Cultural Competence July 2008. The ACE Cultural Competence Committee Margaret M. Andrews, PhD, RN, CTN, FAAN Lauren Clark, PhD, RN, FAAN Katherine Foss,

Cultural Competence

July 2008

The ACE Cultural Competence

Committee

Margaret M. Andrews, PhD, RN, CTN, FAAN

Lauren Clark, PhD, RN, FAAN

Katherine Foss, MS, RN

Sandie Kerlagon, MS, RN

Jo Keuhn, RN, BS(Original Date: 2004)

Cultural Competence in Clinical Settings: An

Introduction for New Nurses

What is Culture?

A definition: Leninger (1985) describes culture as: ‘the values, beliefs, norms, and practices

of a particular group that are learned and shared and that guide thinking, decisions and actions in a patterned way’

Or more simply: the luggage each of us carries around for our lifetime (Spector, 2003)

Culture determines….

Who is healthy & ill What people think causes health & illness What healers are sought to prevent and

treat disease What treatments are used Appropriate sick role behavior How long a person is sick & when he/she

has recovered

the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter.

U.S. Department of Health & Human Services, 2003

Cultural and Linguistic Competence

Campinha-Bacote, 2008

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2

3

Cultural Competence

Begins with understanding of own self

Includes knowledge of various cultural characteristics

Includes an understanding of cultural characteristics

Requires application of cultural knowledge and understanding in the healthcare setting

Non-ethnic CulturesSelected Examples

Socioeconomic status

Sexual Orientation

Handicap/Disability

Occupation

Age

Poverty The Homeless The Affluent/Wealthy

Gay, Lesbian, Bisexual, Transgender

Deaf/Hearing Impaired Blind/Visually Impaired

Nurses, Military

Adolescents, Elderly

The Culture of…..

We must not presume that all people of a certain culture adhere to all aspects of their culture. The healthcare provider must identify which aspects are appropriate for each patient during the admission process.

Cultural Assessment

is a “systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values & practices to determine explicit needs & intervention practices within the cultural context of the people being evaluated.”

Leininger & McFarland, 2006

Explanatory Models

Explain why we are sick to other people and to ourselves to make sense of our misfortune

Example: “You have a terrible cold!”

“You’re right—It is because I got run down and then went outside without a coat yesterday. That’s why I’m sick.”

Explanatory Model Questions What is the patient’s ethnic affiliation? Who are the patient’s major support persons

and where do they live? With whom should we speak about the

patient’s health or illness? What are the patient’s primary and secondary

languages, and speaking and reading abilities? What is the patient’s economic situation? Is

income adequate to meet the patient’s and family’s needs? (Lipson & Dibble, 2005)

Spirituality & Religion

Spirituality refers to a subjective experience of the

sacred, whereas religion involves subscribing to a set

of beliefs or doctrines that are institutionalized.

33%

18%16%

16%

6%

4%4% 3%

Christianity

Islam

Hinduism

Nonreligious

Buddhism

ChineseTraditionalPrimal-indigenousOther

Major World Religions

U.S. Religions

354,194 Congregations

> 1,200 Denominations

Yearbook of American & Canadian Churches, 2002

Spiritual & Religious Healers

Priest

MonkShaman

Elder

BishopRabbi

Medicine Man

Medicine

Woman

Curandero/a

Religion & spirituality in healing….

Prayer, Chants Pilgrimages Fasting Amulets or talismans Healing rituals

Anointing with oil Sacraments Laying on of hands

Religion, Health & Culture

Research demonstrates positive health outcomes for people with strong spiritual and religious beliefs

Congruent with holistic philosophical beliefs about human nature

Dietary & lifestyle practices often promote health & prevent disease (e.g., lower incidence of heart disease among Mormons & Seventh-day Adventists)

Guides moral & ethical decision making

Symbols of Ethnoreligious Identity

Shrines with Buddha, candles, incense, and various artifacts (Buddhist)

