What are the methods a nurse can use to gather cultural information from patients?

1. What are the methods a nurse can use to gather cultural information from patients? How does cultural competence relate to better patient care? Discuss the ways in which a nurse demonstrates cultural competency in nursing practice.

2. Discuss why nutrition is a central component in health promotion. What are some of the nutritional challenges for emerging populations? What roles do nutritional deficiency and nutritional excess play in disease?

By Angel Falkner

Essential Questions

· What is the global impact of health, wellness, and the delivery of care on emerging populations?

· What nursing theories can be utilized when providing culturally competent care to patients?

· What is the impact of race, culture, and ethnicity on individual and collective identity, and how does this influence beliefs regarding health?

· What are some cultural factors that may affect care for emerging populations?

· How do nurses work with individuals, families, communities, and social-cultural networks to influence health promotion?

Introduction

Cultural competence in nursing is an absolute necessity. As populations grow and become more diverse, understanding different cultures and their practices and respecting these differences is imperative to providing holistic care to patients in every health care setting. In order to educate patients effectively and empower them to promote their own health, the nurse must fully engage with them and become acclimated to their specific needs. This chapter will provide details on how to become culturally aware and apply cultural sensitivity to nursing care, particularly as a nurse educator.  Health promotion education will encompass nutrition education and cultural aspects will be discussed.

Health Disparities

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According to the Center for Disease Control (CDC) (2015a), health disparities are the “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations,” (para. 1). Disadvantaged populations include a wide range of ethnicities. Ethnicity differs from race in that it encompasses ideas and practices of a group that shares commonalities of race, language, history, religion, and/or country or place of origin. Race involves ancestry and shared or common physical characteristics. In an effort to support the growing population of disadvantaged persons worldwide, the World Health Organization (WHO) has formulated the following goals centered on global awareness and improvement of health disparities.

· Promoting development

· Fostering health security

· Strengthening health systems

· Researching disparities, health risks, and effective solutions

· Enhancing partnerships

· Improving performance

Nurses are a crucial component to achieving these goals and must be keenly aware of the challenges such populations face. Emerging populations within the United States include:

· Arab Americans

· Asian Americans and Pacific Islanders

· Black/African Americans

· Latino/Hispanic Americans

· Native Americans/Alaskan Natives

· Homeless

· Lesbian/Gay/Bisexual/Transgender/Questioning (LGBTQ)

· Refugees

The federal government has recognized the challenges emerging populations face and has taken steps to promote and support health within these populations. The National Institute of Health (NIH), National Center on Minority Health and Health Disparities (NCMHD), the Office of Disease Prevention and Health Promotion (ODPHP), and the U.S. Department of Health and Human Services (HHS) have all collaborated to formulate plans to help decrease these disparities. Among the more prominently known and mentioned programs is Healthy People 2020. This initiative created by the ODPHP is composed of many goals all focused on health promotion in the United States, including the country’s emerging and disadvantaged populations.

Case Study 

Mohammed immigrated to America from Saudi Arabia with his wife and two small children in 1995. Though they have lived and worked in America for more than 20 years, they have not yet acclimated to Western culture and do not feel truly at home. Because of the political climate, Mohammed has often felt a great deal of discrimination. Though it is not always blatant, the staring and whispers have been enough to make him feel incriminated. He and his family are devout Muslims, and his wife and daughter have often felt endangered in public wearing their hijabs. They have not sought much medical treatment out of fear of being harassed. Now, Mohammed is hospitalized with chest pain and is being informed he must undergo open heart surgery. He is nervous and feels that the whispers, laughing, and stares he receives from the hospital staff are about him, his family, and his culture. His nurse, Ben, admits to his manager that he does feel a bit uncomfortable caring for Mohammed’s family because he is unfamiliar with their culture, and what he does know about Middle Eastern people comes from what he sees in the news media, most of which is associated with terrorism.

Check for Understanding

How can Ben provide culturally competent care for Mohammed and his family given his apprehensions?

Health Equality

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Health equality is based on the premise that all individuals deserve high quality, easily accessible, and affordable health care regardless of ethnicity or race. Unfortunately, the socioeconomically disadvantaged have poor access to quality health care and ultimately have higher rates of illness and premature death (Egen, Beatty, Blackley, Brown, & Wykoff, 2017). Nurses have a duty to provide and advocate for quality care for persons from all backgrounds, in spite of personal bias. Acknowledgment of this inequality is essential to formulating a plan of action that leads to health equality. Equally imperative for the nurse to understand is the concept of health equity, which is the provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH) (Brennan Ramirez, Baker, & Metzler, 2008).

Nurses are in a unique position to advocate for patients’ needs. Nurses are often the first point of contact for patients and are able to form trusting relationships through which the nurse is able to glean important information regarding patients’ needs. In dealing with health inequity, nurses must utilize the power of assessment to identify patients at risk. Once these inequities have been identified, nurses can work together with the patient and interdisciplinary team to come up with a plan of care that helps the patient attain proper resources to meet his or her goals.

There are many frameworks or models within health care that guide nurses and the health care team in identifying and addressing patients’ cultural needs. The nurse utilizes these models in order to personalize the plan of care and provide individualized care that encompasses cultural needs. One such framework is Campinha-Bacote’s (2011) model of cultural competence (see Figure 3.1).

