However, the perception of the female role in society changed, and the goal of many women today is to attend college and pursue a professional career. This change is representative of the integration of new beliefs, ideas, attitudes, and behaviors into the previous cultural system. Within the culture of nursing, the nursing cap was a traditional symbol of the nursing profession. However, because of the expanded role of the nurse, the increased number of men entering the profession, and the relaxed nature of society as a whole, the cap has been abandoned in most practice settings.

Diffusion

Diffusion is the borrowing of traits between two cultures. Diffusion can be direct when two cultures trade commercially, intermarry, or war against one another. Diffusion is forced when one culture subjugates another and forcibly imposes its customs on the dominated group. Indirect diffusion occurs when items or customs move from one group to another without direct contact. This usually involves interactions among three cultures, in which group A's customs may flow to group C because of group B, thus, group B is the mediator of the diffusion or transfer of customs.

Formal Spiritual Assessment Frameworks-table

Framework FICA SPIRITual HOPE Components F: Faith and belief I: Importance of faith C: Faith community involvement A: Address spirituality or spiritual practices in care S: Spiritual belief system P: Personal spirituality I: Integration and involvement in a spiritual community R: Ritualized practices and restrictions I: Implications for medical care T: Terminal events planning (advance directives) H: Sources of hope, meaning, comfort, strength, peace, love, and connection O: Organized religion P: Personal spirituality and practice E: Effects on medical care and end-of-life issues

Discrimination

Discrimination refers to policies and practices that harm a group and its members. The principle of distributive justice (fair allocation of resources) along with the ethical principles of nonmaleficence and beneficence expects health care providers to provide safe, quality health care without discrimination. Nurses are most often concerned with discrimination related to health and health care disparity. Health disparity (a higher burden of illness, injury, or mortality) and health care disparity can be defined from a sociological perspective and can be viewed as a chain of events signified by differences in (1) environment; (2) access to, utilization of, and quality of care; (3) health status; and (4) health outcomes. Health care inequality is a term used to refer to differences in age, rank, condition, lack of excellence in treatment or "dissimilitude" (vast differences in services available). Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their 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. Worldwide health disparities have a tremendous impact on the social and economic well-being of both individuals and societies. According to World Population Review, infant mortality is highest in Afghanistan, 110.6 per 1000 births. Health care is scarce among refugees, poor living conditions add to this burden, and pregnancy complications are often untreated. In the United States, infant mortality rates are 5.8 per 1000 births, which is significantly higher than in comparable developed countries. Black infants less than 1 year of age born in the United States currently have a mortality rate double that of white infants. Pregnancy care is lacking and sometimes absent among low-income mothers in the United States, which may be linked to no access to health care in some states. Gennuso, Blomme, Givens, et al. found that mortality rates among blacks, American Indians, and Alaskan Natives were higher than among whites in every age group. Discrimination in all forms, including through health and health care disparities, harms people and societies in general.

Fundamentals of Nursing pg. 384-400 Ethnicity and Culture Introduction

Ethnicity and culture dramatically affect daily life for people throughout the world. Literally thousands of ethnic and cultural groups are recognized globally as well as within entire countries and regions. Statistics from the U.S. Central Intelligence Agency (CIA) The World Factbook indicate that Algeria has a population made up of only two primary ethnic groups, whereas the Democratic Republic of the Congo has more than 200 African ethnic groups represented. In the United States, the 2021 estimates of U.S. census data identify a population of more than six different races, not including Hispanic or Latino (who may be of any race), with 2.8% of people identifying with two or more races. Migration of people creates nations of diverse cultures and ethnicities. Relocation of individuals and families into foreign countries or regions with cultures different from their own causes challenges to both the immigrants or refugees and the health care providers in the area. Research indicates that patient populations experience lower-quality care and poorer outcomes associated with factors such as race, ethnicity, and language. Health care equity and the elimination of health disparities related to social, economic, and environmental factors is a goal of the Healthy People 2030 initiative. Title VI of the United States Civil Rights Act of 1964 prohibits discrimination based on national origin and limited English proficiency. The Joint Commission (2021) has accreditation standards that health care facilities must meet to improve communication and provide culturally competent care. It is imperative that people who are traveling or have relocated from a foreign country have access to health care information and treatment in their own language that is sensitive to cultural norms. Transcultural nursing as a specialty seeks to address the multifaceted aspects of ethnicity and culture. All nurses need to achieve increasing levels of cultural competence throughout their careers in order to provide unbiased, holistic care.

Ethnocentrism

Ethnocentrism is the tendency to view one's own culture as superior and to use one's own standards and values in judging outsiders. It is a fact that what may be alien or particular to one person or group may be normal, proper, and prized to another person or group. One ethnocentric view can be found in Western medicine. Western medical practitioners tend to believe that their approach to health and healing is far superior to that of non-Western practitioners. Many Western practices, especially the use of pharmacologic interventions, can find their roots in the practices of Eastern and Native American cultures, in which plants and plant extracts are a mainstay. According to Giger and Haddad, nurses must remain cognizant of the fact that their ways are not necessarily the best and that other people's ideas are not "ignorant" or "inferior." Nurses must remember that the ideas of laypersons may be valid for them and, more importantly, will influence their health care behaviors and, consequently, their health status. Ethnocentrism poses serious ethical and quality-of-care concerns. Issues of and decisions about care for diverse cultural groups require that nurses and other health care providers be knowledgeable about the principles, concepts, and theoretical frameworks of transcultural care. Being culturally sensitive and culturally competent is important because preconceived ideas about certain cultures can lead to racial stereotyping of patients, families, and communities by health care providers.

