Cultural concerns in nursing

CULTURAL CONCERNS IN NURSING

Presented by:Jade Kaniowski, Lacey Kelley, Heather Kyle, Laura Lindsey, Kimberly Peters

Cultural Concerns in Nursing

Being aware of or inquiring about a person's cultural or religious beliefs with respect to medical care can help nurses avoid causing cultural pain to patients. These concerns must be a priority when caring for patients and must be respected in order to gain a patient’s trust and to be able to holistically care for them. Caring for patients not only focuses on the physical aspect of health, but must also include the mind and spirit as well.

Culture

Shared system of beliefs, values, and behavioral expectations that provide social structure for daily living.

Cultural Diversity

It is the cultural variety and differences that exist in the world, a society or an institution. It is having a group of diverse people in one place. People working or living together that have different cultures.

Cultural Sensitivity Being aware that cultural differences and similarities exist and that they can have an effect of behavior, values and learning. It also means to be aware and tolerant of these differences and acknowledging them when interacting with others.

Stereotyping

Categorizing individuals or groups of people into an oversimplified or standardized image or idea. It’s when you assume that a belief or characteristic is shared by all in one class, culture or ethic group.

Cultural bias To give an advantage to one cultural over another. To ignore the differences between cultures and impose understanding based on the study of one culture to other cultures. To think one culture has precedence of the other.

Cultural Influences on Healthcare

• Physiologic Characteristics• Psychological Characteristics• Reactions to Pain• Gender roles• Language and communication• Orientation to space and time• Food and nutrition• Socioeconomic Factors

Physiologic Characteristics

Certain racial groups are more prone to specific diseases and conditions.

Examples include:• Keloids• Lactase deficiency and lactose intolerance• Sickle cell anemia

Psychological Characteristics

In most situations, a person interprets the behaviors of another person in terms of her or his own familiar culture.

Reactions to PainHealthcare researchers have discovered that many of the expressions and behaviors exhibited by people in pain are culturally prescribed. Nursing care for patients in pain should be individualized, but important culture-sensitive considerations include the following:

• Recognize that culture is an important component of individuality and that each person holds various beliefs about pain

• Respect the patient’s right to respond to pain in whatever manner is culturally and individually appropriate

• Never stereotype a patient’s perceptions or responses to pain based on the persons culture

Gender roles

In many cultures either the man or woman is the dominant figure and generally makes decisions for the family.

Knowing who is the dominant member of the family is an important consideration when planning nursing care.

Language and communication

• To avoid misinterpretation of questions and answers, it is important to use an interpreter who understands the healthcare system.

• When caring for culturally and ethnically diverse patients it is important to perform a transcultural assessment of communication.

Orientation to space and time

• Personal space is the area around a person regarded as part of the person. This area, individualized to each person and to different cultures and ethnic groups, is the area others should not intrude during personal interactions.

• Different cultures vary in being future, present, or past oriented.

Food and nutrition

Food preferences and how foods are prepared are often related to culture. Patients in a hospital or long term care often do not have a choice in foods. This can be a cause for weight and health changes in a patient.

Socioeconomic Factors

Research suggests that both physical and mental health are associated with Socioeconomic status(SES). In particular, studies suggest that lower SES is linked to poorer health outcomes. Poor health may in turn decrease an individual’s capacity to work, thus reducing their ability to improve their SES.

CULTURALLY COMPETENT NURSING CARE

Providing culturally competent care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from a diverse populations within society.

• Cultural assessment• Guidelines for care

Cultural assessment

When caring for patients from a different culture, it is important to find out how they want to be treated based on their cultural values and beliefs. An effective way to identify specific factors that influence a patient’s behavior is to perform a cultural assessment.

Guidelines for Care

Cultural competency is a process and takes time. It involves developing awareness, acquiring knowledge, and practicing skills. As defined by Campinha-Bacote (2003), the nurses should answer the following questions when caring for culturally diverse patients:

• Am I aware of my personal biases and prejudices toward cultural groups different from mine?

