Free Term Paper On Cultural Competency In Nursing Care
Cultural competency in nursing care
Culture has an important bearing on an individual’s health status and the interpretation of health and disease. In an increasingly multicultural society, culturally competent care is a key imperative for nursing staff. Besides being based on principles of social justice, it also has an effect on treatment outcomes. This work reflects on the concept of culturally competent care, discusses the guiding principles and provides practical examples to illustrate the concept of cultural competence. In the second part, examples from Hispanic (Mexican American) culture are provided to illustrate the importance of culturally competent nursing care.
Understanding cultural competence
Culture is a complex phenomenon that has both tangible and intangible aspects. These manifest as norms, value systems, beliefs and knowledge. Culture is seldom static, i.e., it continually evolves itself over a period of time. Cultural values are passed from one generation to another, and to a large extent, determine the world view of its proponents. (Williamson and Harrison, 2010) Race, religion, gender, sexual orientation and socioeconomic status, are some of the factors that contributes towards shaping the culture. Most modern societies are gradually transitioning to multiculturalism. In health care settings, cultural differences between patients and care providers may be potentially detrimental to the treatment’s success. At a macro level, these barriers are key impediments to attainment of health equity. (Dubbin, Chang and Shim, 2013). The concept of cultural competence in nursing care is a central element in patient-centered care. (Williamson and Harrison, 2010) (Epstein, Fiscella, Lesser & Stange, 2010) It is based on recognition of, and respect for, the patient as a unique individual with his own cultural perspective.
Key determinants of cultural competence
Cultural competence is one of the key strategies for reducing health disparities among ethnic minorities. Initially, cultural competence in health care focused merely on sensitization and training of health providers. However institutional mechanisms and policies are now recognized as an essential pre requisite for culturally competent care. (Douglas, Pierce and Rosenkoetter, etal. 2011)
Delphin-Rittmon, et al. (2013) proposed seven essential components for system-wide cultural competence in occupational settings. These include a strategic organizational framework that is informed by formal assessments, and one that incorporates the patient’s perspectives. Besides management support, other components include, encouraging diversity in recruitment policies, providing avenues for linguistic competency, a realistic time frame for implementation, and, a fair mechanism for grievance redressal. (Delphin-Rittmon, Andres-Hyman, Flanagan and Davidson, 2013)
Appreciation of the socio cultural determinants of health is invaluable for health care providers. For example, awareness of the cultural influences on health seeking behavior (or health related practices) of a particular patient, may help a care provider understand the context of the patient’s behavior. On the contrary, when viewed only from the care provider’s own perspective, the behavior may well be perceived as inappropriate or even offensive. Moreover, systematic quality improvement initiatives should incorporate culturally appropriate methods. e.g., conducting a survey of patients, as a means of getting their feedback, can be useful only if the language used in the survey instrument is comprehended well by the patient. Likewise, process and outcome indicators should also capture the relevance of patient’s experience as he transitions through the medical care process. (Douglas, Pierce and Rosenkoetter, et al. 2011) (Delphin-Rittmon, Andres-Hyman, Flanagan and Davidson, 2013).
Lastly, by recognizing the multifaceted and multidimensional experience of health and illness, culturally competent care fosters a patient-provider relationship based on equal participation in the treatment process. (Epstein, Fiscella, Lesser & Stange, 2010)
Normative standards for culturally competent nursing
Elaborate normative standards have been put in place to facilitate culturally competent nursing. Broadly, these fall under the four headings, based on the substantive areas: clinical practice, research, education, and administration. (Douglas, Pierce and Rosenkoetter, etal. 2011)
The standards primarily draw from the ‘social justice’ framework which embodies an individual’s or community’s right to be treated fairly, and without any discrimination, in all spheres of life. (Epstein, Fiscella, Lesser & Stange, 2010) Applied to health settings, these standards are important for achieving optimal health outcomes, and, indeed instrumental in reducing the health disparities (most notably, among the under privileged segments of society, ethnic minorities, etc.)
In principle, all social enterprises adhere to certain cultural standards. However, the piecemeal application of these standards, and a disregard for the contextual influences, is inimical to both patient’s and nurse’s interests. An expert panel on global nursing and health endorsed a set of twelve normative standards which are meant to guide health facilities towards achieving cultural competence. (Douglas, Pierce and Rosenkoetter, etal. 2011) The standards do not represent independent discrete areas of nursing care. Rather, they are closely interlinked and in their entirety, serve to put in place a continuum of patient-centered ethos in health care.