Presence of prayer beads (Muslim) Amulets and talismans (charms) to ward off illness or

bring good health (Mexican, Puerto Rican, & many African groups)

Rosaries, religious medals, statues, votive candles (Catholics)

Presence of mezuzza (small case containing torah passages on parchment--usually hung in doorway)

Include Religious & Spiritual Factors in Cultural Assessment

Health-related beliefs & practices, e.g., diet, medications, medical & surgical procedures

Religious calendar & holy days Healing practices Religious network for providing spiritual &

emotional support for sick & dying members. Spiritual & religious healers

Religious, Cultural & Civic Holidays

Avoid scheduling medical appointments during holidays

Avoid disruption to holy days (such as fasting during Ramadan)

Promoting Effective Cross-Cultural Communication.....

Always ask, “By what name may I

call you?”

What do Limited-English Speakers Want?

Speaking one’s native language is….

• Easier when feeling ill• More comfortable• More accurate

What is unsafe practice with Limited-English speakers?

Using family members as interpreters Recruiting ad hoc (or untrained)

interpreters Writing instructions in English

Interpreter errors cause medical errors (Levine, JAMA, 2006)

Why not use a family member as an interpreter?

Office for Civil Rights (OCR) Policy Guidance (2000) states that untrained “interpreters”:

May not understand the concepts or official terminology they are asked to interpret or translate

Obstruct the flow of confidential information to the provider.

Fail to disclose intimate details of personal and family life; Clinicians, too, refrain from candid discussions with untrained interpreters present.

Requirements in Using a Translator

• Use approved Interpreter Services

OR

• Use the Interpreter Telephone

Using Appropriate Interpreter Services in Clinical Care

Speak with Charge Nurse for assistance

Call Operator to place call 1-800 number Client code/ID Request language

Directness in Clinical Encounters Americans value

directness: “Spit it out” “Say what’s on your mind”

Languages that depend on subtle contextual cues: Infer meaning Imply, but do not state,

the point

(Japanese, Arabic)

Directness and Subtlety

“Maybe” or “That would be difficult” is probably a polite “no”

Avoid yes/no questions Phrase your inquiry as a multiple choice

question

Nonverbal Communication

Facial expressions, body language, & tone of voice play a much greater role in cultures where people prefer indirect communication & talking around the issue.

Gestures and Facial Expressions

Another culturally influenced aspect of communication is the demonstration of emotion, such as joy, affection, anger, or upset.

Most Koreans, for instance, are taught that laughter & frequent smiling make a person appear unintelligent, so they prefer to wear a serious expression.

While Americans widen their eyes to show anger, Chinese people narrow theirs.

Vietnamese, conversely, consider anger a personal thing, not to be demonstrated publicly.

Smiling & laughter may be signs of embarrassment & confusion on the part of some Asians.

Talking with one’s hands is more common in southern Europe than in northern Europe.

A direct stare by an African American or Arab is not meant as a challenge to your authority, while dropped eyes may be a sign of respect from Latino or Asian patients & coworkers.

Gestures

Use gestures with care, as they can have negative meanings in other cultures.

Thumbs-up and the OK sign are obscene gestures in parts of South America & the Mediterranean.

Pointing with the index finger and beckoning with the hand as a “come here” sign are seen as rude in some cultures much as snapping one’s fingers at someone would be viewed in the United States.

American culture generally expects people to stand about an arm’s length apart when talking in a business situation.

Any closer is reserved for more intimate contact or seen as aggression.

In the Middle East, however, it is normal for people to stand close enough to feel each other’s breath on their faces.

Touch

Different rules about who can be touched & where.

A handshake is generally accepted as a standard greeting in business, yet the kind of handshake differs. North America = hearty grasp Mexico = softer hold Asia = soft handshake with the second

hand brought up under the first is a sign of friendship & warmth

Touch

Religious rules may apply to appropriate touch. Touching between men & women in public is not permitted by

some orthodox religions, so a handshake would not be appropriate.

Ideas about respect are conveyed through touch Touching the head, even tousling a child’s hair as an

affectionate gesture, would be considered offensive by many Asians.