Balancing Multiple Cultures

Every nurse brings at least two cultures into a relationship with patients. The first culture is the nurse's own. The qualities and characteristics of the nurse's personal culture are key determinants of personal and professional behavior. The second culture, which is 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 also has its own separate and unique culture. Both cultures, that of the nurse and of the health care system, must strike a balance with a third culture, that of the patient. When additional health care providers collaborate to provide care, even more cultures must be balanced to provide culturally competent care and achieve positive patient outcomes. The astute nurse must remember that there is as much diversity within a cultural group as there is across cultural groups. Attainment of cultural competence can assist the astute nurse in devising meaningful interventions to promote optimal health among individuals regardless of race, ethnicity, gender, gender identity, sexual identity, or cultural heritage.

Gender Identity

Gender identity refers to how people see themselves—as male or female or something else. While most individuals develop a gender identity congruent with their biologic identity, gender identity can be incongruent with one's sex assigned at birth based on the appearance of the external genitalia. Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals experience unique health disparities. Transgender has come to be widely used to refer to a diverse group of individuals who cross or transcend culturally defined categories of gender and depart significantly from traditional gender norms. The Joint Commission (TJC) provides standards aimed at improving health care for LGBTQ individuals. Although the term culture often connotes a person's racial or ethnic background, there are other types of culture. LGBTQ is an example of a nonethnic culture group based on sexual orientation. Poverty is a culture in the sphere of socioeconomic status and deaf or blind persons are representatives of disability culture.

Health Beliefs

Health beliefs vary significantly among and within cultures. It is critical for nurses and all health care professionals to remember that the health beliefs and opinions of people of the same culture vary according to life experience, education, family values, and many other factors. Asking questions to determine the health beliefs of each patient is essential to provide culturally competent care. Some knowledge of traditionally held beliefs can help guide assessment of health care seeking and treatment options.

Care Planning-table

Icnp Nursing Diagnosis With Supporting Data Spiritual Distress Chronic illness Expressions of hopelessness Statements indicating concern over the recent inability to pray Nursing Outcome Classification (NOC) Coping Reports increase in psychological comfort NursingIntervention Classification (NIC) Coping Enhancement Encourage the use of spiritual resources if desired

Diversity Considerations-table

It is critical that nurses seek specific information based on each unique patient care situation to provide culturally competent care. Some general population and research findings about various cultures and ethnic diversity may be a helpful foundation from which to ask questions and pursue further cultural inquiry with patients. Family • Per Kottak, about 10% of all children live with a grandparent. In 15% of these households, no parent is present. More than 360,000 grandparents over age 60 who continue to work in the labor force have primary responsibility for grandchildren who reside within their household. • Self-care is valued by many American families, with elderly adults living independently, in retirement communities, or in extended-care facilities. • Generational differences exist among individuals within most cultures. It is essential for nurses to listen and ask questions to develop patient-centered plans of care that encompass the needs of all family members when one member requires the care of others. Gender • Gender roles differ greatly among and within cultural groups. • Women in Latino and many other cultures may adhere to a traditional wife/mother/housewife role. • Men may act as the decision makers in traditional South American, Middle Eastern, and Indian cultures. Culture, Ethnicity, and Religion • Most Orthodox and some Conservative Jewish patients require a kosher diet. • Jehovah's Witnesses refuse blood transfusions based on their interpretation of scriptural restrictions on receiving blood. • Many Muslim patients prefer diets that do not include pork products. • Seventh-Day Adventists regard the body as a temple and typically do not eat meat or consume caffeine, alcohol, or tobacco products. Morphology • The results of a study of 25- to 35-year-old Asian and white men indicate that Asians have smaller bones and are shorter and weigh less than whites without any difference in bone strength. • Research indicates that the relationship between body mass index (BMI) and mortality risk is stronger in whites than it is in blacks. This implies that BMI may be a better way to predict mortality risk in whites than blacks. • According to a study by Kim, et al., there are significant differences in the size and shape of knees within the East Asian, white, and black populations. These differences have an impact on the development of total knee replacement prostheses and may affect the success of total knee arthroplasty surgery.

