Jones and Bartlett Publishers NOT FOR RESALE OR DISTRIBUTION

SNL

277277

12CulturePamala D. Larsen and Sonya R. Hardin

INTRODUCTION

Concepts of health and illness are deeply rooted in culture, race, and ethnicity and influence an individual’s illness perceptions and health and ill-ness behavior. Adding to this is the fact that cul-tures are never homogeneous (Helman, 2007), as there are variations and subcultures within each culture, each affecting health and illness percep-tions differently. So, although, one may know the “norms” of Chinese culture, Puerto Rican culture, or Indian culture, for instance, there will always be unique differences in each individual from that culture.

According to the Office of Minority Health Web site on cultural competency (www.omhrc.gov/), culture (and language) influence:

Health, healing, and wellness belief systems■■

How illness, disease, and their causes are per-■■

ceived, both by the patient/consumer and the providerThe behaviors of patients who are seek-■■

ing health care and their attitudes toward providersDelivery of services by the provider who ■■

looks at the world through his/her own “lens” and set of values, thereby potentially

compromising access and care for those of other cultures.

There are factors other than culture that influence health and illness. Factors include, but are not limited to, environment, economics, genetics, age, previous and current health status, personality, social support, and psychosocial factors. Caring for the individual, family, and community, is, therefore, influenced by numerous factors of which culture is only one. In Canada, culture is identified as one of the 12 determi-nants of health (Racher & Annis, 2007).

Currently in the United States there are continuing disparities in healthcare among those of different cultures, races, ethnicities, and socio-economic status [Agency for Healthcare Research and Quality (AHRQ), 2008]. Throughout the liter-ature, becoming culturally competent is seen as the first step in decreasing and eventually eliminating those disparities. Although being culturally com-petent is important on an individual basis, becom-ing so as an organization is just as important. The National Center for Cultural Competence has identified six reasons that organizations should incorporate cultural competence into policy:

To respond to the current and projected ■■

demographic changes in the United States

© Jones and Bartlett Publishers. NOT FOR RESALE OR DISTRIBUTION

© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

278 ■ Chapter 12: Culture

SNL278

To eliminate long-standing disparities in the ■■

health status of people of diverse racial, eth-nic, and cultural backgroundsTo improve the quality of services and health ■■

outcomesTo meet legislative, regulatory, and accredita-■■

tion mandatesTo gain a competitive edge in the market ■■

place; andTo decrease the likelihood of liability/mal-■■

practice claims (National Center for Cultural Competence, n.d.)

Defining Terms

Culture

The literature provides many definitions of culture. Within the nursing literature, each individual with his or her model/theory of transcultural nursing has a different definition. Although there is value in those definitions, perhaps one from medical anthropology offers a broader perspective. Helman (2007) defines culture as “a set of guidelines (both explicit and implicit) that individuals use to view the world and tell them what behaviors are appro-priate” (p. 2). Culture is shared, learned, dynamic, and evolutionary (Schim, Doorenbos, Benkert, & Miller, 2007). This evolution is described by Dreher and MacNaughton (2002) as “people live out their lives in communities, where circumstances gener-ate conflict, where people do not always follow the rules, and where cultural norms and institutions are massaged and modified in the exigencies of daily life” (p. 184).

Typically one thinks of culture as being race and ethnicity bound. However, many other cul-tures exist if a broader definition of culture is used. Examples include the culture of poverty, the culture of cancer survivors, the culture of rurality, and the culture of chronic illness (see Chapter 2) to name a few. Each of these cultures has explicit and implicit guidelines that determine how their members view the world, decide upon appropriate behaviors, and perform those behaviors.

Cultural Competency

Many definitions of culture mandate that there are many definitions of cultural competence. Table 12-1 lists some of the more common defi-nitions found in the literature. The Centers for Disease Control and Prevention National Prevention Information Network (www.cdcnpin.org) lists eight principles of cultural competence. These principles include:

Define culture broadly■■

Value clients’ cultural beliefs■■

Recognize complexity in language interpre-■■

tationFacilitate learning between providers and ■■

communitiesInvolve the community in defining and ■■

addressing service needsCollaborate with other agencies■■

Professionalize staff hiring and training■■

Institutionalize cultural competence■■

Cultural competence for systems and orga-nizations may be seen on a continuum (Rasher & Annis, 2007; Srivastava, 2007). The Cultural Competence Continuum was developed by the National Center for Cultural Competence (NCCC) located at Georgetown University, in Washington, DC. There are six levels on the continuum, span-ning from cultural destructiveness at level 1 to cul-tural proficiency at level 6, the highest level. When an organization is culturally proficient, it holds culture in high esteem and uses this perspective to guide its work (Rasher & Annis, 2007, p. 263).

Cultural Awareness and Sensitivity

Oftentimes we hear the terms cultural awareness and cultural sensitivity. What is their relationship with cultural competency? Purnell (2008a, p. 6) explains awareness as an appreciation of the exter-nal signs of culture, whereas sensitivity is one’s personal attitude toward others of different cul-tures. Although awareness and sensitivity are part


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Introduction ■ 279

SNL

279

backgrounds who have overcome great obstacles and “made it” as individuals. However, this view reflects a lack of awareness to systemic barriers and institutional racism. It is a narrow view that places all responsibility on the individual without acknowledging systemic inequities.

The Myth of Sameness

The assumption of this myth is that someone who shares the client’s ethnicity and language will be able to more effectively provide health care and thus eliminate miscommunication (Masi, 1996; Srivastava, 2007). However this “sameness” may be only on the surface, as there may be many other differences that affect the client and healthcare professional relationship. This also presumes a

of cultural competence, competency implies that awareness and sensitivity have been operational-ized (Schim et al., 2007).

Myths of Culture and Diversity

Myths of culture and diversity must be chal-lenged. Masi (1996) and Srivastava (2007) discuss six myths that can influence caring for culturally diverse clients.

The Myth of Equality

This myth describes that fairness means equal treatment for all (Srivastava, 2007, p. 42). Proponents of this myth cite success stories of individuals of varying ethnic, racial, and gender

TABLE 12-1

Cultural Competency Definitions

Author Definition

Centers for Disease Control and Prevention, 2007

Integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services, thereby producing better outcomes

Spector, 2004, p. 8 Within the delivery of care, the provider understands and attends to the total context of the patient’s situation, and it is a complex combination of knowledge, attitudes, and skills

Mutha, Allen, & Welch, 2002, p. 25 A set of skills, knowledge, and attitudes that enhance (1) your understanding of and respect for patients’ values, beliefs, and expectations; (2) awareness of your own assumptions and value system in addition to those of the US medical system; and (3) your ability to adapt care to fit with the patient’s expectations and preference

Purnell, 1998, p. 6 Having the knowledge, abilities, and skills to deliver care congruent with the client’s cultural beliefs and practice

Office of Minority Health A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals, that enables effective work in cross-cultural situations

Giger & Davidhizar, 2004, p. 8 A dynamic, fluid, continuous process whereby an individual, system, or healthcare agency finds meaningful and useful care-delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL280

This myth dovetails with the one about generaliza-tions, and means that being familiar with a certain culture does not make one competent, as familiar-ity may not allow for individual differences.

Transcultural Nursing

Transcultural nursing had its beginnings in the 1950s with Madeleine Leininger. With her work over more than 50 years, in addition to other theorists, transcultural nursing has evolved as a specific and unique specialty. Transcultural nursing is defined as “as a formal area of study and practice focused on comparative human-care (caring) differences and similarities of the beliefs, values and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people (Leininger & McFarland, 2002, p. 6).

There are a number of reasons that transcul-tural nursing is important in health care today. Leininger and McFarland (2002) summarize eight factors that have led to the development and need for transcultural nursing.