If you need to touch someone for purposes of an examination, explain the purpose & procedure before you begin.

Topics Appropriate for Discussion

What is acceptable for nurse and patient to discuss? Many Asian groups regard feelings as too private to

be shared. Latinos generally appreciate inquiries about family

members, while most Arabs & Asians regard feelings as too personal to discuss in business situations.

In social conversations, Filipinos, Arabs, & Vietnamese might find it completely acceptable to ask the price you have paid for something or how much you earn, while most Americans would consider that behavior rude.

Inappropriate Conversation Topics

Even a seemingly innocuous comment on the weather is off limits in the Muslim world, where natural phenomena are viewed as Allah’s will, not to be judged by humans.

This points to another aspect that relates to privacy.

To many newcomers, Americans seem naively open. Discretion and purposeful communication help us judge when to converse and when to be silent.

Privacy

Discussing personal matters outside the family is seen as embarrassing by many cultures.

Thoughts, feelings, & problems are kept to oneself in most groups outside the dominant American culture.

Privacy boundaries may have implications when medical problems are exacerbated by personal or family problems.

Saving face…. In Asia, the Middle East, & to some extent Latin

America, one’s dignity must be preserved at all costs.

Death is preferred to loss of face in traditional Japanese culture, hence the suicide ritual, hara-kiri, as a final way to restore honor.

Any embarrassment can lead to loss of face, even in the dominant American culture.

To be criticized in front of others, publicly snubbed, or fired, would be humiliating in most any culture.

Seemingly harmless behaviors can be demeaning to some patients.

The Culturally Competent ClinicianAttitudes of the Culturally Competent Clinician

 Understanding: Acknowledging that there can be differences between our Western and other cultures’ healthcare values and practices.

 Empathy: Being sensitive to the feeling of being different.

 Patience: Understanding the potential differences between our Western and other cultures’ concept of time and immediacy.

 Ability: To laugh with oneself and others.

 Trust: Investment in building a relationship with patients, which conveys a commitment to safeguard their well-being.

Non-Verbal Communication

All cultures have rules, often unspoken, about who touches

whom, when & where.

Nonverbal Communication(~65% of all communication)

Touch Facial expressions Eye movements Body posture

Modesty

Cultural Perspectives on Modesty

Patients may prefer clinicians of the same gender

May be taboo for males to examine or treat females (e.g., Middle Eastern groups)

In some Asian & Hispanic cultures, older adults may believe that hospital gowns cause disease by exposing them to cold drafts (related to yin/yang & hot/cold theories of disease)

Pain and Cultural Competence

Pain and Culture

Pain is an abstract concept which can be referred to as:

A personal private sensation

A stimulus that signals harm

A pattern of behavior to protect from harm

Pain Experience

Pain is a universal human experience, but pain reactions are unique to the individual and includes thoughts, feelings, reactions, expectations and past experiences associated with pain.

The experience of pain can also be described in physiologic, psychosocial, economic and spiritual contexts.

What is Included in a Pain Assessment Cross-Culturally?

Pain Expression: Verbal and non-verbal behaviors, including gestures and tone of voice.

Pain Language: Word(s) used to describe pain.

Language or other communication techniques such as pointing to site of pain.

Religious Beliefs: Meaning of pain or suffering.

Rituals and taboos associated with pain or pain treatment.

Pain Assessment and Cultural Factors Social Roles:Ethnic identity and degree of

acculturation: such as primary language used, identification of social support networks.

Family relationships, consider the role(s) the individual has within the family, extended family presence and role in community (such as employment).

Gender and Age Influences. Perception of the healthcare

system:Trust vs. suspicion. Use of traditional/layremedies.Past experience with the healthcare system.

Pain Treatment and Cultural Factors Attitudes and fears about pain

medications or other interventions may impact the patient and/or family compliance with a pain treatment plan.

Physiologic response to medications has race and age variations. For example, body composition of fat and serum protein in the elderly may alter distribution and absorption of medications.