Diversity Considerations-table

Life Span Fowler's Theory of Faith Development describes the developmental phases of faith as follows: • Infant (primal faith): Building trust and loving relationships is fundamental. • Toddler/preschool (intuitive projective faith): With language development comes the ability to find meaning in stories and an understanding of good versus evil. • School age (mythic-literal faith): Spiritual growth happens as a result of finding meaning in social relationships and applying principles of ethical and moral reasoning. • Adolescence (synthetic-conventional faith): Beginning with abstract thinking and the development of self-identity, this is the time of rejecting concrete rules and finding personal meaning in one's own faith beliefs, which may not be thoroughly examined. • Young adulthood (individuative-reflective faith): Self-identity is established with a greater understanding of self and appreciation of different perspectives. At this level, decisions are based on a broader worldview. • Middle adulthood (conjunctive faith): The person has the ability to accept that multiple interpretations of reality exist. An openness to various religions and faith traditions is exhibited in a person who reaches this stage. • Older adult (universalizing faith and the God-grounded self): The person understands self as part of a universal "whole" of love and justice. Gender Gender differences include the following: • Women more often engage in mind-body practices, compassion, gratitude, and the desire to be more positive. • Spirituality may help adolescent males respond to stress more positively and may be a deterrent to substance abuse. Culture, Ethnicity, and Religion • People of African American and Hispanic backgrounds tend to use prayer rather than other spiritual practices. • Cultural practices surrounding illness and death vary depending on the faith tradition of patients and their families. Nurses must ask about preferences and try to accommodate requests as much as possible. Disability • Parents of chronically and terminally ill children report God and spirituality as their most frequent coping resources. • Spiritual practices are important in coping with chronic conditions and disability. Practices should be individualized to meet the patient's needs.

Interprofessional Collaboration and Delegation-table

Methods for Nurses to Enhance Culturally Competent Care • Contact interpreters, specific cultural resource centers, and refugee or migration specialists in the community to become better informed about services available to culturally diverse patients. • Share pertinent information with members of the health care team that will assist in meeting the cultural, language, and spiritual needs of patients and family members. • Assist patients and families with accessing culturally appropriate community services and organizations by providing them with referrals, web-based links, or phone contacts. • Work or volunteer with health care professionals and leaders in community outreach programs to increase awareness of resources and services available.

Nursing Diagnosis

Multiple nursing diagnoses are available to help address patient concerns related to spirituality. After a thorough spiritual assessment, the nurse analyzes the data to determine which problems or nursing diagnoses are most appropriate to address the patient's unique needs. International Classification for Nursing Practice (ICNP) nursing diagnoses that may be identified for patients exhibiting spiritual needs include the following: Spiritual Distress • Supporting Data: Chronic illness, expressions of hopelessness, statements indicating concern over the recent inability to pray Moral Distress • Supporting Data: Cultural conflict between medical treatment and religious beliefs, expressions of concern about rejection by religious community, hesitation in accepting blood transfusion Decisional Conflict • Supporting Data: Unclear personal beliefs, questioning of personal beliefs while making decisions, delayed decision-making

Ethical, Legal, and Professional Practice-table

National Standards for Culturally and Linguistically Appropriate Services 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. 2. Advance and sustain organizational governance and leadership that promotes Culturally and Linguistically Appropriate Services (CLAS) and health equity through policies, practice, and allocation of resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations served. 9. Establish culturally and linguistically appropriate goals, policies, and management accountability, infusing them throughout the organization's planning and operations. 10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs. Use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts and complaints. 15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Socioeconomic Level

Nurses need to be cognizant of the impact of patients' socioeconomic status on their access to health care. It is important to determine the overall economic factors that influence the patient. Historically, patients from lower socioeconomic levels have poorer health and tend to have shorter life expectancies. Research has suggested that a lack of insurance and access to health care often leads to late diagnosis of disease, when medical intervention is less effective. Unfortunately, the level of poverty found in minority populations within all cultures is disproportionately higher than that in the nonminority population. Assessment of a patient's employment status, insurance coverage, and educational background can provide data on financial resources that affect access to and adherence with health care. Economic assessment data are helpful in determining interventions and community resources available for treatment. After gathering, reviewing, and organizing a patient's health assessment data in a culturally competent manner, the nurse is ready to develop a care plan that acknowledges the role of culture in patient-centered care.

Gender Roles

Nurses need to be mindful that equalization of genders is predominantly a Western phenomenon and that many non-Western cultures do not adhere to this cultural ideology. Accommodations must be made to respond to patient preferences regarding gender. Some patients will require direct care from nurses of the same gender, while others may limit speaking or eye contact with people of the opposite gender. Gender equality exhibited through shared decision-making is a concept not universally accepted in many cultures. For example, some women are not permitted to make health care decisions for themselves or their children. In some families, decision-making is viewed as the responsibility of the men. Nurses should be sensitive when a female patient defers to her husband or father, recognizing that although the woman has the legal right in various parts of the world to consent to a procedure, she may not feel that she has the authority to give consent from a cultural standpoint.