Increase in immigration and migration of ■■

people across the worldImplicit expectation that nurses and other ■■

healthcare providers need to know, under-stand, respect, and respond appropriately to care for others of diverse culturesIncrease in the use of technologies in caring ■■

or curing, with different responses and effects on clients of diverse culturesIncreased signs of cultural conflicts, cul-■■

tural clashes, and cultural imposition prac-tices between nurses and those from diverse culturesIncrease in number of nurses who travel and ■■

work in different places in the worldAnticipated legal defense suits against nurses ■■

resulting from cultural negligence, cultural ignorance, and cultural imposition practices in working with diverse culturesRise in gender and the issues and rights of ■■

special groups

narrow definition of culture (race and ethnicity) as opposed to a broader view.

The Myth That Cultural Differences Are a Problem

Health care has often viewed issues of culture and diversity from a negative perspective, that they were problems or barriers to overcome. Srivastava (2007, p. 46) suggests that culture should not viewed as a problem, but as a leverage point, a point that can affect the health outcome of the cli-ent if energy is focused on it.

The Myth That Everything Must Be Acceptable

There is a perception that if something is a cultural value that it must be “accepted.” Masi (1996) sug-gests that respecting an individual’s cultural value not be confused with acceptance. He describes that although that society states that child abuse is unacceptable, that defining child abuse may vary with individuals from different cultures. A prac-tice known as “scratching the wind,” where bruises are caused by cupping and scratches are created by running a coin on the skin, is used to relieve fevers and illness in some cultures. Respecting this cultural value does not mean acceptance of this practice.

The Myth That Generalizations Are Unacceptable

Masi (1996) and Srivastava (2007) suggest that there is a large difference between generalizations and stereotypes. Generalizations are a necessary starting point to understand groups of individu-als as they indicate trends and patterns. These generalizations may help a healthcare professional initiate a conversation with a client. Stereotypes close conversation and knowledge development (Srivastava, 2007, p. 47).

The Myth That Familiarity Equals Competence

Familiarity with cultural differences may make the difference invisible (Srivastava, 2007, p. 48).


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Impact ■ 281

SNL

281

model. With an increasing diverse society, this nar-row view will continue to create a mismatch with clients and their healthcare needs and services.

As we age, the potential for having one or more chronic diseases increases significantly, thus the need to look at demographics of aging Americans is paramount. Currently non-Hispanic older adults account for approximately 83.5% of the older adult population. Projections for 2050 indicate that this percentage will decrease by nearly 20–64%. Given these projections, a cultur-ally competent workforce will be needed to meet the needs of individuals from many cultural and ethnic groups (see Table 12-2).

Health Disparities

Although the focus of this chapter is culture and its influence on individuals with chronic illness, health disparities that occur with individuals from

Growing trend to care with and for people, ■■

whether well or ill, in their familiar or par-ticular living and working environments (Leininger & McFarland, 2002, pp. 13–18)

The Transcultural Nursing Society was founded in 1974 by Leininger as a worldwide organization for nurses and others interested in and prepared to advance transcultural nursing. The society pro-vides a forum to bring nurses together worldwide with common and diverse interests to improve the care for culturally diverse people. The purposes of the society include:

To learn about the beliefs and healthcare ■■

practices of people from diverse and similar cultures.To promote and disseminate knowledge ■■

related to transcultural nursing care.To develop new knowledge that focuses upon ■■

diverse lifeways of cultural groups and their nursing care aspects.To maintain and improve the nursing care of ■■

people whose values, beliefs, and cultures differ.To promote and conduct research to advance ■■

transcultural nursing worldwide.To serve as a forum for discussing issues ■■

related to the development of transcul-tural nursing and its interrelationship with other healthcare providers and disciplines (www.tcns.org).

IMPACT

Changing Demographics

According to the 2000 US Census, approximately 30% of the population is racially and ethnically diverse. The Census Bureau projects that by 2030 this percentage will increase to 40%, with non- Hispanic whites only making up 60% of the US population [Centers for Disease Control and Prevention (CDC), 2007]. Unfortunately our North American healthcare system(s) is based on Western culture, and that includes using a biomedical

TABLE 12-2

Projected Distribution of the Population, Age 65 and Older, by Race and Hispanic Origin, 2000 and 2050

2000 2050

Total 100.0 100.0Non-Hispanic white 83.5 64.2Non-Hispanic black 8.1 12.2Non-Hispanic American

Indian and Alaska Native 0.4 0.6

Non-Hispanic Asian and Pacific Islander 2.4 6.5

Hispanic 5.6 16.4

Note: Data are middle-series projections of the population. Hispanics may be of any race. Reference population: These data refer to the resident population.Source: US Census Bureau. (2000). Population projections of the United States by age, sex, race, Hispanic origin, and nativity: 1999 to 2100. Retrieved from www.census.gov/population/www/projections/natproj.html


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL282

practice with an awareness of different cultures to allocate resources fairly within society. Efforts to address racial, ethnic, and other disparities in health care will require nurses to employ creative interventions to assure culturally competent care for these populations.

Beidler (2005) states that health disparities occur in vulnerable patients who are uninsured, racially and ethnically diverse, and frequently speak languages other than English. Maze (2005) refers to health disparities existing among indi-viduals who are disenfranchised, living in pov-erty, stigmatized, homeless, immigrants, victims of crimes, children, women, prisoners, persons with AIDS, persons with mental illness, and those who have little social support or education. These individuals make up a vulnerable population and may present with a variety of ethical issues for the healthcare professional. For example, illegal immi-grants may be hesitant to provide a name, address, and phone number for follow-up care. Should the healthcare provider try to obtain this information from the illegal immigrant? Remember, the client may be fearful that you will “turn them in” to the authorities.

The article The State of Opportunity in America (n.d.) confirmed that in 2002, 28% of African Americans, 44% of Hispanic Americans, 24% of Asian Americans and Pacific Islanders, and 33% of American Indians and Alaska Natives were unin-sured and more likely to be dependent upon public sources of health insurance. Minorities are more likely to receive inappropriate or insufficient care than are nonminorities (Smedley et al., 2003).

Racial and Ethnicity Classification

In 1997 the Office of Management and Budget (OMB) identified the following categories to be used by federal programs when reporting data: American Indian or Alaska Native; Asian; Black or African American; Hispanic or Latino; Native Hawaiian or other Pacific Islander; and White. American Indian or Alaska Native refers to peo-ple of North and South America and those that

different cultures must be noted as well. Race, ethnicity, and culture sharply divide the health and health care of the population in the United States. Although such disparities have been noted for some time, the Institute of Medicine report, Unequal Treatment (Smedley, Stith, & Nelson, 2003), was a landmark publication that put these disparities in the forefront. This report demon-strated that racial and ethnic disparities in health care, with a few exceptions, are consistent across a range of illness and healthcare services.

The same year that Unequal Treatment was published, the Agency for Healthcare Research and Quality (AHRQ) released the first annual National Healthcare Disparities Report. Their fifth report was released in February of 2008. Overall three themes emerged from their latest report:

Disparities in healthcare quality and access ■■

are not getting smallerProgress is being made, but many of the big-■■

gest gaps in quality and access have not been reducedThe problem of persistent uninsurance is a ■■

major barrier to reducing disparities (AHRQ, 2008, p. 1)

Some of the biggest disparities noted in this latest report include:

Blacks had a rate of new AIDS cases 10 times ■■

higher than whitesAsian adults age 65 and older were 50% more ■■

likely than whites to lack immunization against pneumoniaAmerican Indians and Alaska Natives were ■■

twice as likely to lack prenatal care in the first trimester than whites (AHRQ, 2008, p. iv)

Another national document that addresses health disparities is Healthy People 2010. The two goals of the document are (1) eradicating health disparities, and (2) increasing health-related quality of life. As healthcare professionals, the need is paramount to incorporate appropriate strategies into clinical


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Impact ■ 283

SNL

283

maintain tribal affiliations (Wallman, 1998). An Asian is a person with origins in the Far East, Southeast Asia, or the Indian subcontinent. Black or African American refers to individu-als with origins from any black racial groups of Africa. Hispanic or Latino is an individual of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin. Native Hawaiians or Other Pacific Islanders have origins in Hawaii, Guam, Samoa, or other Pacific Islands. White is a person having origins in any of the original people of Europe, the Middle East, or North Africa. However, with individuals from mixed origins, it may be difficult to assign an indi-vidual to one specific ethnic group.