Also elicit patient beliefs about: Meaning of pain or illness. Expectations of healthcare

providers. Therapeutic goals.

Barriers

Typical barriers to a cultural sensitive pain assessment and treatment by healthcare providers include: Stereotyping. Lack of empathy. Ethnocentrism. Language. Experience or expertise of practitioner and time

constraints.

National Institutes of Health

Facilitates research and evaluation of complementary and alternative practices

Provides information about a variety of methods

What is complementary and alternative medicine?

Includes a broad range of healing philosophies, approaches & therapies

A therapy is called complementary when it is used in addition to conventional biomedical/scientific treatments

An alternative therapy is used instead of conventional biomedical/scientific treatments.

Conventional refers to those widely accepted & practiced by the mainstream medical community

Complementary &

AlternativeTherapies

MassageTherapy

Aroma-therapy

Ayurveda

Chiropractic Therapeutic

Touch

Reflexology

Acupuncture

Shamanism

MusicTherapy

Hypno-therapy

ArtTherapy

Complementary Therapies: What is the Clinical Goal?

Gain the patient’s trust so he/she will tell you the truth about alternative and complementary practices used to treat pain or other symptoms.

What Does the Clinician do with a Patient Using Complementary Therapies?

Check for drug interactions with prescription or over-the-counter medications

Assess for harmful side effects Discourage over-reliance on traditional

healing if it delays necessary biomedical treatment (for example, conditions for which an antibiotic is needed)

Meta-Communicative Cultural Competence

Pay attention to body language, facial expressions & other behavioral cues; much information may be found in what is not said

Avoid yes/no questions; ask open ended questions or ones that give multiple choices; remember that a nod or yes may mean: “Yes, I heard” rather than “Yes, I understand” or “Yes, I agree”

Meta-Communicative Cultural Competence

Consider that smiles & laughter may indicate discomfort or embarrassment; investigate to identify what is causing the difficulty or confusion

Make formal introductions using titles (Mr., Mrs., Ms., Dr.) & surnames; let the individual take the lead in getting more familiar

Meta-Communicative Cultural Competence

Greet patients with “Good Morning” or “Good Afternoon” and when possible, in their language

If there is a language barrier, assume confusion; watch for tangible signs of understanding, such as taking out a driver’s license or social security card to get a required number

Meta-Communicative Cultural Competence

Take your cue from the other person regarding formality, distance, and touch

Question your assumptions about the other person’s behavior; expressions & gestures may not mean what you think; consider what a particular behavior may mean from the other person’s point of view

Explain the reasons for all information you request or directions you give.

Meta-Communicative Cultural Competence

Use a soft, gentle tone and maintain an even temperament

Spend time cultivating relationships by getting to know patients & coworkers

Be open to including patients’ family members in discussions & meetings with patients

Consider the best way to show respect, perhaps by addressing the ”head’ of the family or group first

Meta-Communicative Cultural Competence

Use pictures & diagrams where appropriate;

Pay attention to subtle cues that may tell you an individual’s dignity has been wounded

Recognize that differences in time consciousness may be cultural & not a sign of laziness or resistance

Main Points: Cultural Competence

• By being open-minded and respectful toward their beliefs, values, & practices, you can help patients feel more comfortable.

• Factors that may differ from patient to patient include ethnic, religious, and occupational factors.

• Some people belong to more than one ethnic group, as well as cultural groups, and other people have fewer group identities.

• Importance of religion can vary from person to person. For example, some people keep many daily traditions, such as eating certain foods.

• Others keep traditions only on special occasions, or not at all.

• For many different reasons, religious, ethnic, health, personal preference, etc., a person may eat or avoid certain foods at certain times, or not eat some foods at all.

• Different cultures have different ideas about how to express & respond to pain.

• Some cultures value bearing pain silently, while others expect expressiveness.

• Different cultures have different views about when to seek professional medical help, treat oneself, or be treated by a family member or traditional healer.

Thank you for your time!