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Seeking Professional Nursing Excellence Through Cultural Competence

Mona Newsome Wicks, Ph.D., RN University of Tennessee Health Science Center

Objectives · Explain the importance of cultural competence for excellence in nursing practice, educational programs, and research.

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Identify strategies that enhance cultural competence as a clinician, educator, and researcher.

You will not: · Be an expert on the care of any particular cultural group You will discover: · Salient issues · Guiding principles · Specific strategies Key Definitions: Diversity · Ethnicity · Race · National origin · Gender · Education · Language · Religion · Social class · Sexual orientation · Ability/disability (Andrews & Boyle, 1999) Key Terms Culture is "a complex whole including knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by people as members of society". (Sir Edward Tylor,1871)

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Key Terms Culture is "a set of common understandings, manifest in act and artifact. It is in two places at once: inside one's head as understandings and in the external environment as act and artifact". (Bohannon, 1995) Key Terms Culture is "not only the arts and sciences, religions and philosophies, to which the world culture has historically applied, but also the system of technology, the political practices, the small intimate habits of daily life, such as the ways of preparing and eating food, or of hushing a child to sleep ...."(Margaret Mead, 1995, p. 5) Key Terms Culture guides how people live, what people believe and value, how they communicate, ...their habits, food preferences and, tastes. It guides...how goods and services are distributed, how power and decision-making are designated...prescribes rituals and patterns, ...Most certainly, the ways we I interpret and perceive health and illness and our choices in providing and seeking care.... (Loustaunau & Sobo, 1997). Key Point · Adaptive and contextual · One component of human beings · Dynamic and continuous interaction between culture and ­ Family ­ Sociopolitical values ­ Societal attributes ­ Genes, physiology How Culture Changes Health from other perspectives... · Absence of disease · A resource · A controllable product of the individual · A collective heritage for which society is responsible

(Pierret, 1983)

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What is illness? · Mental illness as gift from God that allows greater understanding of things other cannot understand · Impoverished Jamaica plump female body is appealing · Mainstream U.S. thin body is desired Fundamental Question How do certain populations become disenfranchised, marginalized, and negatively labeled and how does this process reduce access to health care? (Meleis, 1996) Where are we headed? · Culturally competent care is no longer a luxury · Inappropriate care and poor outcomes · Increased health care costs · Increase awareness · Evidence and theory-based knowledge needed to develop interventions Why does culture matter? If health care consumers make decisions about their health based on their cultural beliefs and values isn't it reasonable to expect health care providers' personal beliefs and values to influence the care that we deliver ? 21st Century U.S. Population Demographic Trends 1998 2005 2010 2015 2020 2030 White Black HISP A/PI NA 72.9% 12.1% 10.7% 3.5% 0.7% 69.6% 12.4% 12.6% 4.4% 0.8% 68% 12.6% 13.8% 4.8% 0.8% 66.1% 12.7% 15.1% 5.3% 0.8% 64.3% 12.9% 16.3% 5.7% 0.8% 60.5% 13.1% 18.9% 6.6% 0.8%

U.S. Registered Nurse Demographics by Race/Ethnicity (Graphic)

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Why does culture matter? What happens when the beliefs and practices of providers and recipients of care differ? "If what we know is ...based on exclusionary thought, we are likely to act in exclusionary ways, thereby reproducing the racism, sexism, class oppression, and homophobia of society." (Andersen & Hill-Collins, 1998, p. 13) "Maybe just having an understanding of how Native American health care has been across the U.S. ..would make [health providers] effective because they would know what's happened in the past and not repeat the same mistakes." ­Native American focus group participant How do unconscious and conscious exclusionary practices and beliefs potentially influence the welfare of patients, families, and communities? Health Disparities Differential patterns of morbidity and mortality among groups based on SES, race/ethnicity, and access to care. (Flaskerud & Nyamanthi, 2002) IOM Report: Unequal Treatment "Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable. The real challenge lies not in debating whether health disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them" (Nelson, 2002). The Evidence · Minorities less likely to receive appropriate cardiac treatment · Racial differences in who receives appropriate cancer diagnostic tests and treatments · Black Americans less likely to receive major diagnostic and therapeutic interventions despite higher stroke rate · Minorities less likely to be placed on kidney transplant wait list or to receive kidney dialysis or transplants · Asthmatic African Americans less likely to receive appropriate medications to manage chronic symptoms · African Americans more likely to be diagnosed as psychotic but less likely to receive appropriate meds (Unequal Treatment, 2002)