Examples of Different Cultures

The following examples of the Haitian culture, Mexican culture, and Japanese culture are brief overviews and generalizations of what is known about each culture. Disease labels in each of these cultures have different influences and meanings among clients (Turner, 1996).

In addition, the longer that one is a resident in this country (or other countries), subcultures of the original culture evolve, with each one being more unique.

Haitians

Haitians are from Haiti, an island between Cuba and Puerto Rico about the size of the state of Maryland. The Haitian population in the United States is approximately 365,000 (US Census Bureau, 2005); however, Haitian leaders would argue that there are nearly 1.5 million Haitians in the United States (Colin & Paperwalla, 2008).

The influence of France’s rule of Haiti from 1697 to 1804 identified two distinct categories of Haitians. Members of the upper class used the marker of mulatto (color), the French culture, and the French language to differentiate them-selves from the lower class. Those speaking French rose within the social system. The lower class was

mostly black and spoke the Haitian Creole lan-guage, which is a combination language of multi-tribe slaves of Africa. Today, Creole is the official language of Haiti (Colin & Paperwalla, 2008).

Traditionally, the man has been considered the head of the household, the primary income pro-vider, the decision maker, and the sexual initiator, whereas women are to be faithful, honest, respect-ful, and oversee the house (Dash, 2001). However, that may be changing, as a number of families are becoming matriarchal today (Colin & Paperwalla, 2008). The family unit remains an important con-cept of Haitian culture.

Haitian people are openly demonstrative in their emotions and typically speak loudly. They have a close personal space and may ignore territo-rial space. Many may pretend to understand, when in reality they are nodding to be nice and not to show a lack of understanding. The use of simple and clear instructions is needed when providing education to enhance the health of the individ-ual. Haitians are private, and if they do not under-standing something, will more than likely choose to use a professional interpreter over a family member (Colin & Paperwalla, 2008).

Drinking alcohol and cigarette smoking is culturally approved for men and is the norm. The Haitian diet is high in carbohydrates and fat, with weight loss being a sign of illness. Lifestyle changes needed when faced with a chronic illness will be a challenge for the provider when trying to help clients understand the impact of alcohol, smoking, and diet to a chronic illness (Colin & Paperwalla, 2008).

Even though Haitians are deeply religious, they also have many superstitions. These beliefs include the fear of a loved one not actually dying, but becoming a zombie. If it is believed that an individual is not really dead, they may ask for an autopsy to ensure death. Beliefs of voodoo-ism, with its roots in Africa, are often co-aligned with their religious beliefs. Voodoo occurs when an individual has the power to communicate by trance with ancestors, saints, or animistic deities. This can have an influence on the psychological


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL284

are chosen for special occasions (Berry, 2002). The elderly are valued and respected, and their knowl-edge about health information often takes prece-dence over that of professional healthcare providers (Berry, 2002; Zoucha & Zamarripa, 2008). Younger generations have the obligation to care for the older generations. Typical families are viewed as patriar-chal, with males being dominant and females being passive. Machismo in the Mexican culture views men as having strength, valor, and self-confidence (Zoucha & Zamarripa, 2008).

Because family is a priority for Mexican Americans, it will take precedence over work issues. Many are sensitive to confrontation and difference of opinion, and will shun those chal-lenges, especially in the workplace. Truth is often tempered with diplomacy and tact (Zoucha & Zamarripa, 2008). As an example, in the workplace when a service is promised for tomorrow even though it cannot be completed by then, that prom-ise is made to please the customer, not to deceive. For some Mexican Americans, truth is a relative concept; whereby for most European Americans, it is an absolute value (p. 314).

Mexican American’s concepts of health and illness are a combination of Aztec and Spanish beliefs (Berry, 2002). Within the culture there is a folk belief system, based in part on religion, regarding cause and cure of illnesses. This system stresses the omnipotence of God, the inevitabil-ity of suffering, and the lack of personal control (p. 367). Mexican Americans have a fatalistic worldview and an external locus of control. Thus, if someone becomes ill, that’s just the way things are. With preventive health care in short supply in Mexico, many Mexican Americans believe that what happens to them is God’s will.

A health belief still prevalent today is that illness is caused by a hot and cold imbalance (Gonzalez & Kuipers, 2004). To cure the illness, the opposite quality of the causative agent must be applied (p. 234). Cold diseases or conditions include menstrual cramps, pneumonia, cancer, earaches, arthritis and others. Hot diseases include pregnancy, diabetes, hypertension, infection, and

stance of the client. Hence, illness can be per-ceived as punishment for being evil or occur from evil spirits (Corrine, Bailey, Valentin, Mortantus, & Shirley, 1992). Given that vodo and folk rem-edies are used among this group, providers should always ask what prior home interventions have been tried before prescribing (Galembo & Fleurant, 2005).

Mexicans

Hispanic is a term that is commonly used in the United States to designate all those who speak Spanish. This cultural group includes those from Puerto Rico, Cuba, Mexico, Latin America, and other countries as well. Typically many Hispanic people wish to be described by terms that are specific to their culture, thus using the term Mexican American, is more appropriate (Zoucha & Zamarripa, 2008). Because of the poor econ-omy in Mexico, there has been a constant influx of immigrants from that country during most of the 20th century and now into the 21st century. The media consistently reports stories of undoc-umented aliens who continue to cross the border into the United States to earn money for their fam-ilies left behind in Mexico.

Religious beliefs are very important to Mexican Americans, who believe that there is a divine power that has ultimate control of their lives, and one must accept what God gives (Berry, 2002, p. 365). The majority of Mexican Americans are Roman Catholics, and although they may not all attend formal church regularly, pictures and statues with a religious theme are evident in many of their homes.

The family and kinship are important social structures to Mexican Americans. In addition, this group is collectively oriented versus the indi-vidual orientation so common in North America. Mexican Americans may prefer to live close to their family and extended family, but not necessar-ily in the same household, as has been seen in the past. Family extends beyond the immediate circle to include fictive kin or compadres, friends who


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Impact ■ 285

SNL

285

kidney and liver conditions. Regarding pain, Mexicans perceive it as a part of life and part of the inevitable suffering (Zoucha & Zamarripa, 2008, p. 321).

Generally, Mexican Americans respect health-care professionals because of their training and expertise (Zoucha & Zamarripa, 2008). If health-care professionals demonstrate respect with their clients, can incorporate folk practitioners as nec-essary and appropriate, and the concept of person-alismo into their care, the provider will gain the client’s confidence and trust.

Japanese

A common stereotype is to categorize those from the Far East and Southeast Asia as Asians, versus Japanese, Chinese, Korean, Malaysian, Vietnamese, Thai, and so forth. In fact, using the US Census as an example, Asians include individ-uals from 28 Asian countries (Itano, 2005).

Education is highly valued in Japan, and the illiteracy rate is only 1%. Nearly 95% of students in Japan complete the 12th grade, and the standards for this accomplishment are high. As an exam-ple, calculus is part of the mandatory junior high school curriculum (Turale & Ito, 2008).