Figure 3.1

Campinha Bacote Cultural Competence Model

Note. Adapted from “Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence,” by J. Campinha-Bacote, 2011, OJIN: The Online Journal of Issues in Nursing, 16. Copyright 2011 by OJIN: The Online Journal of Issues in Nursing.

The Campinha Bacote model involves the nurse’s inner reflection and self-journey in providing culturally competent nursing care; it also guides the nurse to provide culturally sensitive care by teaching nurses cultural skills (Campinha-Bacote, 2011).

Cultural skill is guided by Madeleine Leininger’s culture care theory in which Leininger states that cultural assessment “is the systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values and practices to determine explicit needs and intervention practices within the context of the people being served,” (Campinha-Bacote, 2011, para. 6).

This is done by asking culturally appropriate questions that help the nurse identify needs, such as:

· When do you seek treatment from others when you are ill?

· What do you fear most about your sickness or becoming ill?

· What types of treatments are acceptable to you?

· How do you feel your illness affects you in your daily life?

In addition, nurses must also take into consideration the patient’s SDOH. This includes the assessment of the patient’s social, economic, and physical environments that contribute to the patient’s level of risk. Assessing these determinants is a primary step in achieving cultural competence. These factors, which are directly related to the patient’s culture and belief system, have a significant impact on a patient’s overall health status. In essence, these needs are, at times, the basic necessities of life, such as stable housing and nutrition needs that must be addressed before other health concerns become the focus of care (Theiss & Regenstein, 2017).

Scenario

Sheila is a 41-year-old female patient being treated for hypertension. She goes to the nearby urgent care center for persistent headache, and the intake nurse discovers her blood pressure is 172/90. After thorough discussion and assessing for her SDOH, the nurse finds that Sheila has recently become homeless and cannot afford her medications. The nurse understands that resources need to be provided to meet Sheila’s basic needs in order for her to remain compliant with her medical treatment regimen.

Figure 3.2

Social Determinants of Health

Cultural Awareness

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Nurses have the unique opportunity to learn about many cultures and grow their cultural competency skills because of their frequent, if not daily, care of patients from different cultures (Rahimaghaee & Mozdbar, 2017). Culture is “a pattern of traditions, beliefs, values, norms, symbols and meanings among a group of people,” (Byrne, 2016, p. 114). There are many different cultures, all with varying values and beliefs.

Values are the beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group. These beliefs often have heavy influence on perception of health in many ways, including health promotion, health maintenance, when to seek care and treatment, and what types of treatments are acceptable. Value orientation differs in that the collective values of a society shape its overall personality. It is the nurse’s responsibility to understand that some cultural beliefs may incorporate health practices that are considered unsafe or unhealthy to other cultures that do not share the same beliefs.

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A controversial example of this is the practice of female genital mutilation. Female genital mutilation, also known as female genital circumcision, is a practice in which the external female genitalia is partially or totally removed for nonmedical purposes (World Health Organization [WHO], 2018). This practice is seen in countries within the Middle East as well as Africa and parts of Southeast Asia.

The controversy for Western society, as well as other developed countries, lies in the many risks this practice poses to a woman’s health, in addition to the practice being viewed as a violation of human rights (Momoh, Olufade, & Redman-Pinard, 2016). In light of this cultural practice, the nurse must remain sensitive when addressing patients who may have undergone this practice. This includes avoiding the term mutilation, as this might be considered disrespectful to women who have had the procedure and consider it to be a normal part of their culture and not a form of mutilation or cruelty (Momoh et al., 2016).

The nurse must also take child protection issues into account and advocate for patient safety if a minor is at risk for undergoing this procedure. Other controversial practices include refusal of blood or blood products, male circumcision, and beliefs surrounding death and dying. Each culture has different views on different aspects of health that need to be respected, regardless of personal feelings surrounding the practice.

Cultural Competence

What does it mean to be culturally competent? As nurses, caring for all persons regardless of ethnicity, socioeconomic background, race, or culture, is expected. To provide patients with basic nursing care, nurses must have the ability to suspend personal biases and fully respect patients in spite of differences. Providing culturally competent care is a major element in helping to eliminate outstanding health disparities worldwide. Cultural competency does not mean becoming an expert on every culture encountered, but it does mean that nurses should recognize what they do and do not know in order to provide appropriate care.

Cultural competency means being aware of differences related to culture and adjusting plans of care accordingly as well as remaining sensitive and respectful of choices patients may make based on their culture. Campinha Bacote’s cultural competence model is a nursing theory that aids nurses in this process. Becoming culturally competent is considered a continual process that requires continuous education, self-awareness, and evaluation in order to provide holistic, culturally competent nursing care (Campinha-Bacote, 2011). With the influx of immigrants into the United States and the rise in ethnic minorities, nurses will be faced with the issue of culturally competent care on a daily basis. Cultural competence is just one component of providing integrated health care, which includes treating the patient in a holistic way that addresses all of their psychosocial and physical health care needs.

Within different cultural traditions, there are varying healing systems that are specific to maintaining and restoring health; they are traditional and nontraditional care systems (see Table 3.1). Traditional care systems embody more of the health care modalities seen in Western medicine, such as seeking medical attention from a licensed professional.

Nontraditional systems take a more natural approach, utilizing herbs and traditional practices for healing versus modern medicine modalities of care (Gale, 2014). There is a growing acceptance of the use of complementary alternative medicine (CAM) within the United States, which uses a combination of traditional treatments with alternative therapies such as massage, aromatherapy, or acupuncture (Lavretsky, 2017).