• Do I have the skill to conduct a cultural assessment in a sensitive manner?

• Do I have knowledge of the patient’s worldview?• How many encounters have I had with patients from diverse cultural

backgrounds?• What is my genuine desire to be culturally competent?

Assessment Tool

Andrews/Boyle Transcultural Nursing Assessment Guide

This is an example of an assessment guide that is intended to help the learner as he or she strives toward cultural competency.


Cultural Affiliations

With what cultural group(s) does the client report affiliations (e.g., American, Hispanic, Navajo, or combination)? To what degree does the client identify with the cultural group (e.g., “we” concept of solidarity or as a fringe member)?Where was the client born?Where has the client lived (country, city) and when (during what years)? Note: If a recent relocation to the United States, knowledge of prevalent diseases in country of origin may be helpful. Current residence? Occupation?


Values Orientation

What are the client’s attitudes, values, and beliefs about developmental life events such as birth and death, health, illness, and healthcare providers?

Does culture affect the manner in which the client relates to body image change resulting from illness or surgery (e.g., importance of appearance, beauty, strength, and roles in cultural group)?

Is there a cultural stigma associated with the client’s illness (i.e., how is the illness or client condition viewed by the larger culture)?

How does the client view work, leisure, education?

How does the client perceive change?

How does the client perceive changes in lifestyle relating to current illness or surgery?

How does the client value privacy, courtesy, touch and relationships with individuals of different ages, social class (or caste), and gender?

How does the client view biomedical/scientific health care (e.g., suspiciously, fearfully, acceptingly)? How does the client relate to persons outside of his or her cultural group (e.g., withdrawal, verbally or nonverbally expressive, negatively or positively)?


Cultural Sanctions and Restrictions

How does the client’s cultural group regard expression of emotion and feelings, spirituality, and religious beliefs? How are dying, death, and grieving expressed in a culturally appropriate manner?How is modesty expressed by men and women? Are there culturally defined expectations about male-female relationships, including the nurse-client relationship?Does the client have any restrictions related to sexuality, exposure of body parts, certain types of surgery (e.g., amputation, vasectomy, hysterectomy)?Are there any restrictions against discussion of dead relatives or fears related to the unknown?


CommunicationWhat language does the client speak at home? What other languages does the client speak or read? In what language would the client prefer to communicate with you?

What is the fluency level of the client in English—both written and spoken use of the language? Remember that the stress of illness may cause clients to use a more familiar language and to temporarily forget some English.Does the client need an interpreter? If so, is there a relative or friend whom the client would like to interpret? Is there anyone whom the client would prefer did not serve as an interpreter (e.g., member of the opposite sex, a person younger/older than the client, member of a rival tribe or nation)?

What are the rules (linguistics) and modes (style) of communication? How does the client prefer to be addressed?Is it necessary to vary the technique of communication during the interview and examination to accommodate the client’s cultural background (e.g., tempo of conversation, eye contact, sensitivity to topical taboos, norms of confidentiality, and style of explanation)?How does the client’s nonverbal communication compare with that of individuals from other cultural backgrounds? How does it affect the client’s relationship with you and with other members of the healthcare team?How does the client feel about healthcare providers who are not of the same cultural background (e.g., black, middle-class nurse and Hispanic of a different social class)? Does the client prefer to receive care from a nurse of the same cultural background, gender, and/or age?What are the overall cultural characteristics of the client’s language and communication processes?Health-Related Beliefs


Health-Related Beliefs and Practices

To what cause(s) does the client attribute illness and disease (e.g., divine wrath, imbalance in hot/cold or yin/yang, punishment for moral transgressions, hex, soul loss, pathogenic organism)?