Japanese American immigrants are the only group to refer to themselves by the generation in which they were born. For instance, issei refers to first-generation immigrants; nisei, to second-generation immigrants; sansei, to third-generation immigrants; yonsei, the fourth generation; gosei, the fifth generation; and rokusei, the sixth gen-eration. These generational categories provide a framework for understanding their cultural values (Ishida & Inouye, 2004, p. 335).

Japanese society is both structured and tra-ditional. Politeness, personal responsibility, loy-alty, and working together for the greater good are important concepts. Group harmony is stressed above all else. Japan is a collectivist society, where group needs and wants take precedence over indi-viduals. Japanese culture discourages individual-ism. There is much sensitivity to social status and one’s relative position in life (Brightman, 2005; Turale & Ito, 2008).

The culture is also a relatively non–eye-con-tact culture when communicating. For some it is considered disrespectful to look someone directly in the eye, particularly if that individual is in a superior position (Galanti, 2004). Japanese culture is seen as a nontouch culture (Ishida & Inouye, 2004). Although there is touch and close contact with infants, there is much less touch and physical contact between adults. Lastly, the ideal pattern of communication in Japanese society is silent com-munication. Japanese do not appreciate aggressive conversation and prefer to remain silent.

The family is important to Japanese Americans. There is a phrase, kodomo no tame ni (for the sake of the children), that reflects the sacrifices that par-ents and adults make for the success of the next generation (Ishida & Inouye, 2004, p. 342).

Pain is a concept that should not be expressed verbally. Bearing pain is seen as a virtue and one

CASE STUDY

A home health nurse received an angry call from a Mexican American woman after visiting her house the day before. Her infant had been crying and feverish the next morning and the woman recalled the nurse had remarked the child was adorable. The nurse’s compliment and the fact that she had not touched the child, led her to conclude that the nurse had given him the evil eye (www.culturediversity.org/hasp/htm).

Discussion Questions

1. How do you, as the nurse, interpret this wom-an’s behavior?

2. What belief of this woman’s heritage have you as the healthcare professional offended?

3. How can you avoid offending someone in a similar situation in the future?


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL286

diseases such as HIV, hepatitis, or tuberculosis) may emerge (Pearson, 2003).

Poverty impacts migrants such as Mexicans; the North American Indian; and immigrants from the Middle East, India, and China. Providing care to migrants and immigrants poses an added chal-lenge as these individuals are not only impover-ished but also from a different cultural orientation. Healthcare professionals need to consider the cultural and social complexities that increase the challenges of managing chronic illnesses. Being uninsured, having a lower income, and lower edu-cational levels have been associated with a decrease in hypertension and cholesterol screening (Stewart & Silverstein, 2002).

INTERVENTIONS

CLAS Standards

In 2000, the US Department of Health and Human Services (DHHS) Office of Minority Health (OMH) released 14 national standards for culturally and linguistically appropriate services (CLAS) as a means to address and correct inequities in the pro-vision of health care to culturally and ethnically diverse groups. These standards are available at the OMH website (www.omhrc.gov/CLAS). These standards are organized by themes: Culturally Competent Care (Standards 1–3), Language Access Services (Standards 4–7), and Organizational Supports for Cultural Competence (Standards 8–14). Some of these standards are mandates, such as 4, 5, 6 and 7, whereas others are guidelines that should be adopted by federal, state, and national accrediting agencies. One standard, Standard 14, is suggested as voluntary.

Standard 4 mandates that healthcare organi-zations must offer and provide language assistance at no cost to clients during all hours of operation. Standard 5 mandates that healthcare organiza-tions must have a mechanism to provide clients, in their language, information on their rights to receive language assistance. Standard 6 mandates that the language assistance be competent, and

of family honor (Turale & Ito, 2008). In fact in Japan, medications to relieve pain are used much less than in the United States. Furthermore, nar-cotic use, in particular, is restricted.

In Japan today, physicians are clearly in charge of the healthcare team, and are held in high esteem. The majority of hospitals in Japan are managed by physicians as opposed to individuals with a health-care management background. Because self-care is not highly regarded in Japan, and physicians are held in high regard, being told what to do by the physician is expected (Turale & Ito, 2008).

The Chinese culture has influenced the health care of many Asian groups, including the Japanese. For instance, there must be a balance between hot (yang) and cold (yin). Yin and yang are life forces, and it is believed that illness occurs when there is an imbalance between the two forces (Itano, 2005). The approach to care is to restore harmony, order, and control through one’s environment. Harmony is highly valued as a healing mode and to control one’s emotions (Leininger, 2002, p. 459).

Culture of Poverty

The culture of poverty impacts the health care of a socioeconomic group, which is often faced with numerous barriers such as access, cost of care, health literacy, and a focus on surviving from one day to the next. Individuals living in poverty may place health lower on their list of priorities as they attempt to live day to day without finan-cial resources. The lack of financial resources often results in less diagnostic tests, use of generic drugs, goal setting that is short term, and the challenge of ensuring compliance (Benson, 2000).

Poverty is synonymous with a present-moment orientation, a lack of planning ahead, and a fatalistic future. Generation after generation can perpetuate poverty by basing decisions on previous decisions that have been made by family members, parental employment and earnings, family struc-ture, and parent education. With poverty, chronic health issues such as substance abuse, smoking, obesity, and incarceration (which may result in


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Interventions ■ 287

SNL

287

TABLE 12-3

CLAS Standards

Standard 1 Healthcare organizations should ensure that patients/consumers receive from all staff member’s effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2 Healthcare organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

Standard 3 Healthcare organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

Standard 4 Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency, at all points of contact, in a timely manner during all hours of operation.

Standard 5 Healthcare organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6 Healthcare organizations must ensure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7 Healthcare organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

Standard 8 Healthcare organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

Standard 9 Healthcare organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.

Standard 10 Healthcare organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.

Standard 11 Healthcare organizations should maintain a current demographic, cultural, and epidemiologic profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Standard 12 Healthcare organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.

Standard 13 Healthcare organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

Standard 14 Healthcare organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

Source: Office of Minority Health. (2008). US Department of Health & Human Services, National Standards on Culturally and Linguistically Appropriate Services (CLAS). Retrieved from www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=11


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL288

that families and friends should not be utilized unless requested by the client. Standard 7 man-dates that signs should be posted in a facility that reflect the most commonly encountered language in the service area. These signs and patient mate-rials should be easily understood. The remaining standards are guidelines and recommendations (Table 12-3 includes all of the mandated guidelines and recommendations).

To help implement the standards on an orga-nizational level, the Alliance of Community Health Plans Foundation, with funding from the Merck Company Foundation, developed 13 case studies and a final report about making a “business case” for projects addressing the CLAS Standards. Each of these case studies addresses the business ben-efits from addressing the cultural and linguistic needs of clients (Alliance of Community Health Plans Foundation, 2007).

Nursing Frameworks for Practice

Currently a variety of models, theories, and frame-works are available to assist nurses in providing appropriate care for diverse populations. The web-site of the Transcultural Nursing Society (www.tcns.org) provides information about six transcul-tural nursing theories and models. Models include those by Margaret Andrews and Joyceen Boyle; Josepha Campinha-Bacote; Joyce Giger and Ruth Davidhizar; Madeline Leininger; Larry Purnell; and Rachel Spector. Three of those models are dis-cussed in the following text.

Leininger’s Cultural Care Theory of Diversity and Universality

Cultural values, beliefs, and practices impact health and illness and inform and guide the client and his/her family in the choices and patterns of health care. Care is universal; however, patterns of care vary among and between cultural groups with regard to healthcare beliefs and behaviors (Leininger, 2002; Leininger & McFarland, 2002, 2006). Leininger’s Culture Care Theory provides a

theoretical framework for healthcare professionals to discover the differences and similarities between and among cultural groups related to their cultural values, beliefs, and practices. The meanings and uses of these diversities and universalities among the cultures of the world need to be uncovered and understood (Leininger & McFarland, 2002, p. 78).

