NSG 152 Culture
HERITAGE CHAIN Model
Another model is Rachel Spector's HeritageChain (2017), which outlines the variables that impact culturally competent care. These include the cultural heritage of the patient and the provider; the diversity of the area in which patient and provider live and work; the health panoramas of traditional cultural groups; and aspects of health and illness, such as traditional healing versus modern healthcare practices and family support and considerations
Cultural Competences for Nurses
Apply knowledge of social and cultural factors that affect nursing and healthcare across multiple contexts. Use relevant data sources and best evidence in providing culturally competent care. Promote achievement of safe and quality outcomes of care for diverse populations. Advocate for social justice, including commitment to the health of vulnerable populations and the elimination of health disparities. Participate in continuous cultural competence development. The nurse's journey toward cultural competency begins with self-awareness, with identifying areas in which the nurse can improve how she relates to and communicates with individuals with values and beliefs different from her own.
Differences between men and women go beyond anatomy and physiology and cultural or social definitions
Compared to women, men typically are less verbal and more action oriented and have stronger skills in logic, mathematics, and coordination; women tend to be more skilled in languages, perceiving and responding to others' needs, and the arts. However, these are general tendencies and taking them at face value may lead to stereotyping
Developing Cultural Competence
Cultural competence has some basic characteristics: Valuing diversity Capacity for cultural self-assessment Awareness of the different dynamics present when cultures interact Knowledge about different cultures Adaptability in providing nursing care that reflects an understanding of cultural diversity. Cultural competence can be considered a process as well as an outcome, although no one person can be competent in dealing with all types of cultural variations.
Diversity
Cultural differences are not the only hallmarks of diversity. Gender, race, class, sexual orientation, and age are just a few of the differences among individuals living in the United States. In many instances, these factors carry important implications for nursing. For example, African American women are at greater risk for heart disease than any other single population; older adults are at greater risk for injury due to falls; and children are at greater risk for accidental injury. Nurses must be prepared to work with each individual who walks in the door, regardless of that individual's personal background.
Communication
Cultural groups may speak a unique language or a variation of another language. The meaning of words can differ among various groups of people, and misunderstandings may result from lack of common communication. Languages vary in terms of references to time, gender, roles, or common concepts and definitions. Translation of concepts from one language to another may miss contextual embedded meanings and lead to misunderstandings. Misinterpretation of nonverbal communication also may lead to problems. Direct eye contact may show disrespect in some cultures and be a sign of interest and active listening in others. An example of a difference in nonverbal communication is when up-and-down head nodding does not reflect agreement, but instead is an attempt to acknowledge respect for authority.
Values and Beliefs
Culture includes a society's values, beliefs, assumptions, principles, myths, legends, and norms. People living within a culture typically share many of the prevailing society's values and beliefs. People use these values and beliefs to help them define meaning, identify acceptable behaviors, choose emotional reactions, and determine appropriate actions in given situations. Values and belief systems are part of a culture, as are family relationships and roles. To understand patient behaviors in more depth, a nurse must identify which cultures are prevalent demographically in a given area, learn more about those cultures by reading or attending a class about them, and apply that knowledge and experience when providing patient care. Values reflect an underlying system of beliefs.
Concepts Related to Culture and Diversity
Differences among patients that are attributable to culture, ethnicity, race, gender, sexuality, and vulnerability impact the nursing care of patients in a variety of ways. Within the concept of communication, it is important to understand that patients use language differently, speak different languages, and recognize nonverbal cues differently. Therapeutic communication, interpreters, shared languages, and awareness of nonverbal cues can help nurses communicate more effectively with patients from diverse backgrounds. Within healthcare systems, the resources available to the different types of patients depend on a variety of factors, especially whether or not the patients have health insurance and access to resources such as transportation. Patients who live in poverty or who are homeless may need referrals to additional resources. Nurses must advocate for services, such as interpreters or mental health resources, for their patients who do not have the awareness or influence to ask on their own. The professional behavior of nurses must be built on a moral and ethical code. Nursing as a discipline has a culture of its own. Nurses must understand collegial and regional differences to effectively work collaboratively with interprofessional teams. Self-awareness, emotional intelligence, and lifelong learning should be characteristics of a nurse's professional behavior. Another concept related to culture and diversity is sexuality. Gender roles and the timing and type of sexual relationships vary among groups of people. Heterosexual and homosexual variations may also be culturally embedded. Another concept related to culture and diversity is spirituality. Although spirituality may be defined more broadly than religion, cultural variations exist around religious and church doctrines such as Hinduism, Judaism, Buddhists, Christianity, and Muslim practices. Religious practices commonly influence eating or fasting patterns, types of worship, and family roles and responsibilities.
Gender
Traditionally gender has been dichotomized into two groups: men and women. However, it is now known that some people do not fit neatly into these categories of gender
Intersex
a general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male
Diversity
refers to the array of differences among individuals, groups, and communities
Cultural Groups
can be categorized around racial, ethnic, religious, or socially common practice patterns. Race, however, does not equate with culture. Cultural groups often share common characteristics such as language, customs, beliefs, and values
Bias
can be defined as favoring a group or individual over another.
Elements of a culture
A physical element - The geographic area in which a society is located An infrastructure element - The framework of the systems and processes that keep a society functioning A behavioral element - The way people in a society act and react to each other A cultural element - All the values, beliefs, assumptions, and norms that make up a code of conduct for acceptable behaviors within a society.
Cultural Transmission
A society is a group of people who share a common culture, rules of behavior, and basic social organization. Culture is transmitted, or learned and shared, by people living together in a society. Cultural characteristics, such as customs, beliefs, values, language, and socialization patterns, are passed from generation to generation. Culture is transmitted from one generation to the next through language, material objects, rituals, customs, institutions, and art. Through the use of a common language, people learn how to live by the rules governing the society and how to earn money or trade goods or services to meet basic needs, such as food and shelter. Culture can influence everything the members of a society think and do.