Fundamentals of Nursing pg. 403-413 Spiritual Health Introduction

Nursing has a long history of recognizing and integrating spiritual care into nursing care, beginning with the religious orders in the Middle Ages and continuing with Florence Nightingale in the 1800s to the present. Research has demonstrated that higher levels of spiritual health are associated with better coping with chronic disease, addiction prevention, better psychological functioning, positive health behaviors, and a better quality of life as well as decreased pain levels, lower anxiety, and less depression. Spiritual well-being and coping are particularly important in the oncology and end-of-life patient population. Higher levels of spiritual well-being are associated with less financial strain and suicidal ideation. Spirituality is also associated with family resilience following stroke and with finding hope in cases of dementia. Ruth-Sahd, et al., report that spirituality affects patient length of stay and the level of satisfaction associated with their care. The body of spirituality research has led to the requirement by The Joint Commission (TJC) to provide spiritual care within a multidisciplinary environment in hospitals. Traditionally, chaplains were the primary providers of spiritual care, but with the adoption of TJC's requirement, spiritual care became multidisciplinary in focus. Aspects of spiritual care are included in the American Nurses Association (ANA) scope and standards of practice, Social Policy Statement, and Code of Ethics. The American Association of Colleges of Nurses (AACN) Essentials of Baccalaureate Education requires registered nurse graduates to be capable of conducting a spiritual assessment and recognizing the impact of spirituality on health care. In order to provide holistic care, it is imperative to integrate spiritual needs into each patient's care plan. Spirituality and religion are complementary yet distinctly different concepts. Spirituality focuses broadly on the search for meaning in life, death, and existence, whereas religion is an organized, structured method of practicing faith and faith tradition that expresses one's spirituality. Nurses must explore and appreciate the roles that both play in people's lives to better understand patients' attitudes toward health, illness, and health care as well as their cultural differences.

Health Assessment Questions-table

Nutrition • What foods do you commonly eat? • What are your favorite foods? • Which foods do you eat to be healthy? How often do you eat them? • What kinds of food do you like to eat when you are not feeling well, and which ones do you avoid? • Do you have access to the types of food you need? • Which foods do you eat on holidays or special occasions? • Are there foods you do not eat for cultural or religious reasons? If so, what are they?

Spiritual Assessment Cues-table

Patient Cue Category Verbal Nonverbal Environmental Situational Examples • Asks for prayer or chaplain • Asks whether the nurse has time to talk • Talks about topics related to life, death, or purpose • Talks about faith • Uses religious words in conversation • Asks frequent questions about diagnosis; needs to talk • Expresses concerns about family • Exhibits neediness • Is angry or noncompliant • Seems depressed or withdrawn • Has emotional outbursts and cries quietly • Has religious books, jewelry, or symbols and/or has prayer objects • Displays family pictures • Has a life-threatening diagnosis or life-changing condition • Is facing death • Faces treatment decisions

Acquisition of Cultural Identity

People develop and maintain their cultural identity through a variety of methods. When relocating to a new country or region, members of some cultural and ethnic groups choose to integrate into their new cultural environment, whereas others within these groups prefer to retain their traditional patterns of dress and behavior. Recognizing these differences allows nurses to appreciate the needs of culturally diverse patient populations.

Spiritual Practices

People search for meaning and purpose by engaging in activities to promote their spirituality. These activities are called spiritual practices. Overall, spiritual practices promote three types of activities: connecting with oneself through reflection, connecting with others through relationships, and connecting with a higher power through faith rituals. Reflection is the process of contemplating experiences, sometimes even life-changing experiences, and searching for meaning in those events. For example, many nursing students choose to enter nursing school because they have had a life experience that called them into nursing (e.g., a death in the family, observation of nurses in action, a desire to help people). The process of choosing nursing as a career involves engaging in reflection and finding personal meaning in the nursing profession. Not all life experiences require reflection, but those that do often help the person grow spiritually. Many people use methods such as intellectual, artistic, and meditative practices as well as communing with nature to facilitate the process of reflection. People may express their spirituality within relationships with others. Great meaning can be found in friendships, family relationships, and partner and spouse relationships. These connections with other people can support and contribute to spiritual growth. Nursing students frequently discuss meaningful clinical experiences with their colleagues in the course of searching for meaning and purpose in their chosen profession. Such interactions can also help them to cope with stressful life experiences and promote spiritual growth and transcendence. Some people find meaning in prayer, which is spoken or unspoken communication with a higher power. The specific mode of praying often is influenced by the person's religious or faith belief system.

Language Development in Acculturation-table

Pidgin Pidgin is an example of how language develops during the acculturation process. Pidgin English is the local language in some regions of the world. • Pidgin is a mixed language that develops to facilitate communication between members of different groups who speak different languages. • It usually develops because of trade or colonialism and is a simplified form of English. It blends the basics of English with the grammar and pronunciations of the native language. • Pidgin English was first used for commerce in Chinese ports and developed in other forms in Papua New Guinea and West Africa. • Nurses who practice in areas where Pidgin English is spoken need to be fluent in Pidgin and English, although most medical terms sound similar in both dialects.

Prejudice

Prejudice is a negative attitude toward an entire category of people, often an ethnic or racial minority. Sometimes, prejudice results from ethnocentrism—the tendency to assume that one's own culture and way of life represent the norm or are superior to all others. Prejudice includes "labeling" groups or cultures, for example, as lazy or materialistic. Nurses are guilty of prejudicial thinking if they anticipate certain patient behavior based on a patient's appearance or on previous interactions with people of similar ethnicity or culture. There is no room for prejudice in professional nursing practice. Unchecked prejudicial thoughts and actions may lead to discrimination and unequal care of individual patients.