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·Time length between an abnormal mammogram and the follow-up diagnostic test to determine presence of cancer more than twice as long for Hispanic, Asian American, and African American women than Caucasian women ·Asian American, Hispanic, and African American residents of nursing homes significantly less likely than Caucasian residents to have sensory and communication aids like glasses and hearing aids http://www.ahcpr.gov The wealthier, the healthier... Income <$15,000 $15,000 - $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 or more Healthy People 2010, HHS Why Do Health Disparities Occur? · Provider · Patient · Health care system issues (Brach & Fraser, 2000) Provider Contributions · Well-meaning people who are NOT overtly biased demonstrate unconscious negative ideas · Time constraints may foster stereotypes · Uncertainty about patient's condition Patient Contributions ·Lack of trust ·Historical issues ·Failure to follow through with care prescription System Contributions ·Health care occurs in groups or systems ·Institutional commitment ·Accountability ·Practices and policies homogeneity-focused So what can we do? Start with ourselves.... By examining our personal values % poor or fair health 20.6 15.1 8.1 5.9 2.7

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Values · A set of beliefs about truth and worth · Influence choices such as treatment decisions · Shared culture and language not equal shared to values · Heterogeneity within groups ­ Age, class, education, gender, geographic location, political and religious beliefs, and tradition Why Examine Values? ·Cultural competence requires an awareness of and respect for values of different others ·Knowing what is valued helps to identify preferences and biases Issues to Consider · What values and biases do you bring to the · provider­care recipient relationship? · How have your family of origin and nursing education influenced your beliefs? · What knowledge and experience do you have to draw on? · What values do you share with the patient? · How comfortable are you with who you are? · What are the potential benefits of seeking cultural competence? Values Clarification · Self-reflection is a precursor to understanding and collaborating with different others

· Process that allows the nurse to discover prized values and deeper knowledge of self · Personal values influence translation of professional values · Values evolve throughout life

Values Clarification Exercise · Write down two values you learned as a child · · · Who taught you these values? Do these values influence you today? How? If not, why not? Have your values changed? Which values have changed and why?

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Which value is most important? Which will affect your behavior in an ethical situation such as a treatment choice?

(Spradley & Allender, 1996; Chitty, 1997; Clark, 1996) Individualism and Collectivism · Autonomy · Individual rights, rewards, and input · Competitiveness · Achievement · Self-sufficiency · Assertiveness · · · · · · · Maintenance of group harmony Interpersonal harmony Group solidarity Commitment to relationships Gentleness Cooperativeness Indirectness

Cultural Variations Anglo-American Values ·Individualism ·Independence and freedom ·Competition & achievement ·Materialism ·Technology focused ·Instant time and actions ·Youth & beauty ·Equal rights b/w genders ·Leisure time highly valued Traditional Japanese Values ·Duty &obligation to kin and work group ·Honor/national pride ·Patriarchal obligations & respect ·Honor toward elders ·Group compliance ·High educational standards ·Futurists ·Politeness & ritual

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Provider Assumptions as Barriers · Moral obligations and medical ethics based on Judeo-Christian beliefs

· Patient bill of rights built upon this belief system · Obligation to truth-telling and provide all information to patient or surrogate · We only include the family in informed consent when patient is legally unable to

decide (Alexander, 2002) Culture, Scholarship, and Excellence · Inclusive thinking is important in the construction and transmission of knowledge

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Knowledge from other groups reveals the partiality of knowledge Restructuring knowledge has broad implications Inappropriate social policy and treatment decisions

Challenges Related to Cultural Diversity · Race is a social construction · "Medicalization" of race · Race versus ethnicity · Marginalization of vulnerable groups Social Construction of Race · Widely believed that race is biological

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Greater variation within "races" than between Most human variation explained by geography ­ Sickle cell ( Turks, Greeks, and equatorial Africans) ­ Lactose intolerance (Southern Europeans, eastern and Southern Africans, Japanese, and Native Americans)

Case Study · An 8-year old boy, European phenotype · Acute abdominal pain and anemia · Temperature 37.9oC · Surgery scheduled · Red corpuscles with hemolytic qualities · Undiagnosed sickle cell anemia · Parents from Grenada (Indian, northern European, and Mediterranean descent) 8