What are the client’s cultural beliefs about ideal body size and shape? What is the client’s self-image vis-à-vis the ideal?What name does the client give to his or her health-related condition?What does the client believe promotes health (eating certain foods, wearing amulets to bring good luck, sleep, rest, good nutrition, reducing stress, exercise, prayer, rituals to ancestors, saints, or intermediate deities)?

What is the client’s religious affiliation (e.g., Judaism, Islam, Pentecostalism, West African voodooism, Seventh-Day Adventism, Catholicism, Mormonism)? How actively involved in the practice of this religion is the client?

Does the client rely on cultural healers (e.g., curandero, shaman, spiritualist, priest, minister, monk)? Who determines when the client is sick and when he or she is healthy? Who influences the choice/type of healer and treatment that should be sought?In what types of cultural healing practices does the client engage (use of herbal remedies, potions, massage, wearing of talismans, copper bracelets or charms to discourage evil spirits, healing rituals, incantations, prayers)?

How are biomedical/scientific healthcare providers perceived? How does the client and his or her family perceive nurses? What are the expectations of nurses and nursing care?

What comprises appropriate “sick role” behavior? Who determines what symptoms constitute disease/illness? Who decides when the client is no longer sick? Who cares for the client at home?

How does the client’s cultural group view mental disorders? Are there differences in acceptable behaviors for physical versus psychological illnesses?


NutritionWhat nutritional factors are influenced by the client’s cultural background? What is the meaning of food and eating to the client?With whom does the client usually eat? What types of food are eaten? What is the timing and sequencing of meals?What does the client define as food? What does the client believe comprises a “healthy” versus an “unhealthy” diet?Who shops for food? Where are groceries purchased (e.g., special markets or ethnic grocery stores)? Who prepares the client’s meals?How are foods prepared at home (types of food preparation, cooking oil(s) used, length of time foods are cooked, especially vegetables, amount and type of seasoning added to various foods during preparation)?Has the client chosen a particular nutritional practice such as vegetarianism or abstinence from alcoholic or fermented beverages?Do religious beliefs and practices influence the client’s diet (e.g., amount, type, preparation or delineation of acceptable food combinations, e.g. kosher diets)? Does the client abstain from certain foods at regular intervals, on specific dates determined by the religious calendar, or at other times?If the client’s religion mandates or encourages fasting, what does the term fast mean (e.g., refraining from certain types or quantities of foods, eating only during certain times of the day)? For what period of time is the client expected to fast?During fasting, does the client refrain from liquids/beverages? Does the religion allow exemption from fasting during illness? If so, does the client believe that an exemption applies to him or her?


Socioeconomic ConsiderationsWho comprises the client’s social network (family, friends, peers, and cultural healers)? How do they influence the client’s health or illness status?How do members of the clients social support network define caring (e.g., being continuously present, doing things for the client, providing material support, looking after the client’s family)? What is the role of various family members during health and illness?How does the client’s family participate in the promotion of health (e.g., lifestyle changes in diet, activity level, etc.) and nursing care (e.g., bathing, feeding, touching, being present) of the client?Does the cultural family structure influence the client’s response to health or illness (e.g., beliefs, strengths, weaknesses, and social class)? Is there a key family member whose role is significant in health-related decisions (e.g., grandmother in many African American families or oldest son in Asian families)?Who is the principal wage earner in the client’s family? What is the total annual income? (Note: This is a potentially sensitive question.) Is there more than one wage earner? Are there other sources of financial support (extended family, investments)?What insurance coverage (health, dental, vision, pregnancy) does the client have?What impact does economic status have on lifestyle, place of residence, living conditions, ability to obtain health care? How does the client’s home environment (e.g., presence of indoor plumbing, handicap access) influence nursing care?


Organizations Providing Cultural SupportWhat influences do ethnic/cultural organizations have on the client’s receiving health care (e.g., Organization of Migrant Workers, National Association for the Advancement of Colored People, Black Political Caucus, churches such as African American, Muslim, Jewish, and others, schools including those which are church-related, Urban League, community-based healthcare programs and clinics)?