Cultural Competencies for Institutions
Administration and governances Orientation and education Language Staff competencies
Poverty
Although people who are homeless can be considered impoverished, many families with adequate shelter live in poverty. Children and those living in female-headed households are at greatest risk of living in poverty. Of those households living in poverty, 28.2% are headed by a woman, compared to 5.4% married couples and 14.9% male-headed households
Homelessness
Among the most vulnerable patients are those who are homeless. Homeless patients present unique and complex challenges because they often live in dangerous, unsanitary conditions; have diets that are severely lacking in nutrients; and have very few resources for coping with illness. They must find shelter and food every day and cannot predict what the next day will bring. People who are homeless have difficulty obtaining, keeping, and storing medications. A high incidence of substance abuse and mental illness limits their ability to provide self-care. An important nursing intervention in addition to providing care to those who are homeless is to identify resources to help these patients.
Environmental Control
An individual's relationship to nature varies among cultures. Different health practices, values, and experiences with illness can be associated with an external or internal locus of control. Rotter (1966) theorized that individuals believe either that they can control certain aspects of their lives (internal locus of control) or that outside sources control their lives (external locus of control). Those who believe in an internal locus of control over their health will be motivated to eat healthy, exercise, and make use of other wellness measures. For example, a European American would more likely follow an internal locus of control based on the cultural belief of independence and care for self. Those who follow an internal locus of control tend to respond well to preventive medicine. Those with an external locus of control will feel that outside influences will care for their health. For example, those of the Muslim faith believe the status of their health is Allah's will. Those who follow an external locus of control are less likely to be as engaged in preventive measures as they do not see themselves as being in control of their health.
Implementation
Implementation should involve a care plan that incorporates the patient's cultural beliefs and practices. Promote Safety Promote Adequate Nutrition Promote Physical Mobility
How can you advocate for this patient's values and beliefs while she is in the rehabilitation center?
Care within institutional settings should always be individualized to address each patient's unique values and beliefs. Nurses can advocate for patient-centered care in the context of treatment planning and assist in establishing practices that are flexible enough to address these needs. As partners in care, nurses should encourage patients to participate in treatment decisions and assert their right to continue cultural and spiritual practices. One area of emphasis may be monitoring policies that may present barriers to culturally sensitive care, such as restrictive visitation policies. Activities should be tailored to meet the diverse needs of the populations served. Food services should be equipped to handle diverse preferences and needs. All patients should have access to pastoral services or other spiritual resources.
Susceptibility to Disease
Certain ethnic groups or races may tend toward developing specific diseases. African Americans, for example, have a higher incidence of hypertension and sickle cell disease. Cystic fibrosis occurs almost exclusively in Caucasians. Native Americans have a higher incidence of diabetes (33%) than any other race (Spanakis & Golden, 2013). Sometimes, however, an individual's susceptibility to disease is not so obvious but may be discerned as a nurse takes a health history, including the health of any parents, grandparents, and siblings.
Age
Children and older adults are considered vulnerable populations. Both older adults and children often depend on others for nutrition, healthcare, transportation, and personal safety. Many older adults live on limited incomes. In 2014, there was a great disparity between men's and women's income for those over 65: the average income for a man was $31,169; for women it was $17,375 More than 4.5 million (10%) older adults live in poverty, while 2.5 million (5.3%) live close to the poverty line ( Ageism is defined as discrimination against older adults. U.S. culture places an emphasis on youth, beauty, and productivity, which minimizes respect and access to opportunities for older adults. The increasing use of the internet and technology as a primary means of sharing and retrieving information also has implications. More and more older adults are embracing technology and the internet, particularly in those with higher education and/or spouses However, those who have less education or do not have access to technology resources are left behind.
Social Differences
Communication Environmental Control Religious Variations Space Time Biological Variations Susceptibility to Disease Skin Color
Importance of cultural competence
Cultural, ethnic, racial, and other differences make nursing care both a privilege and a challenge. Same quality of care but not the same care. Care that encompasses their culture. Nurses who are able to develop cultural competence and practice evidence-based care that is relevant to all of their patients will gain confidence in their abilities and greater personal benefit from their work with individual patients. A culturally competent practice begins with gaining a greater understanding of the differing values and beliefs of others and recognizing how these differing values and beliefs affect patients in all aspects of providing care.
Space
Culture defines an individual's perception of personal space. Comfort may result from honoring the boundaries of personal space, whereas anxiety can result when these boundaries are not followed. Practices regarding proximity to others, body movements, and touch differ among groups. Variations of intimate zones and social public distance occur among cultural groups, and a healthcare provider needs to be aware that what he perceives as normal or appropriate may be produce anxiety for others
World view
Each culture has its own worldview or understanding of the world. refers to how the people in a culture perceive ideas and attitudes about the world, other people, and life in general. A culture's worldview supports its overall belief system, which is developed to explain the mysteries of the universe and of life that each society tries to understand: What is the meaning of life? How do individuals know their purpose in life? What is reality? How much can be known about values and beliefs? Is there a God or power beyond me? How was the universe created? What happens after death? How do we care for the sick?
US "melting pot"
Each family or group of immigrants brings its own culture, adding to what has been described as the "melting pot" that is the United States. The image of a melting pot implies the assimilation of multiple ethnic groups and their cultural practices into a single national identity with national allegiance and values. However, as these groups become established in the American culture, part or all of their ethnic identity remains. Instead of a melting pot, the United States should be considered a salad bowl of different flavors or a mosaic of the unique qualities of the cultural groups, coming together to make one America.
Sexism
Gender bias results in sexism and occurs when male values, beliefs, or activities are preferred over female. Sexism may be overt or covert. "Overt" means "done or shown openly" while "covert" means "not displayed or openly acknowledged."