The social structure of the client and his or her family such as economics, religion, and world-view influence cultural care meanings, expres-sions, and patterns in different cultures (Leininger & McFarland, 2002, p. 78). Embedded within these structures are generic (folk) care practices, which are separate and distinct from profes-sional care practices (Leininger, 1997; Leininger & McFarland, 2002). This theoretical tenet is par-ticularly instructive for healthcare providers. For example, an individual with chronic pain may rely on the home remedies taught by an elder in the family or use a variety of herbs and compounds that have been obtained from a traditional healer to manage pain. The healthcare provider must be vigilant in the belief and use of generic care prac-tices, and incorporate those into the plan of care. The last theoretical tenet of Leininger’s theory pro-vides three modes of nursing decisions and actions for culturally congruent care: (1) culture care pres-ervation and maintenance, (2) culture care accom-modation and/or negotiation, and (3) culture care restructuring and/or repatterning (Leininger, 2002; Leininger & McFarland, 2002, 2006).

As an example, Mrs. Huerta has degenerative arthritis. Her mother was a traditional healer in the village where she grew up. As a young child, Mr. Huerta learned the healing ways and prac-tices from her mother. As an elderly woman, Mrs. Huerta continues to use these traditional methods to manage her chronic pain. When Mrs. Huerta was admitted to the acute care setting, she brought with her remedies that have brought her comfort and relief in the past. Leininger’s three modes of nursing decisions and action are informative and directive for the nurse to provide culturally compe-tent care for Mrs. Huerta. The nurse can incorpo-rate these home remedies into the care within the


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL

289

The Purnell Model for Cultural Competence

Purnell’s Model for Cultural Competence is graphically represented in a model that includes both the macro and micro concepts. The model is depicted by four concentric circles, each depict-ing a macro concept. The outer circle represents global society, and is defined as “world communi-cations and politics; conflicts and warfare; natural disasters and famines; international exchanges in business, commerce, and information technology; advances in the health sciences; space explora-tion; and the increased ability for people to travel around the world and to interact with diverse soci-eties” (Purnell, 2008b, p. 20).

The second circle is the community, and it is defined as a group of people living that have com-mon interests, but not necessarily living in the same geographic area. It is the physical, social, and symbolic characteristics of the community that enable it to feel connected, not common geogra-phy (p. 21). The third circle represents the family that is made up of two or more individuals who are emotionally connected, and who or may not live together. The fourth circle represents the indi-vidual who is continually adapting to his or her community (p. 22).

The model’s organizing framework comprises 12 microconcepts, or domains, that are intercon-nected and common to all cultures with impli-cations for health and health care. To assess the ethnocultural attributes of the community, family or person, each of the following domains needs to be addressed:

Overview, inhabited localities, and topo-■■

graphyCommunication■■

Family roles and organization■■

Workforce issues■■

Biocultural ecology■■

High-risk behaviors■■

Nutrition■■

Pregnancy and childbearing practices■■

Death rituals■■

acute setting, the nurse can talk with Mrs. Huerta, or, in the event the home remedies Mrs. Huerta is taking are known to be unsafe or contraindicated with her present care regime, the nurse can explore alternative comfort and pain relief strategies with Mrs. Huerta. The cultural care values, beliefs, and practices are honored and maintained. Therefore, Leininger advocates cultural holding knowledge by healthcare providers in order to provide cultur-ally competent care and further, to minimize the potential for cultural inappropriate care that has the potential for harm and pain to the healthcare client and his/her family.

Giger-Davidhizar Transcultural Assessment Model

The Giger-Davidhizar Model was developed ini-tially in 1991. The model is built upon concentric concepts with the client, a unique cultural being, in the center. The next circle contains concepts of religion, culture, and ethnicity (2004). The last circle focuses on six cultural concepts: (1) com-munication, (2) space, (3) social organization, (4) time, (5) environmental control, and (6) biological variation.

Communication refers to all human interac-tion and behavior, both verbal and nonverbal. Space refers to the distance between individuals when they interact, communicate, or reside together. Time can be past, present, or future oriented. How individuals view this concept is often uncovered through their style of communication. Individuals who focus on the past, attempt to maintain tradi-tion, whereas those focused on the present do not formulate goals. Environmental control refers to the ability of the individual to control nature and to plan and direct factors in the environment that affect them. If persons come from cultural groups where there is external control, there may be a fatalistic view ultimately resulting in the belief that seeking health care is useless. Biological differ-ences, especially genetic variations, exist between individuals. These biologic differences among var-ious racial groups are often less understood (Giger & Davidhizar, 2004).


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL290

It is difficult to understand others’ beliefs if you do not have an awareness of your own, and how they may influence your attitudes toward others.

The use of symbols to facilitate communica-tion in healthcare facilities can serve as a means to represent a world object, place, or concept. Unfortunately in hospitals, universal symbols on signs are rare; instead text in another language is more often found. The idea of symbols for health-care signage originated from the subway system in Mexico City, which uses cultural icons to identify destinations. In 2003, Hablamos Juntos utilized a consultant to explore the use of healthcare sym-bols for wayfinding, including recommendations for future steps (Hablamos Juntos, 2008). The con-clusion of the white paper was that symbols were a viable option for wayfinding in health care, that a set of tested symbols, publicly available, would help designers of health facilities increase commu-nication and understanding. A total of 28 symbols were developed, with 17 of them being understood by at least 87% of a subject group of 300 partici-pants from four language groups: English, Spanish, Indo-European, and Asian languages. This infor-mation is readily available, but why haven’t facili-ties implemented these symbols?

Communication can be difficult between dif-ferent cultures because of misunderstandings, inability to speak a language, or the use of tech-nical terminology. Each culture has patterns for word choice, inflection, gestures and facial expres-sions, eye movement and eye contact, volume and speed of speech, use of silence, directness, and the degree of emotion. Nonverbal cues also impact communication. The amount of personal space, social space, and public space often differ between cultures, and one should always note another per-son’s comfort zone.

Health Assessment

As the initial step in the nursing process, it is critical that healthcare professionals understand certain cultural behaviors related to their physi-cal assessment. Simple things like eye contact and touch can greatly affect an individual’s response

Spirituality■■

Healthcare practices■■

Healthcare practitioners (Purnell, 2008b, p. 22)■■

Purnell (2008b) also includes barriers to appro-priate health care that individuals, families and communities may face. The barriers are termed the 12 A’s of which healthcare professionals need to be aware. Barriers include availability, accessibil-ity, affordability, appropriateness, accountability, adaptability, acceptability, awareness, attitudes, approachability, alternative practices, and addi-tional services available.

Communication

Communication is the crux of cultural care. It is important for nurses to be aware of appropriate body stance and proximities, gestures, languages, listening styles, and eye contact when communi-cating with clients, as different cultural groups, nearly 3000 worldwide, vary widely in their ideas regarding these (Narayanasamy, 2003). Differences in language between the client and healthcare pro-fessional impede detection of health needs, treat-ment, and patient care. For nursing interventions to be effective, it is imperative that nurses give attention to all aspects of the client’s care as well as the communication process involving them.

The practice of cultural care requires negotia-tions and compromise as well as an understand-ing of how the patient views his health problem. Clients cared for by a nurse who has developed an awareness of cultural care practice have the oppor-tunity to be fully acknowledged. Nurses who have an awareness of appropriate cultural care practice need to encourage their peers and promote the delivery of cultural care nursing by utilizing it in their everyday nursing practice.