Educational BackgroundWhat is the client’s highest educational level obtained?Does the client’s educational background affect his or her knowledge level concerning the healthcare delivery system, how to obtain the needed care, teaching-learning, and any written material that he or she is given in the healthcare setting (e.g., insurance forms, educational literature, information about diagnostic procedures and laboratory tests, admissions forms)?Can the client read and write English, or is another language preferred? If English is the client’s second language, are materials available in the client’s primary language?What learning style is most comfortable/familiar? Does the client prefer to learn through written materials, oral explanation, or demonstration?


Religious AffiliationHow does the client’s religious affiliations affect health and illness (e.g., life events such as death, chronic illness, body image alteration, cause and effect of illness)?What is the role of religious beliefs and practices during health and illness? Are there special rites or blessings for those with serious or terminal illnesses?Are there healing rituals or practices that the client believes can promote well-being or hasten recovery from illness? If so, who performs these?What is the role of significant religious representatives during health and illness? Are there recognized religious healers (e.g., Islamic Imams, Christian Scientists practitioners or nurses, Catholic priests, Mormon elders, Buddhist monks)?


Cultural Aspects of Disease IncidenceAre there any specific genetic or acquired conditions that are more prevalent for a specific cultural group (e.g., hypertension, sickle cell anemia, Tay Sachs, G6PD, lactose intolerance)?Are there socioenvironmental diseases more prevalent among a specific cultural group (e.g., lead poisoning, alcoholism, HIV/AIDS, drug abuse, ear infections, family violence)?Are there any diseases against which the client has an increased resistance (e.g., skin cancer in darkly pigmented individuals, malaria for those with sickle cell anemia)?

Biocultural VariationsDoes the client have distinctive physical features characteristic of a particular ethnic or cultural group (e.g., skin color, hair texture)? Does the client have any variations in anatomy characteristics of a particular ethnic or cultural group (e.g., body structure, height, weight, facial shape and structure [nose, eye shape, facial contour], upper and lower extremities)?How do anatomic, racial, and ethnic variations affect the physical examination?


Developmental ConsiderationsAre there any distinct growth and development characteristics that vary with the client’s cultural background (e.g., bone density, psychomotor patterns of development, fat-folds)?What factors are significant in assessing children of various ages from the newborn period through adolescence (e.g., expected growth on standard grid, culturally acceptable age for toilet training, introducing various types of foods, gender differences, discipline, socialization to adult roles)?What is the cultural perception of aging (e.g., is youthfulness or the wisdom of old age more highly valued)?How are elderly persons handled culturally (e.g., cared for in the home of adult children, placed in institutions for care)? What are culturally acceptable roles for the elderly?Does the elderly person expect family members to provide care, including nurturance and other humanistic aspects of care?Is the elderly person isolated from culturally relevant supportive persons or enmeshed in a caring network of relatives and friends?Has a culturally appropriate network replaced family members in performing some caring functions for the elderly person?


Retrieved from:http://www.ons.org/clinicalresources/specialpopulations/Transcultural/media/ons/docs/clinical/MulticulturalToolkit/tools-andrewsboyle.pdfSource:Transcultural Concepts in Nursing Care (3rd ed.) by M.M. Andrews and J.S. Boyle, 1999, Philadelphia: Williams and Wilkins. Copyright 1999 by Williams and Wilkins.

Validity: Transcultural theories, models, and research studies http://www.tcns.org/files/TransculturalConceptsinNursingCareSummary.pdf

http://www.tcns.org/files/TransculturalConceptsinNursingCareSummary.pdf

http://www.tcns.org/files/TransculturalConceptsinNursingCareSummary.pdf

Nursing Interventions: Cultural Needs

• Respect patient autonomy and promote the good of the patient by being consistent with culturally competent care/rationale: Leever (2011) states that one must be sensitive to the cultural background by respecting the autonomy of the patient instead of forcing our own values or ways of doing things upon our patients. Nurses should not assume that autonomy is linked to selfishness by the patient, but that allowing for patient autonomy is intended to promote one’s own good. Autonomy is individual liberty and allowing patients to make their own choices without coercion or constraint.