These guidelines are the result of a comprehensive review of documents with inputs from a wide range of stakeholders, including, nursing organizations, health professional associations, United Nations and NGO organizations.
Standard 1 Social justice
Standard 2 Critical reflection
Standard 3 Knowledge of cultures
Standard 4 Culturally competent practice
Standard 5 Cultural competence in health care systems and organizations
Standard 6 Patient advocacy and empowerment
Standard 7 Multicultural work force
Standard 8 Education and training in culturally competent care
Standard 9 Cross cultural communication
Standard 10 Cross cultural leadership
Standard 11 Policy development
Standard 12 Evidence based practice and research
Practical nursing examples for achieving culturally competent nursing care:
Critical reflection (or Reflexivity)
Certain cultures consider congenital deformities as a taboo subject. This may prevent them from seeking treatment for an affected child. Community nursing involves interacting with communities in their own settings. This facilitates a good understanding of the contextual factors that may have a potential impact on health. By considering the cultural reasons preventing the family from seeking treatment, a nurse can look for appropriate ways to improve the child’s quality of life. (e.g. by rehabilitative care or using orthotic devices) Instead of confronting the parents with the scientific rationale, she can take time to gain family’s confidence and explain the benefits of the treatment, perhaps also by giving some examples of similar children who benefited from treatment.
Broad knowledge of cultural traditions is valuable for nursing professionals and lends them the ability to take appropriate measures. For example, there are certain cultural dietary habits which need to be taken into account while planning the patient’s diet and treatment regimen. e.g., Hindus consider cow as their holy animal and therefore eating beef is prohibited by religion. By being aware of this potential for conflict beforehand, the nurse can avoid a situation where inadvertent inclusion of beef, in the meal, may be distressing for the patient. In this instance, lack of awareness of the cultural differences may end up jeopardizing the patient’s recovery. e.g., the patient may refuse to receive any treatment from that particular hospital
Cross cultural communication
Good communication between nurse and patient is paramount to the success of treatment. (Douglas, Pierce and Rosenkoetter, etal. 2011) Further, nurse should be empathetic and non-judgmental when dealing with deviant behaviors. For example, a drug-addict receiving rehabilitative therapy. An emotionally labile person may need to be dealt in a non-judgemental manner. By demonstrating empathy and respect for the patient and providing means to alleviate the withdrawal symptoms, a nurse can make a critical contribution in the rehabilitation process. To be able to do this, nurse should be trained and sensitized to recognize and resolve the barriers.
Patient advocacy and empowerment
Through training and experience nurse should be able to recognize the effect of institutional policies and work place norms, on a patient’s treatment. Owing to their technical and social standing in the society, nurse has a duty to act as an advocate for patient’s rights. Nurse should be able to identify behaviors that are prejudicial, stigmatizing or offensive to a patient’s sensibilities (e.g., ethnocentrism, intimidating behavior or use of abusive language by another staff, etc.). In such instances nurse should respect patient’s autonomy and look to resolve the situation with a certain level of flexibility, to the extent that it doesn’t affect the patient’s care. In case certain institutional policies are causing inter cultural conflict, nurse should take recourse to appropriate action, and if deemed necessary, to take initiative for appropriate modification of policies or even disciplinary action.
Evaluating whether cultural needs are met
In trans-cultural settings, perhaps the most important determinant of nurse-patient relationship is the ability to communicate effectively. Good communication will help understand how the patient relates to the medical care process and also his special needs, if any. Implementation of standards for culturally competent nursing, both at the institutional and personal level, will ensure a thorough assessment of the cultural needs of patients. Moreover, during assessment the nurse should not assume the patient’s context and cultural needs, on the basis of appearance or other social variables. (e.g., patient’s race and ethnicity) (Williamson and Harrison, 2010) Even within the same culture, there may be considerable heterogeneity, and by avoiding stereotypical assumptions, the nurse can prevent any false assumptions affecting the assessment of patient. Often this may be difficult to achieve. In such cases, communicating with patient’s attendants or taking help from other more experienced colleagues will help.