Giger and Davidhizar (2004) have developed guidelines for communication (see Table 12-4). Although these are general guidelines, they pro-vide a basis or a starting point. Although all of the guidelines are important, perhaps the initial one that is most important is to assess your own per-sonal beliefs about persons from different cultures.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL

291

TABLE 12-4

Communication Guidelines

Assess your personal beliefs surrounding persons from different cultures.1. Review your personal beliefs and past experiencesa. Set aside any values, biases, ideas, and attitudes that are judgmental and may negatively affect careb.

Assess communication variables from a cultural perspective3. Determine the ethnic identity of the patient, including generation in Americaa. Use the patient as a source of information when possibleb. Assess cultural factors that may affect your relationship with the patient and respond appropriatelyc.

Plan care based on the communicated needs and cultural background3. Learn as much as possible about the patient’s cultural customs and beliefsa. Encourage the patient to reveal cultural interpretation of health, illness, and health careb. Be sensitive to the uniqueness of the patientc. Identify sources of discrepancy between the patient’s and your own concepts of health and illnessd. Communicate at the patient’s personal level of functioninge. Evaluate effectiveness of nursing actions and modify nursing care plan when necessaryf.

Modify communication approaches to meet cultural needs4. Be attentive to signs of fear, anxiety, and confusion in the patienta. Respond in a reassuring manner in keeping with the patient’s cultural orientationb. Be aware that in some cultural groups discussion with others concerning the patient may be offensive and c. impede the nursing process

Understand that respect for the patient and communicated needs are central to the therapeutic relationship5. Communicate respect by using a kind and attentive approacha. Learn how listening is communicated in the patient’s cultureb. Use appropriate active listening techniquesc. Adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by cultured.

Communicate in a nonthreatening manner6. Conduct the interview in an unhurried mannera. Follow acceptable social and cultural amenitiesb. Ask general questions during the information-gathering stagec. Be patient with a respondent who gives information that may seem unrelated to the patient’s health problemd. Develop a trusting relationship by listening carefully, allowing time, and giving the patient your full attentione.

Use validating techniques in communication7. Be alert for feedback that the patient is not understandinga. Do not assume meaning is interpreted without distortionb.

Be considerate of reluctance to talk when the subject involves sexual matters8. Be aware that in some cultures sexual matters are not discussed freely with members of the opposite sexa.

Adopt special approaches when the patient speaks a different language9. Use a caring tone of voice and facial expression to help alleviate the patient’s fearsa. Speak slowly and distinctly, but not loudlyb. Use gestures, pictures, and play acting to help the patient understandc. Repeat the message in different ways if necessaryd. Be alert to words the patient seems to understand and use them frequentlye. Keep messages simple and repeat them frequentlyf. Avoid using medical terms and abbreviations that the patient may not understandg. Use an appropriate language dictionaryh.

Use interpreters to improve communication10. Ask the interpreter to translate the message, not just the individual wordsa. Obtain feedback to confirm understandingb. Use an interpreter who is culturally sensitivec.

Source: Giger, J. & Davidhizar, R. (2004). Transcultural nursing: Assessment and intervention (4th ed.) (p. 35). St. Louis: Mosby.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL292

Professional Education

The need for education about different cultures to progress toward cultural competency is evi-dent. There are an increasing number of resources available online that may provide assistance. For instance, the National Technical Assistance Center at the University of Hawaii provides information

to the healthcare professional and determine what can and cannot be done regarding the individual’s health care. Giger and Davidhizar (2004) have pro-vided a table with some basic cultural variations that may be seen in health assessment (see Table 12-5). Again, as with all cultures, there is unique-ness in each individual, and these behaviors should be seen as general guidelines only.

TABLE 12-5

Behaviors Related to Health Assessment

Cultural Group Belief/Practice Nursing Implication

African Americans Dialect and slang terms require careful communication to prevent error.

Question the client’s meaning.

Mexican Americans Eye behavior is important. An individual who looks at and admires a child without touching the child has given the child the “evil eye.”

Always touch the child you are examining.

American Indians Eye contact is considered a sign of disrespect. Recognize that the client may be attentive and interested even though eye contact is avoided.

Appalachians Eye contact is considered impolite or a sign of hostility. Verbal patter may be confusing.

Avoid excessive eye contact.

American Eskimos Body language is very important. Individual seldom disagrees publicly with others. May nod yes to be polite, even if not in agreement.

Monitor own body language.

Jewish Americans Orthodox Jews consider excess touching offensive, particularly from members of the opposite sex.

Establish whether client is an Orthodox Jew and avoid excessive touch.

Chinese Americans Individual may nod head to indicate yes or shake head to indicate no. Excessive eye contact indicates rudeness. Excessive touch is offensive.

Ask questions carefully and clarify responses. Avoid excessive eye contact and touch.

Filipino Americans Offending people is to be avoided at all cost; nonverbal behavior is very important.

Monitor nonverbal behaviors.

Haitian Americans Touch is used in conversation. Direct eye contact is used to gain attention and respect.

Use direct eye contact when communicating.

East Indian Hindu Americans

Women avoid eye contact as a sign of respect. Be aware that men may view eye contact by women as offensive. Avoid eye contact.

Vietnamese Americans Avoidance of eye contact is a sign of respect. The head is considered sacred; it is not polite to pat the head. An upturned palm is offensive in communication.

Limit eye contact. Touch the head only when mandated and explain clearly before proceeding to do so. Avoid hand gesturing.

Source: Giger, J. & Davidhizar, R. (2004). Transcultural nursing: Assessment and intervention (4th ed.) (p. 15). St. Louis: Mosby.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL

293

Putting the Pieces of the Puzzle Together

Schim, Doorenbos, Benkert, and Miller (2007) view the bigger picture as culturally congruent care versus culturally competent care. Leininger was the first to use the term culturally congruent care, and Schim and colleagues’ model builds on Leininger’s work and definition. Culturally congruent care is defined as:

Those cognitively based assistive, sup-portive, facilitative or enabling acts or decisions that are tailor made to fit with individual, group, or institution cultural values, beliefs and lifeways in order to pro-vide or support meaningful beneficial and satisfying health care or well-being servic-es (Leininger, 1991, p. 49).

Schim and colleagues apply the puzzle metaphor to this care and see the finished puzzle with four constructs (2004, p. 105). These constructs include cultural diversity, cultural awareness, cultural sen-sitivity, and cultural competence.

Cultural Diversity■■

varies in quality and quantity across place and time; is dynamic, ever-changing

Cultural Awareness■■

cognitive construct; a reality to be contem-plated and a corresponding capacity for processing knowledge

Cultural Sensitivity■■

affective or attitudinal construct; attitude about their own person and others

Cultural Competence■■

behavioral construct; is the action that is taken in response to diversity, awareness, and sensitivity

Schim and colleagues suggest that there is one piece missing from their puzzle model and that is the client, whether it be an individual, family, or community. The client “layer” of the puzzle, although essential, is not visualized in the current model (p. 106).

about Asian Americans and Pacific Islanders to increase the potential of individuals with disabili-ties in these groups to gain employment. Their Web site contains overviews of each culture, news-letters, success stories, and training (http://www.ntac.hawaii.edu).

The DHHS OMB has developed Culturally Competent Nursing Modules for nurses to increase awareness, knowledge, and skills in caring for those from diverse populations (Scott, 2008). The content of those modules are focused on the themes of the CLAS Standards. There is no cost for the modules, and continuing education credit is offered.

The National Center for Cultural Competence based at the Georgetown University Center for Child and Human Development (http://www11.georgetown.edu/research/gucchd/nccc) has mul-tiple resources available on their Web site. The center also has a Curricula Enhancement Module Series.

The Commonwealth Fund with their work in cultural competency provides papers, a video, and presentations on their Web site (http://www.commonwealthfund.org). This fund has sup-ported significant research in the area of cultural competency.