(Witzig, 1996; Annals of Internal Med., 125(8), 675-689.) Case Study · An 24-year old man classified as black · Upper abdominal pain for 24 hours and anemia · State told by physician he had "sickle cell" · Admitted with sickle cell crises and transfused · Witnessed cardiac arrest and expired after 75 minutes · Bright red blood in pharynx and esophagus but good oxygenation · Normal hemoglobin · Cause of death: bleeding peptic ulcer (Witzig, 1996; Annals of Internal Med., 125(8), 675-689. What Else Can I Do? Cultural Competence! Key Terms: Cultural Competence A set of congruent behaviors, attitudes, and policies, that come together in a system, agency, or among professionals and enables them to work effectively in cross-cultural situations. (Alexander, 2002) Complex integration of attitudes, knowledge, and skills to facilitate communication and appropriate interactions between persons of diverse cultures. (American Academy of Nursing, 1993) "Care that takes into account issues related to diversity, marginalization, and vulnerability due to culture, race, gender, and sexual orientation. This care is guided by nursing theories, models, and/or research". (National Academy of Nursing expert panel, 1990)

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Characteristics include:

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Commitment Awareness of differences Self-awareness Meanings of behavior Knowledge of learner's culture Adapt practice and behaviors

(Ronnau, 1994) Comittment Attitude Value others Admit ignorance Commit to learning about others Awareness of Differences Facilitates knowledge acquisition Failure to recognize differences may create barriers and conflict Self-Awareness Personal culture influences thoughts, beliefs, actions, standards, and messages Results in the recognition that beliefs and behaviors are culturally conditioned Meaning of Behavior Meanings vary across cultural groups Meanings may vary within cultural groups Facilitate culturally appropriate care and effective cross-cultural communication Knowledge of Other Cultures Continuous process Meaning of health and illness Issues that effect outcomes Omniscience is unrealistic Focus on seeking appropriate knowledge

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Developing Cultural Competence Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounter (Campinha-Bacote, 1995) Cultural Awareness Deliberative cognitive process Appreciative of and sensitive to other cultures Stimulated by: -Guided self-study -Open discussions -Cultural experiences Cultural Knowledge Seek educational opportunities Gain familiarity Explore barriers Cultural Skill Learn to conduct cultural assessment Facilitates all interpersonal relationship needs Prevents "cultural blind spot syndrome" -Because a patient looks and behaves like the provider, the assumption is made that there is no cultural difference Cultural Encounter Engage in interactions with diverse groups Requires ongoing refinement of knowledge Recurrent encounters (experiential learning) with theoretical content prevents stereotyping. (Campinha-Bacote, et al., 1996) Cultural Assessment · Self-identified ethnicity, race, or group · Language, communication style · Religious beliefs and practices · Illness and wellness behaviors · Healing beliefs and practices · Typical nutritional patterns and preferences · Family system issues: decisions and information · Lifestyle and habits · Time · Space

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General Communication Strategies Strategies to Promote Effective Cross-Cultural Communication · Pronounce name correctly · · · Use appropriate titles Gender sensitivities Do not shorten names without permission Messages that convey bias or inequities Avoid slang, pejorative, or derogatory terms to describe persons of different racial, ethnic, or religious groups · · · · · Avoid terms that may be offensive to others Only identify people by race, color, gender, ethnic origin, or religion when appropriate Refrain from telling demeaning stories or jokes Use language that is inclusive rather than exclusive Avoid the use of endearments rather than proper names

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Challenges Related to Cultural Diversity · Interaction between culture and social, historical, and political factors

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Language as a potential barrier Contribution of all players Myth of culture as homogeneous and constant

Strategies to Improve Cultural Competence: Clinicians · Change is slow · Discomfort, resistance, dissonance, anger · Journal · Dialogue with confidant · Communicate respect · Consistent verbal and non-verbal messages · Education and training

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Strategies to Improve Cultural Competence: Educators · Single course vs. integration vs. both · Teaching strategies ­ Journal ­ Group work ­ Case studies ­ Immersion experiences ­ Discussions ­ Specific groups vs. general principles ­ Read broadly Strategies to Improve Cultural Competence: Researchers · Community-based model of research · Costs and benefits to the community · Establishing trust and respect · Designing studies to facilitate participation

Strategies to Improve Cultural Competence: Systems

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Increase awareness among general public, health care providers, insurance companies, and policy makers Promote equity via evidence-based guidelines Eliminate levels of care based on insurer Interpretation services Recruitment and retention Training Coordination of services Community health workers Culturally competent health promotion Including family or community members Coordinating care with traditional healers

Assumed Benefits · Services consistent with population needs · Increased customer recruitment, satisfaction, retention, and care access · Maximize use of limited resources · Improved overall health outcomes (Alexandar, 2002) What the evidence indicates about these strategies..... Where do we begin? Culturally competent care is "...the gold standard of nursing care". (Joel, 1998)

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Seeking Professional Nursing Excellence Through Cultural Competence

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