Evaluation
Goals may include: The patient expresses that cultural needs were met. The patient is able to verbalize understanding of medical diagnosis and treatment plan. The patient is able to collaborate with the care team when using complementary therapies. The patient is able to meet nutritional needs. Evaluating how successfully the patient is able to follow the treatment regimen while observing cultural practices and rituals is essential to determining patient outcomes but also provides a way for nurses to evaluate whether or not they provided culturally competent care that promoted improved patient outcomes.
South American and Eastern Cultures
Health is a state of harmony that encompasses the mind, body, and spirit. Preference for respected healers from the culture of origin (e.g., herbalists, midwives, curanderos) Belief that food can restore imbalances Interdependence with family, community, and group acceptance are valued Emphasis on traditional methods of maintaining, protecting, and restoring health
North American and Western Cultures
Health is viewed by many as the absence of disease. Use of specialty practitioners (e.g., pediatricians, obstetricians) Recognition that food affects biophysical processes, functions Independence, individualism, freedom are valued Emphasis on use of modern (Western) healthcare practices to maintain or treat health issues
Skin Color
Historically, skin color has been associated with racial definitions. However, labeling of people based on their skin color should be avoided. Healthcare providers need to explore ethnic variations and not make assumptions based on skin color. As a nurse, when doing skin assessment, it is important to know that darker skin tones require closer inspection and enhanced lighting to observe changes (e.g., when assessing for changes in oxygenation). Skin color changes such as erythema and cyanosis are subtle, and palpation and lighting will need to be used for skin assessment. In addition, skin color does impact some prevalence statistics: African Americans and Native Americans have lower incidences of skin cancer due to higher levels of melanin.
How might a pediatric patient's development be impacted if his or her mother is homeless?
Homelessness and being raised in a culture of poverty can impact growth and development. Appropriate maturation depends in part on a sense of constancy, stability, and safety. When basic needs for food, shelter, and security are not met, the child cannot access the resources and energy necessary to gain mastery over developmental tasks.
Multiculturalism in US
Immigration Each year, approximately 1 million individuals obtain legal permanent resident status in the United States. The majority of those who immigrate are from Asian countries, primarily India Seek freedom from an oppressive government, religious freedom, and still others freedom from poverty, as refugees and claim family sponsorship. Nurses should take into consideration that some immigrants have fled such horrors as civil unrest, war, and oppression. Their psychologic scars may run deeper than the physical ones.
Disparities and Differences
In many ways the United States is a nation that celebrates culture and diversity. From Greek festivals to soul food to Tex-Mex, from gay pride parades to Chinese New Year, there is plenty of diverse heritage and society to celebrate. Unfortunately, these differences also give rise to disparities of opportunity, and these include disparities that relate to healthcare. Nurses should be alert to practices in their work environment that impact the quality of care offered to individuals of any ethnic group. Healthcare practices should be accessible and culturally relevant, and patient preferences should be at the core of decision making. Nurses should work collaboratively to ensure quality care and provision of best-practice methods to all patients. The recommendations for reducing these disparities in healthcare include increasing awareness of them among the public, healthcare providers, insurance companies, and policy makers. In addition, more diverse healthcare providers are needed in underserved communities, and more interpreters are needed in clinics and hospitals to improve the quality of care.
You are a nurse working in a children's rehabilitation center. A 6-year-old girl who is recovering from a motor vehicle accident comes to your center for an extended stay. She speaks a little English. Her family has recently moved here from China, and her parents likewise have limited English. Although they are grateful for the help they are receiving, they are very stressed about their daughter's situation. How might the nurse assess this family's values and beliefs in light of the family's inability to speak English?
It would be essential for the nurse to find a professional who is able to communicate with the patient and her family in their native language. The nurse may do so by finding a bilingual professional in the healthcare facility to interpret for the family or through electronic or telephone language banks.
LEARN Model
L: listen E: explain A: acknowledge R: recommend N: negotiate
LGBTQ individuals (lesbian, gay, bisexual, transgender, and queer/questioning)
LGBTQ individuals are at higher risk for such health problems as obesity, mental health issues, substance abuse, and violence Social determinants affecting the health of LGBTQ individuals largely relate to oppression and discrimination. Examples include: Legal discrimination in access to health insurance, employment, housing, marriage, adoption, and retirement benefits Lack of laws protecting against bullying in schools Lack of social programs targeted to and/or appropriate for LGBTQ youth, adults, and older adults Shortage of healthcare providers who are knowledgeable about and culturally competent in providing LGBTQ healthcare. Nurses must advocate for a physical environment that contributes to healthy LGBTQ individuals, including: Safe schools, neighborhoods, and housing Access to recreational facilities and activities Availability of safe meeting places Access to health services.
Standards of Competence
Maintaining cultural competence is an ongoing process. Nurses continually assess, modify, and evaluate the care provided to culturally diverse patients. In 2011, Douglas et al. addressed current standards for culturally competent nursing care. Their 12 standards are: Social justice Critical reflection Knowledge of cultures Culturally competent practice Cultural competence in healthcare systems and organizations Patient advocacy and empowerment Multicultural workforce Education and training in culturally competent care Cross-cultural communication Cross-cultural leadership Policy development Evidence-based practice and research.
Religious variations
Many religions are practiced, including Protestant Christianity, Catholicism, Judaism, Hinduism, Islam, and Buddhism. Religion refers to a set of doctrines accepted by a group of people who gather together regularly to worship that offer a means to relate to God or a higher power, nature, and their spiritual being. Religion plays a greater role in some communities than in others. One town may sponsor a living nativity at Christmas, whereas the next may ban religious observances on government property altogether. See the module on Spirituality for more information.