Measuring Cultural Competence From the Patient’s Perspective

As health care tries to ascertain “best practices” in providing culturally competent care, who bet-ter to ask than the patient? The Commonwealth Fund’s division of health policy, health reform, and performance improvement has identified five domains of culturally competent care that can best be assessed from the patient perspective. The five components include (1) patient–provider commu-nication, (2) respect for patient preferences and shared decision-making, (3) experiences leading to trust or distrust, (4) experiences of discrimination, and (5) linguistic competency (Ngo-Metzger et al., 2006). The five components have been incorpo-rated into a conceptual framework as well.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL294

Health Disparities Report produced by the AHRQ and Healthy People 2010 would provide evidence of decreasing health disparities.

In addition, as suggested by the Commonwealth Fund, giving credence to patients’ perceptions of cultural competence makes sense. Healthcare pro-fessionals may think they are culturally competent,

OUTCOMES

The literature is clear that providing culturally competent (or congruent) care is a primary strat-egy in reducing or eliminating racial and eth-nic health disparities in the United States. Thus outcome measures such as the annual National

There is consensus that self-care practices play a significant role in the management of chronic illness; however, we don’t know how self-care is influenced by culture. This study interviewed 167 African Americans with one or more chronic illnesses from two urban counties in California to determine their self-care practice and influences to those practices. Participants were interviewed three times over the course of a year. The sample included individuals of varying health insur-ance status and different age groups. The most common illnesses included diabetes, asthma, and heart disease or hypertension. Interview data were divided into low-income and middle-income groups, with a further step of categorizing individuals as uninsured, Medicaid, Medicare, or pri-vately insured. Groups were analyzed separately and then cross-group comparisons were made.

Self-care practices among African Americans were found to be culturally based. The partici-pants described idea systems and behavioral practices that were shared by most in the sample. Three culturally based factors were central to the development of their self-care practices and included: (1) spirituality; (2) social support and advice; and (3) nonbiomedical healing traditions. These factors were present regardless of socioeconomic status (p. 2069).

Spirituality. Almost all participants reported that a belief in God or a higher power helped them to manage their illness. Spirituality was a part of their daily practices. Participants cited the importance of focusing on inner strength derived from their religion and cultural values.Social Support and Advice. Emotional support was highly valued and came from a variety of sources. Both men and women reported that their mother was a major source of support. In addi-tion, social support came from children to parents as children reminded their parents of medica-tions, treatments, self-care, doctor’s appointments, and so on. Friends also reenforced self-care.Nonbiomedical Healing Traditions. Many times these healing traditions were shared with the participants from their mothers. Although traditional medicine was used, it was augmented with nontraditional remedies.Nursing Implications. This study underlined the value of being aware of clients’ cultural prac-tices and how they influence self-care in chronic illness. Although we have valued self-care as an important component in caring for patients with chronic illness, the cultural component of such care has been underemphasized. With the exception of church-based interventions, public health practice often overlooks the feasibility of building on cultural practices.

Source: Becker, G., Gates, R.J., & Newsom, E. (2004). Self-care among chronically ill African Americans: Culture, health disparities, and health insurance status. American Journal of Public Health, 94(12), 2066–2073.

EVIDENCE-BASED PRACTICE BOx


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Outcomes ■ 295

SNL

295

but do their patients agree? Ngo-Metzger and col-leagues (2006) suggest monitoring patient populations through both quantitative and qualitative methods

STUDY QUESTIONS

Why does culture matter in the care of an 1. individual, family, or community?How does one become culturally 2. competent?Distinguish between being culturally sensi-3. tive, aware, and competent?Standard 12 of CLAS states: Healthcare 4. organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. What strategies would facilitate standard 12?

Evaluate the barriers to health care in a 5. culturally diverse client you have recently seen using Purnell’s identified barriers of availability, accessibility, affordability, appropriateness, accountability, adaptability, acceptability, awareness, attitudes, approach-ability, alternative practices, and additional services available.How do the different transcultural nursing 6. theories view cultural competence?How are the different cultures (Haitian, 7. Japanese, and Mexican) similar and different in their views of health and illness?Explain how becoming culturally competent 8. might decrease health disparities.

that examine health literacy, English proficiency, lan-guage spoken at home, and the use of complementary and alternative medical practices (p. 26).

INTERNET RESOURCES

Association of Asian Pacific Community Health Organizations: www.aapcho.org/site/aapcho/section.php?id=10942Black Health Network: www.blackhealthnet.comCenter for Cross-Cultural Health: www.crosshealth.comCenters for Disease Control and Prevention National Prevention Information Network: www.cdcnpin.orgDiversity in Medicine: www.amsa.org/divEthnoMed: www.ethnomed.orgHablamos Juntos: www.hablamosjuntos.org/signage/symbols/default.symbols.aspHRSA Health Disparities Collaborative: www.healthdisparities.net/hdc/html/home.aspxInitiative to Eliminate Racial and Ethnic Disparities in Health: raceandhealth.hhs.govMinority Health Program University of North Carolina at Chapel Hill: www.minority.unc.eduMulticultural Health Communication Service: www.mhcs.health.nsw.gov.au/Multicultural Audiovisual Resources: ublib.buffalo.edu/libraries/units/hsl/ref/av.htmlMultilingual Health Education Net: multilingual-health-education.netNational Center for Cultural Competence: www11.georgetown.edu/research/gucchd/nccc/documents/Materials_

Guide.pdfNational Multicultural Institute: www.nmci.orgNational Standards for Culturally and Linguistically Appropriate Services: www.omhrc.gov/CLASOffice of Minority Health Resource Center Health Resources and Services Administration: www.omhrc.govProvider’s Guide to Quality and Culture: erc.msh.org/quality&cultureResources for Cross Cultural Health Care: www.diversityrx.org


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL296

Agency for Healthcare Research and Quality (2008). National healthcare disparities report 2007. Rock-ville, MD: US Department of Health and Human Services. AHRQ Pub. No. 08-0041.

Alliance of Community Health Plans Foundation (2007). Making the business case for culturally and linguistically appropriate services in health care: Case Studies from the field. Retrieved on May 31, 2008 from www.achp.org/page.asp?page_id=1059

Becker, G., Gates, R.J., & Newsom, E. (2004). Self-care among chronically ill African Americans: Culture, health disparities and health insurance status. Amer-ican Journal of Public Health, 94(12), 2066–2073.

Beidler, S.M. (2005). Ethical issues experienced by com-munity-based nurse practitioners addressing health disparities among vulnerable populations. Interna-tional Journal for Human Caring, 9(3), 43–50.

Benson, D.S. (2000). Providing health care to human beings trapped in the poverty culture. Physician Executive, 26(2), 28–32.

Berry, A. (2002). Culture care of the Mexican American family. In M. Leininger & M.R. McFarland (Eds.). Transcultural nursing: Concepts, theories, research and practice (3rd ed.). (pp. 363–373). New York: McGraw Hill.

Brightman, J.D. (2005). Asian culture brief: Japan. Retrieved on May 31, 2008 from http://www.ntac.hawaii.edu/

Centers for Disease Control and Prevention. (2007). Cul- tural competence. Retrieved from www.cdcnpin.org/scripts/population/culture.asp

Centers for Disease Control and Prevention. (2007). Office of Minority Health and Disparity. Retrieved on February 15, 2008 from www.cdc.gov/omhd/

Colin, J.M., & Paperwalla, G. (2008). People of Haitian heritage. In L. Purnell & B. Paulanka (Eds.). Transcul-tural health care: A culturally competent approach. (3rd ed.) (pp. 231–247). Philadelphia: F.A. Davis.

Corrine, L., Bailey, V., Valentin, M., Mortantus, E., & Shirley, L. (1992). The unheard voices of women: Spiritual interventions in maternal-child health. Maternal Child Nursing, 17, 141–145.