Race

Race is thought by many to have a biologic basis. However, this assumption is not true. Race is a socially constructed concept that tends to group people by common descent, heredity, or physical characteristics. It has been a practice in the United States to use the rule of descent to categorize people by race. The rule of descent arbitrarily assigns a race to a person based on a societal dictate that associates social identity with ancestry. For example, in some states, if people have any ancestors of minority descent, they are classified as a member of that minority, no matter how remote the ancestry. This practice divides society and perpetuates disparities in health care because it assigns people to groups that have been historically deprived of equal access to health care, wealth, power, and privilege. It automatically places children of mixed unions in the group of their minority parent, which is called hypodescent. For example, Tiger Woods, Mariah Carey, and Susan Phipps, who challenged the Louisiana law of one thirty-second "Negro blood," are categorized by their minority parents/ancestors.

Racism

Racism is an unfounded belief that race determines a person's character or ability and that one race is superior or inferior to another. Scientific evidence indicates that no one race is culturally or psychologically superior to another, and past studies that have reached other conclusions have been found to be seriously flawed in their methodology or inherently biased. Despite the preponderance of these scientific findings, some people still maintain that their race is superior to all others. According to Purnell, "race includes physical characteristics that are similar among members of the same group such as skin color, blood type, and hair and eye color. Although there is less than a 1% genetic difference among the races, those differences are significant when it comes to conducting health assessments and prescribing medications". According to Schaefer, race is a social construction and the process of defining races typically benefits those who have more power and privilege than others. Health care professionals play a vital role in counteracting racism by providing unbiased, equal access and culturally sensitive care to people of every race and culture. For example, the Lee, et al. examination of racial and ethnic disparities in the management of acute pain in United States emergency departments found racial disparities in analgesia use; black patients were less likely than whites to receive analgesia for acute pain. Hispanics were also less likely to receive analgesia. This research demonstrates how health care disbursement can be influenced by race.

Faith Community Nursing

Registered nurses may provide spiritual care through faith community nursing (formerly parish nursing), an area of nursing practice that originated from the work of the Reverend Dr. Granger Westberg in the mid-1980s. Some roles of a faith community nurse are health adviser, health educator, advocate, liaison to faith and community resources, coordinator of volunteers, and developer of support groups. Faith community nurses seek to provide holistic care by focusing on the mind, body, and spirit in addition to community wellness. Parish nursing was designated as a specialty by the ANA in 1997. Faith Community Nursing: Scope and Standards of Practice, 3rd edition defines the parameters of faith community nursing. Faith community nurses come from many faith traditions; recognized groups include Jewish Congregational Nurses and Muslim Crescent Nurses as well as registered nurses working within a wide variety of Christian traditions. The Westberg Institute, formerly known as the International Parish Nurse Resource Center, provides educational and resource materials for this specialty in collaboration with the ANA and the Health Ministries Association.

Religion

Religion provides a structure for understanding spirituality and involves rites and rituals within a faith community. Many people express their spirituality through religion. Most religions celebrate life events such as birth, marriage, and death with rituals such as baptism, marriage ceremonies, and funerals. Religion can provide a process of discerning meaning and purpose during crises, particularly crises involving health. Religious faith rituals are important in promoting health. Religious traditions may challenge accepted medical culture, such as when people of the Jehovah's Witnesses faith refuse lifesaving blood transfusions for themselves or family members. During the assessment process, nurses must seek information from patients regarding their personal religious practices that may affect medical treatment. An important point in this context is that although some religions are known for specific faith traditions or rituals, not all members of a religious community may subscribe to commonly held beliefs or customs. It is always better for nurses to ask patients about specific spiritual needs or beliefs rather than assuming their adherence to the tenets of their professed religion.

Ethical, Legal, and Professional Practice-table

Responsibilities Associated With Spiritual Care • Because of privacy and Health Insurance Portability and Accountability Act (HIPAA) requirements, health care providers cannot contact a faith community without the consent of the patient. Therefore, most health care institutions ask, as part of the admission process, whether a faith community should be notified. • The Joint Commission requires a spiritual assessment be conducted with patients receiving care in a variety of settings, including hospitals, long-term care facilities, or homes. The health care facility or organization determines the exact content of the spiritual assessment. • Provision 1 of the American Nurses Association's "Code of Ethics for Nurses with Interpretive Statements" stresses the importance of considering religious and spiritual beliefs in planning patient-, family-, or community-centered care. • The International Council of Nurses Code of Ethics for Nurses urges all nurses to promote environments in which the human rights, customs, spiritual beliefs, and values of individual patients, families, and communities are respected.