Sexuality
RELATIONSHIP TO CULTURE AND DIVERSITY Sexual orientation, homophobia, heterosexism. NURSING IMPLICATIONS assist in advocating for LGBTQ healthcare needs and access. Recognize same-sex partners as family and patient support.
Integrative Health Approaches
Natural products. Dietary supplements, including fish oil and herbal supplements such as turmeric Mind and body practices. Meditation, yoga, acupuncture, chiropractic medicine, massage therapy
Is the use of the son for interpretation valid for a legal consent for treatment?
No, the son should not be used to interpret for legal consent for several reasons: Family members have personal and emotional attachments to loved ones and may not want to upset their loved one by conveying bad or disturbing news. Therefore, a family interpreter may add his own opinion or withhold key parts of the intended message. Interpretation is a very complex task, and professional interpreters are fluent in all of the legal, medical, or technical terminology that they may need to interpret. They are also aware of the professional and ethical responsibilities of trained interpreters to deliver unbiased translations. Finally, inaccurate interpretations may have serious health consequences if the information has not been delivered accurately through an impartial professional interpreter.
Biological Variations
People differ genetically and physiologically. These biological variations among individuals, families, and groups produce differences in susceptibility and response to various diseases among people of different cultures and all walks of life (Figure 24-5). The field of ethnopharmacology addresses variations in pharmacodynamics and pharmacokinetics among cultural groups. Nurses are responsible for monitoring patients' responses to the drugs they give and thus must be aware of these differences. In addition, some enzyme deficiencies occur more commonly in some cultural groups. For example, lactose deficiency (the inability to absorb milk by-products) or other malabsorption disorders are seen with increased incidence in Asian and African cultural groups.
Social Differences
People learn the social behaviors practiced in their cultures and communities. These behaviors differ from culture to culture, from community to community. They may also be practiced by members of subcultures who decide to maintain traditional cultural practices, whereas others from the same culture living nearby may choose to adapt to the dominant culture The terms subculture and minority are sometimes used to label groups characterized by specific norms, beliefs, and values that coexist or even oppose those of the dominant culture. Some common social behavioral variations among people of different cultures involve communication, environmental control, hygiene, space, time, and social organization. These ethnic differences exist within smaller cultural groups within a larger society. Within the United States, social differences are evolving as individuals from different cultural groups relocate for college or work and interact with people from other cultures, and as the numbers of individuals of different cultural groups change over time. For instance, there has been a silent move of Native Americans from the reservations to the cities. This migration is partially due to violence on the reservations, poverty, and other socioeconomic factors
Nursing Diagnoses
Powerlessness Spiritual Distress Religiosity, Risk for Impaired Fear Decisional Conflict Resilience, Risk for Impaired Anxiety Health Maintenance, Ineffective Coping, Ineffective Social Interaction, Impaired. (NANDA-I © 2014) Disturbed Thought Processes
Nurses' Self-Awareness and Cultural Humility
Professional nurses must possess self-awareness. Self-awareness is critical to developing sensitivity to differences while supporting a sense of cultural humility rather than superiority over others. Cultural humility is the "ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]" As a nursing student, you may find your personal values to be in conflict with professional values. For example, you may find yourself uncomfortable with a certain ethnic group or religious faith. Yet a nurse, or any healthcare provider, cannot refuse to care for a person on the basis of cultural identity. Instead, your profession calls you to practice cultural humility, realizing that the person needs care, not judgment.
Purnell's Model of Cultural Competence
Purnell's (2014) model of cultural competence identifies how individuals, families, communities, and the global society all possess 12 domains of culture: Overview, inhabited localities, and topography Communication Family roles and organization Workforce issues Biocultural ecology High-risk behaviors Nutrition Pregnancy and childbearing practices Death rituals Spirituality Healthcare practices Healthcare practitioners.
Healthcare Systems
RELATIONSHIP TO CULTURE AND DIVERSITY Availability of healthcare services for vulnerable populations may be low. Availability of resources varies by community. NURSING IMPLICATIONS Unequal distribution of facilities and resources. Recognize cultural and group differences among healthcare providers. Seek to advocate for vulnerable populations. Refer patients in need of additional resources to social services and nonprofit service agencies.
Communication
RELATIONSHIP TO CULTURE AND DIVERSITY Listening, clarification, reflection, and all therapeutic communication techniques are important when communicating with people different from you. NURSING IMPLICATIONS Use therapeutic communication skills. Identify translation and interpreter resources in your organization. Use language that the patient understands.
Professional Behaviors
RELATIONSHIP TO CULTURE AND DIVERSITY Recognize personal values and professional values. NURSING IMPLICATIONS Self-awareness of cultural competence.
Spirituality
RELATIONSHIP TO CULTURE AND DIVERSITY Recognize religious beliefs related to dietary regimen or times of fasting. NURSING IMPLICATIONS Show respect for religious differences, leaders, and practice. Recognize that your personal spiritual and religious beliefs will not be universally shared with your patients. Be nonjudgmental of differences. Support patient religious practices.
Comfort
RELATIONSHIP TO CULTURE AND DIVERSITY The verbalization of pain and preferred comfort measures may differ based on cultural expressions, gender norms, or other factors. NURSING IMPLICATIONS Patients' reaction to pain may range from stoicism to hysterics. Nurses must assess and accept a variety of patient responses to pain and provide myriad interventions that include opioids, nonopioids, adjunct therapy, and complementary and alternative methods for reducing pain and increasing comfort.
Class
Socioeconomic variations contribute to a society stratification based on money and access to resources.
Learning Cultural Confidence
Students begin by developing cultural awareness of how culture shapes beliefs, values, and norms. Students develop cultural knowledge about the differences, similarities, and inequalities in experience and practice among various societies. Students develop cultural understanding of problems and issues facing societies and cultures when values, beliefs, and behaviors are compromised by another culture. Students develop cultural sensitivity to the cultural beliefs, values, and behaviors of their patients. This reflects an awareness of their own cultural beliefs, values, and behaviors that may influence their nursing practice. Students and nurses develop cultural competence and provide care that respects the cultural values, beliefs, and behaviors of their patients. Nurses practice lifelong learning through ongoing education and exposure to cultural groups.