With the increasing consumer-orientation of medical care services, meeting the cultural needs of patients is a key imperative. Doing so is one of the steps towards reducing health inequities in the society. Correct perception of the client’s needs is essential. Nonetheless, as a health professional, it is also a nurse’s duty to prevent any harm to the patient. (by any acts of commission or omission) This includes taking care not to accede to demands that are not in patient’s best interests. In such cases, patience, good communication and explanation by nurse often helps to resolve the situation. However, it is also essential to respect standards of medical care, ethical norms and institutional rules and regulations. In case the patient’s demands are in violation of any of these, they should not be accommodated. In any such cases clear explanation of the rationale for a particular action or (inaction) is in order.
Part 2 Demonstrating Culturally Competent Nursing Care
Peculiar Hispanic values may predispose them to emotional lability and stress. For example, their culture places a premium on being self sufficient and not soliciting support from outside their families. In case a breadwinner for the family is not able to provide adequate financial support, it is likely to end up in, for example, stress and psychosomatic disorders. Generally, Hispanic families resent asking for external help. (College of Nurses of Ontario, 2009) In times of chronic illness, the tendency to refrain from seeking help from neighbors, colleagues or friends may be damaging for the whole family.
Another example of situations where Hispanic cultural values may affect a patient’s well-being is that of Alzeihemer’s disease. This is a chronic debilitating disease associated with senility, and, severe cognitive & memory impairment. Even in settings where health services targeting such patients are available and easily accessible, strong cultural preference for self-sufficiency means that may not avail these services.
Likewise, Hispanics tend to conceal from others in case a family member has a psychiatric disorder. Senile patients with psychiatric disorders may suffer unnecessarily even if accessing good psychiatric services is easily feasible.
Similarly, cultural ethos may also prevent Hispanics from accessing special services for children with learning disability. Such children are often stigmatized and end up having a severely restricted social life. In such situations, child will not benefit from social and medical services.
Hispanic culture is against life-support in terminal illnesses. Moreover, the culture does not sanction the practice of advance directives for a patient’s end-of-life care choices. In other religion or sub culture, for e.g., Christians, advanced directives can help in alleviating the stress of family members since they can be sure that the patient’s last wishes are already known.
Moreover, Hispanics tend not to resort to hospice care as they place value on caring for their relatives at home. Thus patient may be denied palliative care or other supportive treatment options that might be available during hospice or nursing home care. This may affect the whole family.
Typically health care providers are not comfortable discussing end of life care. But culturally competent care should involve detailed discussion about the patient’s condition and about the available treatment options. While communicating with a Hispanic family, technical jargon or euphisms should not be used. Use of simple language will help the nurse to do away with potential communication barriers, thus leading to a good understanding of the patient’s need as well as the family’s wishes. Nurse can then advise the family on the best possible course.
American Nurses Association. (2009). Code of ethics with interpretive statements. Available online at http://nursingworld.org/ethics/code/protected_nwcoe813.htm . Accessed Feb. 7, 2015.
Cultural Responses to Health Among Mexican American Women and Their Families http://www.nursingcenter.com/lnc/journalarticle?Article_ID=691987#sthash.YuPdR9os.dpdf
Delphin-Rittmon, M.E., Andres-Hyman, R., Flanagan, E.H. and Davidson, L. (2013). Seven essential strategies for promoting and sustaining systemic cultural competence. The Psychiatric Quarterly; 84(1):53-64.
Douglas, M.K., Pierce, J.U., Rosenkoetter, M., Pacquiao, D., Callister, L.C. and Hattar-Pollara, et al. (2011). Standards of practice for culturally competent nursing care: 2011 update. Journal of Transcultural Nursing;22(4):317-33.
Dubbin, L.A., Chang, J.S. and Shim, J.K. (2013). Cultural health capital and the interactional dynamics of patient-centered care. Social Sciences & Medicine; 93:113-20.
Epstein, R.M., Fiscella, K., Lesser, C.S., Stange, K.C. (2010). Why the nation needs a policy push on patient-centered health care. Health Affairs;29(8):1489–1495.
Williamson, M. and Harrison, L. (2010). Providing culturally appropriate care: a literature review. International Journal of Nursing Studies;47(6):761-9.
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