Rituals

Rituals are formal, stylized, and repetitive actions performed in special places at special times. These actions convey information about participants and are used to inform others about the beliefs and traditions of a culture. Rituals, through their repetitive nature and generational transmission, translate into enduring messages, values, and sentiments. These repetitive actions include participation in individual and group activities, such as praying, dancing, fasting, singing, meditating, and reading sacred texts. Death and birth rituals vary greatly from one culture to another. All of these activities have implications for the delivery of nursing care. Rituals can sustain and provide support for patients during a time of illness or suffering. In caring for patients, nurses need to be aware of their own beliefs and feelings regarding certain rituals as well as understand how these rituals may affect their patients and families.

Spirituality and Religious Orientation

Rooted in the culture of groups, spirituality and religious orientation help define many health beliefs and health practices. Some form of religion or multiple religions exists in every culture. Different cultures have various views of religion. Established religion seeks to define the spiritual world and give meaning to the divine. It attempts to provide an explanation for events that seem difficult to understand. Religious organizations may offer worship services, small groups, service opportunities, and provide a support community for individuals. Spirituality involves more than the formal beliefs and rituals seen in most religious groups. Spirituality refers to behaviors and beliefs that strengthen a person and provide meaning to the individual's life. Some people may identify themselves as being spiritual without an affiliation with an organized religious group. While spirituality and religion share some overlapping characteristics, they are not the same; religion addresses questions related to what is true and right and helps people determine where they belong in the scheme of life, while spirituality emphasizes the journey for meaning, purpose, direction, and values in life. For many people, spirituality is a stabilizing force among mind, body, and spirit. For a nurse to complete a thorough cultural assessment, the nurse must inquire about religious preferences and determine the extent to which spirituality or religion affects a patient's physical and emotional well-being. In many cases, aspects of religion and spirituality significantly affect patients' ability to cope with adversity and health-related challenges.

Skin Color

Skin color probably is the most significant biologic variation that nurses encounter in the delivery of culturally competent care. Variations in skin color may be attributable to genetic makeup or may be the result of mutations and environmental factors. The darker a patient's skin is, the more challenging assessment for changes becomes. Procedures used in assessing dark-skinned people are quite different from those used in assessing light-skinned people. Skin color varies in conditions such as jaundice, pallor, and some rashes. In assessing a dark-skinned patient for oxygenation, it is particularly important to examine the least pigmented areas, such as the buccal mucosa, lips, tongue, nail beds, and palms of the hands. The examiner should not rely on the skin tone alone. To establish the baseline skin color, the nurse must observe skin surfaces that have the least amount of pigmentation, which includes the underside surface of the forearm, the palms of the hands, the soles of the feet, the abdomen, and the buttocks.

Socialization

Socialization is the process of being reared and nurtured within a culture and acquiring its characteristics. This process can and does occur on many different levels: within families, communities, schools, and spiritual or religious groups. Socialization usually occurs within the structure of a group that influences the health care behaviors and beliefs of its members and can directly and indirectly affect the administration of health care by the nurse.

Assessment

Some nonnursing models for cultural assessment were used before the development of various transcultural nursing assessment models. Madeleine Leininger's Transcultural Theory and Assessment Model was the first tool developed for nurses to appropriately assess a patient's culture and evaluate the impact of culture on nursing care. Since the development of Leininger's assessment tool, other nursing models have been developed to assist nurses in providing culturally congruent and competent care. The Giger and Davidhizar Transcultural Assessment Model is a framework for collecting data related to six cultural domains: communication, space, social orientation, time, environmental control, and biologic variation. Using these questions and others that are similar will help identify and address the cultural needs of patients and families. Regardless of the format used to conduct a cultural assessment, the nurse needs to be sensitive to several factors that affect how people from culturally diverse backgrounds may interact with others and their environment and how they may view health care. Realizing the potential impact of these factors will help nurses recognize important cues and develop culturally sensitive treatment plans that meet each patient's individual needs.

Health Assessment Questions-table

Spiritual Health • Do you have family in the area? (Assess for family importance, relationships, and meaningful experiences at this time.) • Is there anyone you would like to call? • How are you handling this hospitalization or illness? • What faith practices or beliefs will help you cope with this illness or hospitalization? • Do you have any dietary or treatment guidelines/restrictions related to your spiritual/religious beliefs? • Do you belong to a faith community? Do you want the community to be notified? Would you like a chaplain to visit?

Spiritual and Religious Institutions

Spiritual and religious institutions have a profound impact on individual and group socialization. These institutions can greatly influence health beliefs and often provide an entry point for health care access in impoverished communities and less developed countries. Religious practices usually are rooted in culture. Religions may have a set of beliefs that define health and the behaviors that prevent or treat illness. For example, most Jehovah's Witnesses oppose receiving blood transfusions based on their religious principles found in the Bible at Genesis 9:4, Leviticus 17:10-11, and Acts 15:28-29. Nurses caring for known members of the Jehovah's Witness faith community should verify and document patient preferences to ensure that religious beliefs are respected during medical treatment.