• Communicate respect to achieve cross-cultural competent care by caring for all patients equally, regardless of cultural background/rationale: Mackenzie (2011) states that culture has a profound influence of the perception of respect and the ways respect can be communicated varies across different cultures. Nurses must be aware of the cultural background of their patients and know the proper ways to communicate to develop a respected relationship with their patients. It is usually not just a single instance of perceived disrespectful communication that damages a relationship, and often a relationship can still be established as the nurse learns the cultural background of their patients.

• Be culturally aware and culturally sensitive of your own views and those of your patients by being aware of your own culture, bias, and world wide views and how they influence your care delivery and respect, accept, and value your own and other’s personal attitudes, values, beliefs, and practices that reflect cultural background/rationale: Starr (2011) states that culturally congruent care results from interactions between clients and their care providers. Perspectives from both parties are need to develop and evaluate culturally congruent care.

Case StudyA female patient in her mid 40's comes into the hospital screaming while holding her abdomen. She can not speak any English. Jane RN asks the patient her name. She replies, “Maria”. Jane RN asks the patient her last name. She again replied, “Maria”. Jane RN and her patient went through this over and over. Jane RN could not speak any Spanish and the patient could not speak any English. After several minutes of her holding her abdomen and yelling at the Jane RN in Spanish, The RN got out the over-the-phone interpreter. Jane RN was then connected to a nice lady who interpreted everything she said. The interpreter was very calming to the patient. Jane RN learned her patient’s name and that she had been having horrible abdominal pain for 2 days. After doing some tests, we found that she had appendicitis. She was very afraid and had a lot of questions. We again communicated with the over-the-phone interpreter. Jane RN learned a lot about her patient and her culture and the RN felt that she bonded with her patient. Since that patient, Jane RN has had several more Hispanic patients. She has learned that Hispanic women often express their pain loudly. Jane RN has seen other nurses that she works with become very annoyed at the way Hispanics vocalize their pain. It is important not to generalize the way patients should express themselves. We must accept them and become familiar with their culture.

Case Study Questions

1.Based on Andrews/Boyle Transcultural Nursing Assessment Guide what do you believe the number one cultural consideration in the situation with Maria should be?2. Name one Nursing Diagnosis with Intervention for the patient in this case study.3. Do you feel the care givers in this case study were culturally competent?

Links to Learn More…

• http://www.culturediversity.org/index.html• http://www.apa.org/about/gr/issues/socioeco

nomic/ses-health.aspx• http://www.barnesjewish.org/about/diversity

http://www.culturediversity.org/index.html

http://www.apa.org/about/gr/issues/socioeconomic/ses-health.aspx


http://www.barnesjewish.org/about/diversity

ReferencesFernandez, V. M., & Fernandez, K. M. (2011, November 05). Transcultural nursing: Basic concepts and case studies. Retrieved from http://www.culturediversity.org/index.html

Davidhizar, R., & Giger, J. (2004). A review of the literature on care of clients in pain who are culturally diverse. International Nursing Review, 51(1), 47-55.

Paniagua, C. T., & Taylor, R. E. (2008). The Cultural Lens of Genomics. Online Journal Of Issues In Nursing, 13(1), 2.

Parikh, A. (2008). Cultural assessment manual. Retrieved from http://www.dbhds.virginia.gov/2008CLC/documents/clc-Trn-AmieParikh-revis-cult- assess.pdf


Lillis, C., & Taylor, C. R. (2008). Fundamentals of nursing, the art and science of nursing care. (6th ed.). New York, NY: Lippincott Williams & Wilkind.

Cultural concerns in nursing

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