Dash, J.M. (2001). Culture and customs of Haiti (Culture and Customs of Latin America and the Caribbean). Westport, CT: Greenwood Press.

REFERENCES

Dreher, M., & MacNaughton, N. (2002). Cultural com-petence in nursing: Foundation or fallacy? Nursing Outlook, 50, 181–186.

Galanti (2004). Caring for patients from different cul-tures: Case studies from American hospitals (3rd ed.). Philadelphia: University of Pennsylvania.

Galembo, P., & Fleurant, G. (2005). Vodou: Visions and voices of Haiti. Berkley, CA: Ten Speed Press.

Giger, J., & Davidhizar, R. (2004). (Eds.). Transcultural nursing: Assessment and intervention (4th ed.). St. Louis: Mosby.

Gonzalez, T., & Kuipers, J. (2004). Mexican Americans. In J. Giger and R. Davidhizar (Eds.). Transcultural nursing: Assessment and intervention (4th ed.), (pp. 221–253). St. Louis: Mosby.

Hablamos Juntos (2008). Language policy and prac-tice in health care. Retrieved on February 15, 2008 from www.hablamosjuntos.org.

Healthy People 2010 – Midcourse Review (2005). Retrieved on March 6, 2008 from www.healthy-people.gov/data/midcourse/default.htm

Helman, C.G. (2007) Culture, health and illness (5th ed.). London: Hodder Arnold.

Ishida, D., & Inouye, J. (2004). Japanese Americans. In J. Giger & R. Davidizar (Eds.) Transcultural nursing: Assessment and intervention (4th ed.) (pp. 332-361). St. Louis: Mosby

Itano, J.K. (2005). Cultural diversity among individuals with cancer. In C. H. Yarbro, M.H. Frogge & M. Goodman (Eds.). Cancer nursing: Principles and practice (6th ed.) (pp.69–94). Sudbury, MA: Jones & Bartlett.

Leininger, M. (Ed.). (1991). Culture care diversity and universality: A theory of nursing. New York: National League of Nursing.

Leininger, M. (1995). Transcultural nursing concepts, the-ories, research and practices. New York: McGraw-Hill Inc.

Leininger, M. (1997). Overview of the theory of culture care with the ethnonursing research method. Jour-nal of Transcultural Nursing, 8(2), 32–53.

Leininger, M. (2002). Culture Care Theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing, 13, 189–192.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

SNL

297

References ■ 297

Purnell, L. (2008a). Transcultural diversity and health-care. In L. Purnell & Paulanka, B. (Eds.). Transcul-tural health care: A culturally competent approach (3rd ed.). (pp. 1–18). Philadelphia: F.A. Davis.

Purnell, L. (2008b). The Purnell model for cultural competence. In L. Purnell & Paulanka, B. (Eds.). Transcultural health care: A culturally competent approach (3rd ed.). (pp. 19–55). Philadelphia: F.A. Davis.

Purnell, L., & Paulanka, B. (1998). Transcultural health care: A culturally competent approach. Philadel-phia: F.A. Davis.

Rasher, F.E., & Annis, R.C. (2007). Respecting culture and honoring diversity in community practice [Electronic version]. Research and Theory for Nurs-ing Practice: An International Journal, 21(4), p. 255–270.

Schim, S., Doorenbos, A., Benkert, R., & Miller, J. (2007). Culturally congruent care: Putting the puz-zle together [Electronic version]. Journal of Trans-cultural Nursing, 18(2), 103–110.

Scott, D.E. (2008, January/February). The multicultural health care work environment [Electronic version]. The American Nurse. Retrieved May 30, 2008 from www.NursingWorld.org

Smedley, B.D., Stith, A.Y., & Nelson, A.R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, D.C.: The National Academies Press.

Spector, R. (2004). Cultural diversity in health and ill-ness (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

Srivastava, R.H. (2007). Understanding cultural com-petence in health care. In R.H. Srivastava (Ed.). The healthcare professional’s guide to clinical cul-tural competence (pp. 3–27). Toronto: Mosby Elsevier.

Stewart, S.H., & Silverstein, M.D. (2002). Racial and ethnic disparity in blood pressure and cholesterol measurement. Journal of General Internal Medi-cine, 17, 458–464.

Turale, S., & Ito, M. (2008). People of Japanese heritage. In L. Purnell & B. Paulanka (Eds.). Transcultural health care: A culturally competent approach (3rd ed.). (pp. 260–277). Philadelphia: F.A. Davis.

Turner, D.W. (1996). The role of culture in chronic ill-ness [Electronic version]. American Behavioral Sci-entist, 39(6), 717–728.

Leininger, M.M., & McFarland, M.R. (2002). Transcul-tural nursing: Concepts, theories, research & prac-tice (2nd ed.). New York: McGraw-Hill.

Leininger, M.M., & McFarland, M.R. (2006). Culture care diversity and universality: A worldwide nursing theory (3rd ed.). Sudbury, MA: Jones & Bartlett.

Masi, R. (1996). Inclusion: How can a health sys-tem respond to diversity. In A.S. Zieberth (Ed.), Pinched: A management guide to the Canadian health care archipelago (pp. 147–157). Nepean, ON: Pinched Press.

Maze, C.D. (2005). Registered nurses’ personal rights vs. professional responsibility in caring for members of underserved and disenfranchised populations. Journal of Clinical Nursing, 14(5), 546–554.

Narayanasamy, A. (2003). Transcultural nursing: How do nurses respond to cultural needs? British Jour-nal of Nursing, 12(3), 185–194.

National Center for Cultural Competence. Georgetown University Center for Child and Human Devel-opment. Retrieved May 29, 2008 from www11.georgetown.edu/research/gucchd/nccc/resources/cultural5.html

National Prevention Information Network, Centers for Disease Control. Retrieved May 22, 2008 from www.cdcnpin.org/scripts/population/culture.asp.

Ngo-Metzger, Q., Telfair, J., Sorkin, D.H., Weidmer, B., Weech-Maldonado, R., Hurtado, M., et al. (2006). Cultural competency and quality of care: Obtain-ing the patient’s perspective. The Commonwealth Fund. Retrieved May 22, 2008 from www.com-monwealthfund.org/publications/publications_show.htm?doc_id=414116 .

Office of Minority Health. (2008). U.S. Department of Health & Human Services, Cultural Competency, Retrieved May 28, 2008 from www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=11

Office of Minority Health. (2008). U.S. Department of Health & Human Services, National Standards on Culturally and Linguistically Appropriate Services (CLAS). Retrieved from www.omhrc.gov/tem-plates/browse.aspx?lvl=2&lvlID=11

Opportunity Agenda, The. Building the national will to expand opportunity in America (n.d.). The state of opportunity in America. Retrieved November 26, 2007 from www.opportunityagenda.org

Pearson, L. (2003). Understanding the culture of pov-erty. The Nurse Practitioner, 28, 4–6.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N


SNL298

Zoucha, R., & Zamarripa, C.A. (2008). People of Mex-ican heritage. In L. Purnell & B. Paulanka (Eds.). Transcultural health care: A culturally competent approach (3rd ed.) (pp. 309–324). Philadelphia: F.A. Davis.

U.S. Census Bureau (2005). 2005 American Community Survey. Retrieved April 8, 2008 from www.census.gov/

Wallman, K.K. (1998). Data on Race and Ethnicity: Revising the Federal Standard. The American Stat-istician, 52, 1, 31–33.


© J

ones

and

Bar

tlett P

ublis

hers

NOT F

OR R

ESALE O

R DIS

TRIBUTIO

N

Documents

Jones and Bartlett Publishers NOT FOR RESALE OR DISTRIBUTION