Assessment

Spiritual assessment is a process of determining spiritual needs; it can take many forms. To comply with TJC's requirement, many institutions incorporate initial spirituality-focused questions into the hospital admission process. The admissions office or the admitting care provider may ask initial screening questions about the patient's religious tradition, whether the patient's faith community should be notified, and whether care providers need to know of the patient's spiritual or religious needs or practices. Some spiritual assessment frameworks use acronyms to structure this information. Nurses assess for spiritual needs on an ongoing basis to determine what holds meaning and purpose in the patient's life. The assessments happen during conversations about family and friends, social supports, employment, or day-to-day life activities outside the health system. Nurses should encourage their patients to lead these conversations and pay attention to nonverbal cues such as facial expression or tone of voice. For instance, when a patient's eyes brighten at the mention of a particular event or person, that subject can be identified as a meaningful aspect of the patient's life. Patients are at high risk for spiritual distress (disruption of a belief or value system) in certain situations that threaten their understandings and sense of purpose in life. For example, patients may develop spiritual needs in the face of a life-changing diagnosis or other health crisis. Patients may require spiritual care when they are faced with the need to make health care decisions. These types of situations require that patients reflect on their beliefs and purpose in life, personal values, and the way their decisions affect others. Patients may need assistance in such difficult times so as to lessen the degree of their spiritual distress. Nurses must be alert to such situations so that they can intervene appropriately. Patients exhibit spiritual needs using both verbal and nonverbal cues. In many cases, spiritual distress may be expressed as anger, depression, neediness, or crying. Nurses must be attentive to each patient's health situation and behaviors to determine whether spiritual care is needed. Nurses should be observant of potential religious needs. Religious people often use certain expressions in their day-to-day conversations, such as "God willing" or "blessings." Religious objects in the patient's room—such as holy books, religion-oriented jewelry, or prayer objects—may indicate a religious orientation to spirituality. To promote spiritual health, nurses must be attentive to these verbal, nonverbal, environmental, and situational cues indicating a need for spiritual care and must recognize the patient's spiritual or religious orientation.

Spiritual Care

Spiritual care in nursing practice is a mutual, purposeful, interactive process between a nurse and a patient, which may include family, to promote the patient's spiritual health. Nurses provide spiritual care in the moment when they recognize a patient's need to finding meaning and purpose in life. Overall, spiritual interventions include being with a person holistically, determining the spiritual need through active listening and probing, and performing actions to address that need. Those actions include promoting hope through self-reflection, facilitating spiritual practices, and encouraging support from others. Specific interventions to achieve these aims will vary. The nurse may encourage the patient to discuss the meaning of a new diagnosis or encourage the patient to share that meaning with loved ones. The nurse may also refer a patient to a chaplain or preferred spiritual adviser for support, to baptize an at-risk infant in an emergency situation, to pray with a patient on request, or to facilitate implementation of faith-related rituals for a patient facing a life-changing experience such as birth or death. Spiritual care differs according to the patient's developmental age. Spiritual care must be provided in a manner consistent with a patient's own faith and developmental level. Research has shown that patients want nurses to be present to them and integrate spirituality in their care, particularly when they are critically ill. Creating an environment of compassion and caring so that patients and families feel comfortable in expressing their spiritual needs is a prerequisite to providing spiritual care. If the patient does not experience compassionate warmth from the nurse, the patient will not accept spiritual care. Patients who describe themselves as being atheists (believing that God or higher powers do not exist) or agnostics (believing that the nature or existence of God is unknowable) require compassionate, nonjudgmental care similar to that given to all other patients. It is essential for nurses to respect the personal beliefs of everyone, even if they are dramatically different from their own. If the beliefs of a patient change because of a health crisis, referral to a chaplain, member of the clergy, or spiritual adviser may become appropriate.

Spirituality

Spirituality is the expression of meaning and purpose in life or the manifestation of one's innermost self. Humans express spirituality through their unique capacity for thought and contemplation as well as their ability to explore meaning and purpose in life. That unique human dimension of self is the spirit, and the expression of the spirit is spirituality. Various belief systems define spirit differently. Some believe the spirit to be the brain, whereas others believe it to be a complex entity or phenomenon that connects with a higher power, or God. Regardless of any particular belief system, humans are capable of high levels of thought, and this exploration of meaning and purpose in life affects their behavior and health. Spirituality is universal among humans and is a central dimension of health, affecting its physical, psychological, and social aspects. Spirituality involves movement toward growing as a human being throughout life. Such growth happens over time in an ebb-and-flow fashion. Transcendence is the process of moving beyond one's current self. Spirituality requires faith, a belief beyond self that is based on trust and life experience rather than scientific data. The ability to have faith allows people to demonstrate hope (confident expectation) of a positive outcome in the face of challenging circumstances. Both faith and hope are related to how people practice spirituality.