LEARN Model
The LEARN model can be used as a tool for developing cultural competency. Below is a modification of the LEARN model that can help nurses include cultural behaviors in a patient's healthcare: Listen to the patient's perception of the problem. Explain your perception of the problem and of the treatments ordered by the physician. Acknowledge and discuss the differences and similarities between these two perceptions. Review the ordered treatments while remembering the patient's cultural parameters. Negotiate agreement. Assist the patient in understanding the medical treatments ordered by the physician, and have the patient help to make decisions about those treatments as appropriate (e.g., choosing cultural foods that are permitted on an ordered diet).
How might an adolescent's development be impacted by the realization that he or she is homosexual?
The adolescent could potentially experience impacted development in the form of facing cultural stigma against homosexuality.
Race
The concept of race is complex. Historically, race has often been defined by physical attributes linked to continents of origin: Asia, Europe, Africa, and the Americas. Variations of skin color and hair texture have traditionally been used as markers of race. The dialogue about race and genetics is ongoing The oppression of a group of people based on perceived race is known as racism. Although racism is often perceived as overt acts of hostility, racism can also be insidious policies, procedures, traditions, and rules that benefit one group of people over another. For example, not providing translation services or not offering expensive diagnostic or treatment modalities based on race contributes to unequal treatment and injustice.
Time
The concepts of time, duration of time, and points in time vary among cultures. Past-oriented cultures, for example, value tradition. Individuals from cultures that closely follow tradition may not be receptive to new procedures or treatments. Present-oriented cultures focus on the here and now, and individuals from these cultures may not be receptive to preventive healthcare measures. Some cultural groups have no understanding of linear time, and individuals from these cultures may miss appointments or be late (Spector, 2017). Healthcare providers are very regulated by clock hours influencing wake, sleep, work, and mealtimes. Not all cultural groups are regulated by clock hours.
Gender Roles
The genders also differ in access to and control over resources and decision-making power in the family and community. The extent of these differences is often cultural. Gender roles, often in interaction with socioeconomic circumstances, influence exposure to health risks, access to health information and services, health outcomes, and the social and economic consequences of ill health. Nurses must recognize the root causes of gender inequities when designing a nursing plan of care. To obtain positive outcomes, health promotion and disease prevention and treatment need to address gender differences. For example, millions of women are injured as the result of spousal or significant other abuse, but the magnitude and health consequences of interpersonal violence against women have often been neglected in both research and policy. Generally, there seems to be an assumption that interventions will be just as effective for men as for women. Many health promotion programs may be gender-blind and based on research that neither accounted for nor controlled for the gender of the study participants. Only in the mid-1990s did pharmaceutical companies begin to look at pharmacokinetic differences between males and females. Understanding the differences in responses between genders has led to research on how drugs affect women as well as those from different races and cultural backgrounds. Biological differences such as genetics, hormones, and metabolic influences combine to play a part in shaping different symptoms as well as morbidity and mortality rates By improving their understanding of how gender differences impact patient health, nurses can develop a plan of care that meets the specific and unique healthcare needs of each patient. It is important that nurses not allow their own gender bias or preconceived beliefs to affect their ability to assess and plan appropriate care for the individual patient. Health-promoting interventions aimed at inclusion in a safe and supportive environment promote a trusting nurse-patient relationship. Nurses should promote an environment in which patients can access essential services that address the differences between men and women in an equitable manner. When planning care, nurses who take into consideration the biological differences and social vulnerability of men and women are more likely to see positive outcomes for their patients.
Cultural differences can present barriers to necessary care.
The importance, or lack of importance, of family members' involvement in managing illness and disease Lack of trust in the healthcare system and providers The belief that illnesses are not linked to scientific pathophysiology Refusal of modern healthcare providers to believe the mind-body connection Fear or denial of death or life after death Cultural assumptions about disease and illness that may influence the presentation of symptoms or the response to treatments. ***Many cultures will not continue treatments and medications once they feel well. This is particularly true when discussing terminal illness and dying. Although cultural beliefs and behaviors change over the years as a cultural group adapts to new ideas and conditions, some individuals may retain traditional behaviors and thinking and continue to follow the beliefs and practices as always. Tension can arise when different health belief systems conflict with each other. The result may be anxiety, anger, or fear. The healthcare provider may reduce a patient's discomfort and promote trust by showing a nonjudgmental attitude of respect. A nurse must also recognize the common defense mechanisms such as anger, avoidance, denial, intellectualization, or projection that may be used when an individual feels threatened. Professional nurses work with and care for people who have differing values and beliefs. It is important for nurses to understand how their own cultural beliefs and practices inform who they are as nurses, in part to strengthen their own value systems but also to ensure they are sufficiently self-aware to keep from projecting their own beliefs and values onto their patients.
How can the nurse respect Mr. Avromovitch's diversity requirements while maintaining facility policy and meeting the patient's healthcare needs?
The nurse can advocate for Mr. Avromovitch's right to exercise full participation in his healthcare and to make choices that are consistent with his beliefs. The nurse can ensure that all persons caring for Mr. Avromovitch are aware of his modesty needs—that, if available, male healthcare workers are assigned to him, and that extra care is taken to drape and cover him or carry out as many self-care activities privately as he desires. The nurse can also elicit other needs and preferences related to care and ensure that these are incorporated into the plan of care.
The patient's family wishes to pray at the child's bedside using candles, which are not allowed because of the risk for fire related to oxygen use. How can you advocate for this family while maintaining safety?