Planning

TJC standards affirm the importance of spirituality and spiritual well-being with regard to improved patient outcomes. Based on assessment findings and identified nursing diagnoses, nurses must individualize and prioritize care for every patient. In developing a patient-centered plan of care, the nurse must decide the order in which spiritual concerns and other patient problems are to be addressed. As appropriate, the spiritual needs component of the care plan should include specific goals or outcome statements, as in the following examples: • "Patient will report the ability to pray after counsel by the hospital chaplain." • "Patient will report that her religious beliefs have been integrated into her care plan." • "Patient will discuss treatment choices with a trusted confidant to explore acceptable options before beginning treatment next week." A patient's spiritual adviser, clergy person, rabbi, or imam is an important member of the interdisciplinary health care team. In the absence of a personal spiritual adviser identified by the patient, many medical facilities have interfaith chaplaincy departments to assist in providing appropriate spiritual care. When problems or nursing diagnoses involving spiritual concerns emerge during the assessment process, collaboration with and patient referrals to the hospital chaplain may be indicated.

Characteristics of Culture

The art, literature, clothing, customs, language, religion, and religious rituals of a particular group of people are manifested by their culture. Thus, people and their patterns of life make up the culture of a particular region or country, and cultures vary throughout the world. Such differences extend across geographic boundaries, and this diversity in cultures results in the diversity of people everywhere. Because culture consists of a system of beliefs held by the people of a region as well as their principles and moral values, behavioral patterns of people from a particular geographic region of the world contribute to the region's culture. Four basic elements of culture are recognized: Culture is (1) learned, (2) symbolic, (3) shared, and (4) integrated.

Family

The family is the basic unit of society in all cultures. From an economic perspective, a family is a social unit that works together to meet material needs. From a sociological perspective, a family is a social unit that interacts within the larger society. Family also may be viewed as the basic unit in which personality develops and subgroup relationships, such as that between parent and child, are created. Societal changes in the family unit have created variations of the basic family unit, such as single-parent families, extended families, and blended families. All of these variations will have an impact on how the nurse delivers care to members of these family groups.

Cultural Concepts

To understand the complexities of ethnicity and culture more fully, nurses must be aware of both helpful and detrimental concepts that affect cultural competence. By becoming familiar with these ideas, nurses can better provide culturally sensitive care.

Transcultural Nursing

Transcultural nursing focuses on human caring-associated differences and similarities among the beliefs, values, and patterned life ways of cultures to provide culturally congruent, meaningful, and beneficial health care. It is both a specialty and a general practice area that focuses on worldwide cultures and comparative cultural caring, health, and nursing phenomena. Established as a formal area of inquiry and practice in the 1970s, the goal of transcultural nursing is to provide culturally congruent care. The founder and central leader of transcultural nursing is Madeleine Leininger, who, as a graduate clinical nurse specialist in psychiatry, discovered major cultural differences among children and parents. She was among the first to realize the need to address culture as a critical and missing dimension of care. Transcultural nurses provide knowledgeable, competent, and safe care to people of diverse cultures. When conducting a cultural assessment of the patient, the ability to see the situation from the patient's point of view is known as an emic or insider's perspective; looking at a situation from an outsider's vantage point is known as an etic perspective. Transcultural nurses are specialists, generalists, and consultants. Functioning in diverse clinical practice settings and in schools of nursing, they assist others to become sensitive to and knowledgeable about diverse cultures. They may identify cultures that are neglected or misunderstood and may help health care systems assess how they serve, or fail to serve, diverse cultures in a community. Transcultural nurses are committed to cultural openness, a lifelong commitment that promotes cultural self-awareness and continuing development of transcultural skills. Leininger developed the Sunrise Model to depict the essential components of her Theory of Cultural Care Diversity and Universality. A basic tenet of Leininger's theory is that human beings are inseparable from their cultural background and social structure, worldview, history, and environmental context. Gender, race, age, and class are embedded within the social structure. Biology, emotions, and other dimensions are studied from a holistic view and are not fragmented or separated. Leininger's work stresses the importance of comprehensive cultural assessment.

Nutritional Needs

Understanding a patient's food patterns is critical to providing culturally congruent dietary counseling. The role of food in a culture, food rituals, common foods and spices, dietary limitations, and nutritional deficiencies are all factors to be assessed by the nurse. For example, nurses may be viewed as culturally incompetent if they attempt to prescribe a diet including pork products to a patient of Islamic or Orthodox Jewish background. Food has a significant role in socialization in many cultures. The celebration of specific holidays often centers on the preparation and sharing of traditional foods with family and friends. In addition to cultural influences, socioeconomic status may dictate food selection. Individuals and families with limited financial resources may have to choose between purchasing healthy foods or affordable foods. The inability to afford foods for a healthy diet leads to severe nutritional deficiencies in many cultures. In view of the cross-cultural variation in diets, nurses need to ask about the specific diets and traditional foods of their patients.

Evidence-Based Practice and Informatics Spiritual Assessment Data Accessibility in Electronic Health Records-table

• Most electronic health records (EHRs) incorporate spiritual assessment and intervention flowsheets for documentation of spiritual care. Health care agencies integrate spiritual assessment tools such as the FICA Spiritual History Tool, HOPE Questions for Spiritual Assessment, or organization-specific flow sheets to monitor progress and ensure evidence-based care. • Because spiritual care is multidisciplinary, spiritual documentation must be viewed by all health care providers—including physicians, nurses, chaplains, and social workers—to ensure integrated, patient-centered care.