The nurse could attempt to provide the family with battery-operated candles or lights that simulate candles.
Nursing Process - culture and diversity
The nursing process is interwoven in providing culturally competent care. In each step, the nurse should be considerate of the patient's cultural background and practices. This holistic approach will help both the patient and the nurse create a therapeutic plan of care.
Planning
The patient will remain safe through the use of interpreters, educational materials written in the patient's primary language, and other cultural bridges of communication between the healthcare team and the patient. The patient will meet nutritional needs during hospitalization through meal accommodation, nutritional counseling, and incorporation of preferred foods in the meal plan. The patient will perform ADLs and increase mobility when appropriate. Both patient and family members will verbalize understanding of necessity of early mobility and independence with ADLs.
What nursing diagnoses and interventions would be appropriate for Mr. Avromovitch's plan of care?
The plan of care will need to address Mr. Avromovitch's anxiety related to perceived threats to his value/belief systems: Reassure the patient that his values and beliefs will be integrated into his care. Have the patient list needs and preferences and discuss ways that healthcare members can accommodate those needs. Mr. Avromovitch may be experiencing feelings of powerlessness related to being in an unfamiliar setting and not being in control of his health at this time. Acknowledge the patient's concerns about losing control. Encourage the patient's participation in treatment decisions. Allow the patient to carry out activities independently as much as possible. Facilitate access to rituals and routines that are consistent with the patient's spiritual needs and values and beliefs.
Assessment
The provision of culturally competent care begins with incorporating culture into the initial nursing assessment. Areas for assessment include the use of traditional healing practices such as herbal supplements or mind-body practices (e.g., cupping, acupuncture); cultural practices related to food preparation and preferences; religious or cultural practices at specific times of day or during the week; health beliefs; and preferences for care, such as whether or not women prefer to be examined by a female nurse. Nursing assessment of the patient's values and beliefs includes assessing for the use of complementary and alternative therapies.
How might involvement of an interpreter to facilitate communication impact the patient and her family's values and beliefs? How can you overcome this problem?
There are several potential problems with using interpreters. Some, but not all, interpreters have cross-cultural knowledge and can interpret both words and the meanings behind them. Meanings and context can be lost in interpretation. Interpreters must be careful to interpret only what each party is trying to convey and to avoid introducing personal biases. The age or sex of the interpreter may be an issue. The addition of an interpreter can interfere with building rapport. Some of these issues can be addressed by ensuring that only professional interpreters are used, establishing clear role expectations, and speaking directly to the patient and family rather than to the interpreter.
Undocumented Immigrants
Undocumented immigrants often do not seek healthcare until their condition becomes critical. This behavior results from a complex combination of factors. Many are uninsured, do not speak English, and have not yet learned the culture of their new homeland. Many believe that accessing healthcare will result in legal consequences, up to and including deportation. For some, the differences between the U.S. healthcare system and the medical practices and beliefs of their culture of origin create an additional barrier. These factors combine to create fear in the undocumented immigrant patient who needs medical attention Special healthcare concerns related to this population include lack of preventive care inadequate immunization status lack of past medical records. Because they enter the country without border screening, risks of diseases such as tuberculosis and HIV are much higher. Many feel more comfortable seeking help from traditional healers. Others receive their health information from television, the internet, community members, or family members, which can lead to misinformation and improper treatment. States and regional politics vary across the country with regard to whether or not government or healthcare facilities are required to ask for proof of citizenship when providing care. Further, some states require reporting undocumented people, which also impedes those people's willingness to seek care. The nurse needs to be familiar with the laws within the state of nursing practice. When providing care to patients who may be or are known to be undocumented immigrants, the nurse has the ethical and moral imperative to deliver the same high-quality care delivered to any patient. Use of an interpreter or interpreter system will improve the quality of communication if the patient does not speak English or does not speak English well enough to understand the information presented. Thorough screening, nursing history, and assessment contribute to determining both current condition as well as risks, preventive care needs, and understanding of self-care upon discharge. Because access to healthcare for this population is unpredictable, nurses should maximize each opportunity to care for and teach self-care to these patients.
Pt. speak other languages
What language do you speak? Do you speak any English? How long have you lived here? Describe the illness or problem that brings you here today. What do you think caused your problem? When did it start? Why do you think it started when it did? What does your sickness do to you? How severe is your sickness? What do you fear about your sickness? What helps make it better? Worse? What kind of treatment do you think you need? Are there any religious practices we need to know about? Who is your family? Who makes decisions most of the time? Who can you go to for help when you need it?
Guidelines for using an interpreter include the following:
When possible, use an interpreter to translate and provide meaning behind the words. To protect patient confidentiality and to guard against the possibility of the interpreter misunderstanding medical information, avoid using a family member as an interpreter. If possible, use an interpreter of the same gender as the patient. Address your questions to the patient, not the interpreter, but maintain eye contact with both the patient and the interpreter. Avoid using metaphors, medical jargon, similes, and idiomatic phrases. Observe the patient's nonverbal communication. Plan what to say, and avoid rephrasing or hesitating. Use short questions and comments. Ask one question at a time. Speak slowly and distinctly, but not loudly. Provide written materials in the patient's language as available.
US Races
White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander
Subculture
a group of people within a culture whose practices or beliefs are distinct or separate from the dominant or parent culture. More broadly - religious sects, ethnic groups, and even devotees of some genres of music or philosophy.
Minority
an individual or group of individuals who are outside the dominant group. Although demographics can vary from one area to another, in the United States, African Americans, Hispanics, and Native Americans are among those generally considered minority groups.
Health Disparity
as "a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.
Cultural Values
describe preferred ways of behaving or thinking that are sustained over time and used to govern or guide a cultural group's actions and decisions. When people live together in a society, cultural values often determine the rules people live by each and every day. These rules may be variously stated, but they basically address similar values.
Cultural practices
have meanings that give the group its worldview and that reflects the social organization of the culture as a whole.
Cultural Competence
having an awareness and acceptance of cultures and the ability to interact effectively with people of diverse cultures
Biases related to sexual orientation
homophobia (fear, hatred, or mistrust of gays and lesbians often expressed in overt displays of discrimination) heterosexism (view of heterosexuality as the only correct sexual orientation)
Cultural characteristics
include observable behaviors as well as the unseen values that influence those behaviors. History of origin Holiday customs Styles of dress General worldview Religious beliefs and practices Birth and death rituals and practices Food preferences and eating patterns Values Roles and patterns of relationships Leadership structure Health and illness beliefs and behaviors Social systems Concept of time Concept of personal space Gestures and facial expressions Concept of self Common language
Cultural Humility
incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-clinician dynamic and to developing mutually beneficial and advocacy partnerships with communities on behalf of individuals and defined populations is the "ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]"
cultural belief system
influences an individual's decisions and actions in society regarding everything from preparing food and caring for the sick to rituals of death and burial. Scientific and medical advancements may or may not impact a culture's belief systems. Belief systems differ in every culture. The beliefs of a society are passed from generation to generation by word of mouth and by rituals, such as reading certain stories or books on holidays cultural practices are rooted in the individual's religious faith or practices Children learn the belief system of their culture from parents and other family members who teach them any number of values and beliefs, including those about "right or wrong." Differing opinions may originate from religious beliefs or social conditions. People make decisions about "right or wrong," and as things change, people adapt and the culture evolves. are based on people's experiences and exposures to differences found in our world. As people's knowledge and understanding grow, their belief systems expand. Knowing why we believe what we believe builds self-awareness and understanding of differences in our own beliefs compared with the beliefs of others. Culturally based beliefs and traditions can affect the course and outcome of disease and illness. Healthcare providers and patients bring their respective cultural backgrounds and expectations to each interaction. These differences can impact both the expectations and practices of the patient and the provision of services by nurses and other healthcare professionals.
Sexual Orientation
is a continuum ranging from those who have a strong preference for a partner of the same sex to those who strongly prefer someone of the opposite sex. Homosexual individuals prefer a partner of the same sex, with the term lesbian used to describe women who prefer to develop intimate relationships with other women. The term gay may refer to homosexual women or men, but is more commonly used to describe men who are homosexual. Heterosexual individuals prefer to develop an intimate relationship with a partner of the opposite sex. Bisexual individuals are physically attracted to both males and females.
Alternative Therapies
is a term used to describe use of these diverse therapies instead of conventional therapies
Ageism
is defined as discrimination against older adults. U.S. culture places an emphasis on youth, beauty, and productivity, which minimizes respect and access to opportunities for older adults.
Cultural Competence
is the ability to apply the knowledge and skills needed to provide high-quality, evidence-based care to patients of diverse backgrounds and beliefs to overcome barriers and access resources promoting health and wellness.
Asssimilation
is the process of adapting to and integrating characteristics of the dominant culture as one's own. People typically benefit by exchanging ideas, natural resources, and goods.
Acculturation
is the process of not only adapting to another culture but also accepting the majority group's culture as one's own. Because culture is complex, members of a cultural group may engage in many behaviors and habits unconsciously, making them difficult to explain to others. Sometimes assimilation and acculturation are implicit and covert, whereas other times assimilation can be overt and coercive.
Ethnic Groups
large groups of people who have common characteristics, including nationality, language, values, and customs, and they share a cultural heritage. Examples of ethnic groups are the large Cuban American population living in and around Miami, Florida; the Lakota Sioux, one of three major ethnic groups that make up the Great Sioux Nation; and the Hmong populations living in western North Carolina and in the Minneapolis-Saint Paul area in Minnesota.
Multiculturalism
many cultures and subcultures coexisting within a given society in which no one culture dominates. In a multicultural society, human differences are accepted and respected. Classrooms in an academic setting may be considered multicultural when all students are socialized to succeed and all learning styles are valued and understood.
Dominant Group
may be one that is dominant by reason of its numbers or as a result of having influence, power, money, and position to remain dominant while reinforcing rules and norms that benefit its own interests
Enculturation
or cultural transmission, is exemplified by a process children use to learn cultural characteristics from adults. These characteristics are often normalized, meaning that certain characteristics are used to define acceptable rules and procedures of behaviors. People biologically inherit physical traits and behavioral instincts, but they socially inherit cultural characteristics. An individual learns culture from other people in a society. Enculturation occurs in families until the children are ready to leave and establish their own values, beliefs, and practices through exposure to other cultural or societal practices through work, marriage, or higher education. Enculturation may continue among family members who live close to each other, celebrate religious holidays together, or otherwise work to maintain the culture within their family and limit their exposure to cultural differences. The great variety of cultural characteristics provides a broader perspective of cultural differences and respect.
Oppression
or the systematic limitation of access to resources, may be covert or subtle and typically is linked to laws, education, or even healthcare norms and regional access to services and transportation.
Stereotyping
overgeneralization of group characteristics that reinforces societal biases and distorts individual characteristics Even within genders, individual diversity is expected; for example, some women may be highly coordinated, mathematically skilled, and uninterested in the arts. No conclusion about an individual can ever be drawn based on a simple term such as woman or man.
Disability Status
place in continuum of disability, such as acuteness of injury, chronicity of disability, or terminal nature of illness Many patients have physical or cognitive disabilities. Terms - mental deficiency, mental retardation, mental handicap, developmental disability, and learning disability are examples. Patients with an intellectual disability and their families experience poorer healthcare compared with the general population. Living with an intellectual disability is often challenged by coexisting complex and chronic conditions and can lead to economic hardship and family conflict. Both intellectual and physical disability can impair the individual patient's ability to participate in health promotion and to provide self-care. The American Association of People with Disabilities (2016) is the nation's largest cross-disability rights organization. It is an important advocacy, resource, and referral organization for individuals with disabilities and their families, friends, and advocates. Nurses working with patients with disabilities must develop trusting relationships so they can successfully assist patients with disabilities and their families and caregivers and enable them to find resources.
Prejudices
prejudgments about cultural groups or vulnerable populations that are unfavorable or false because they have been formed without the background knowledge and context on which to base an accurate opinion.
Social Justice
recognizes that in society, not all groups are treated equally. Nursing has a long history and current mission to promote social justice by promoting a balance among groups in the sharing of resources, rights, and responsibilities Using a lens of social justice enables individuals and organizations to follow a code of ethics that promotes equitable distribution of resources and seeks equitable rights for all individuals, thus providing advocacy for people who lack access to resources.
Complementary Therapies
refers to any of a diverse array of practices, therapies, and supplements that are not considered part of conventional or traditional medicine and that are used in addition to conventional treatments.
Vulnerable Populations
refers to groups of people in our culture who are at greater risk for diseases and reduced lifespan due to lack resources and exposure to more risk factors. Poverty is a major culprit in vulnerable populations (World Health Organization, 2016). Persons in poverty are at risk for malnutrition, poor housing, violence, and limited or no access to healthcare. Other conditions associated with vulnerability include age, disability, health/disease state, education status, language spoken, and socioeconomic situation. All vulnerable populations are less able than others to safeguard their needs and interests adequately. The most vulnerable are those households with the fewest choices and the greatest number of disabling factors. Patients from vulnerable populations are more likely to develop health problems because they have the greatest number of risk factors and the fewest options for managing those risks. limited access to healthcare and are more dependent on others for helping them meet their healthcare needs. Those from vulnerable populations are likely to be older, living in poverty, homeless, in abusive relationships, mentally ill, chronically ill, or children. It is not uncommon for vulnerable individuals to belong to more than one of these groups. They face multiple challenges, statistically poorer outcomes and shorter lifespans, and higher mortality and morbidity rates due to cumulative or combinations of risk factors. They may be from any culture, ethnicity, age, or gender, although they are more likely to be women than men. Nurses face many challenges when caring for individuals who are vulnerable. Their physical, social, and emotional needs are complex, and many have multiple chronic conditions that can complicate care still further. Assessing the patient from a vulnerable population requires the nurse to investigate all systems, determine stressors and coping mechanisms, and help the patient identify potential resources. The welfare of vulnerable populations depends on the nation's willingness to provide the necessary programs to promote health and well-being. Other issues impacting the provision of healthcare to vulnerable populations include accessibility and transportation. Impoverished children living in very rural communities, for example, may not have access to fluoridated water and may be an hour from the nearest dentist who accepts Medicaid. A primary focus of healthcare, as outlined by Healthy People 2020, is to reduce the disparity of access to healthcare among groups. Healthy People 2020 defines a health disparity as "a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. 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"
Transgender
refers to individuals who do not identify with the gender assigned to their body. Genderqueer or gender nonconforming are terms adapted by those who don't identify with either male or female; rather, they identify as both an individual who identifies as transgender may have typical female anatomy but feel like a male and seek to become male by presenting as male and taking hormones or electing to have gender reassignment surgeries. A genderqueer person might have feelings of being both male and female
Culture
refers to the patterns of behavior and thinking that people living in social groups learn, develop, and share
Institutional Bias
related to gender results in sexist practices within an organization. Nurses need an awareness of cultural variations of gender, as they will be caring for diverse patient needs. What might be considered sexism by one culture may not be in another. The wearing of a hijab, or head scarf, is an example. In some regions of the world, women are required by Islamic tradition to cover; however, in other areas of the world women have a choice to cover their heads. Some Muslim women find wearing the hijab empowering. Because their bodies are covered, they cannot be sexualized. Because many women view wearing a hijab as an expression of faith, doing so should not necessarily be seen as a sign of sexism. Another example of perceived sexism is that of the Hmong culture. In this culture, women typically do not make healthcare decisions, even regarding their own bodies. Typically, the woman's husband or father makes the decision, but sometimes, an elder man makes the healthcare decision for the woman. A woman could have an abscessed tooth, but the elder, not the patient, would determine if the tooth should be extracted because having males make medical decisions is preferred by many in this culture.
Classism
s the oppression of groups of people based on their socioeconomic status. The lack of access to resources is apparent in some of the people at the lowest economic level such as the homeless, those living in poverty, or undocumented immigrants.
Cultural competent nurses
should respect and advocate for human dignity. Stereotyping, prejudice, and discrimination can threaten the delivery of healthcare services and adversely affect patient outcomes. Nurses need to understand and recognize these attitudes in themselves and others in order to reduce their effects on the patients they serve. To overcome barriers to multiculturalism, nurses must have a deep understanding of vulnerable patients who are impacted by racism, sexism, classism, and heterosexism.
Discrimination
the restriction of justice, rights, and privileges of individuals or minority groups, may occur when dominant groups reinforce their rules and regulations in a way that limits opportunities for others.
process of acculturation
they may choose to discard some practices from their culture of origin in exchange for practices of the dominant culture. Therefore, nurses need to ask appropriate questions to assess individual cultural practices rather than make assumptions. For example, some patients of Chinese background may be practicing Buddhists who prefer traditional Chinese practices such as herbs and acupuncture; others may belong to a different faith and completely embrace Western medicine; while still others may blend practices in ways that make sense to them. Careful assessment of the individual patient is necessary to avoid making assumptions and stereotyping.
Todays nurse
work with diverse populations of patients w/ varying socioeconomic, cultural, and spiritual backgrounds and patients, values and belief systems. To provide culturally aware nursing, nurses must examine their own cultural values and beliefs.
