Download Stanhope: Foundations of Nursing in the Community: Community

Stanhope: Foundations of Nursing in the Community: Community-Oriented
Practice, 3rd Edition
Chapter 5: Cultural Influences in Nursing in Community Health
Annotated Lecture Outline
I.
Immigrant health issues
A. Changes in immigration legislation since 1965 have increased immigration to the
United States. However, American citizens are ambivalent in their attitudes and
policies about immigration. About 85% of immigrants have entered the country legally.
Immigrants need to live in the United States for 10 years to be eligible for all
entitlements, such as Aid to Families of Dependent Children, food stamps, Medicaid,
and unemployment insurance. Illegal immigrants are eligible only for emergency
medical services.
B. It is estimated that immigrants add about $10 billion to the economy annually and that
in their lifetime immigrant families will pay $80,000 more in taxes than they consume
in services. A dilemma is that taxes typically are paid to the federal government,
whereas the services used are paid for by the states and localities.
C. Other issues affecting health care of immigrants are language barriers; differences in
social, religious, and cultural background between the immigrant and the health care
provider; providers’ lack of knowledge about diseases of specific immigrant groups;
and the fact that many immigrants rely on folk health care practices not known to
health care providers.
D. Refugees are persons who have come to the United States as a result of a disaster or
war in their home country.
II.
Culture, race, and ethnicity are important factors in understanding cultural behavior.
A. Culture consists of a set of ideals, values, and assumptions about life that are widely
shared among a group of people. Culture develops over time and is resistant to change.
The organization of each culture distinguishes one culture from another. Organizational
elements include language and the arts, childrearing practices, religious practices,
family structure and values, and attitudes. Nurses should know these organizational
elements to provide culturally appropriate care.
B. Race refers primarily to a social classification that relies on physical markers, such as
skin color, to identify group membership. Individuals may be of the same race but of
different cultures.
C. Ethnicity involves the shared feeling of peoplehood among a group of individuals. It is
based on individuals sharing similar cultural patterns (such as values, beliefs, customs,
behaviors, and traditions) that over time create a common history. Ethnicity represents
the identifying characteristics of culture.
III.
Cultural competence is an ongoing life process. Cultural competence is a combination of
culturally congruent behaviors, practice attitudes, and policies that allows nurses to work
effectively in cross-cultural situations. Nurses develop cultural competence in different
ways, but development occurs mainly by working with clients of other cultures and through
the nurses’ awareness of these experiences.
A. Achieving cultural competence comes through cultural awareness, cultural knowledge,
cultural skill, engaging in cultural encounters, and cultural desire.
1. Cultural awareness is an appreciation of and sensitivity to the client’s values,
beliefs, practices, lifestyle, and problem-solving strategies.
2. Cultural knowledge provides nurses with an understanding of the elements of
cultures and the information necessary to provide effective nursing care.
3. Cultural skill reflects the effective use of cultural awareness and cultural knowledge
to meet clients’ needs. In a cultural encounter, nurses integrate the importance of
culture at all levels of care as they make changes to meet the culturally unique
needs of the client.
4. Cultural encounter involves all interactions, not just those that are health related.
5. Cultural desire is the nurse’s intrinsic motivation to provide culturally competent
care.
B. Dimensions of cultural competence. Strategies used by culturally competent nurses to
provide care that reflects the clients’ values are cultural preservation, cultural
accommodation, cultural repatterning, and cultural brokering.
1. Decisions of cultural preservation support clients in maintaining those aspects of
their culture that promote healthy behaviors.
2. Decisions of cultural accommodation include those aspects of the culture that are
crucial to providing satisfying care.
3. Decisions of cultural repatterning involve working with clients to develop healthpromoting behaviors.
4. Cultural brokering is advocating, mediating, negotiating, and intervening between
the health care culture and the client’s culture on behalf of the client.
IV. Inhibitors to developing cultural competence
A. Stereotyping relates to ascribing certain beliefs and behaviors to groups without
recognizing individual differences within the groups.
B. Prejudice is the emotional reaction to deeply held beliefs about other groups. It usually
denotes negative attitudes.
C. Racism, a form of prejudice, refers to the belief that persons who are born into a
particular group are inferior in intelligence, morals, beauty, self-worth, and so forth.
D. Ethnocentrism or cultural prejudice is the belief that a person’s cultural group
determines the standards of behavior by which all other groups are to be judged.
E. Cultural blindness is the tendency to ignore all differences between cultures and to act
as though the differences do not exist.
F. Cultural imposition is the process of imposing an individual’s values on others.
G. Cultural conflict is a perceived threat that may arise in cases of misunderstanding of
expectations between clients and nurses, when either group is not aware of or denies
cultural differences.
H. Cultural shock is a feeling of helplessness, discomfort, and disorientation experienced
by an individual attempting to understand or effectively adapt to a cultural group with
different practices, values, and beliefs.
V.
Cultural nursing assessment is a systematic way to identify the cultural beliefs, meanings,
symbols, and practices of individual groups. It is important for nurses to listen to clients’
perceptions of their problems. It is also important for nurses to explain their perceptions of
problems to their clients.
A. Nurses use a cultural nursing assessment to help them identify and understand clients’
perspectives of health and illness. A variety of tools are available to assist nurses in
conducting cultural assessments. The focus of such tools varies, and selection should be
determined by the dimensions of culture to be assessed. During initial contacts with
clients, nurses should either perform a brief cultural assessment or begin an in-depth
one. To help them in conducting cultural assessments, nurses should be aware of a
variety of principles; these include the following:
1. Be aware of the environment.
2. Know about community social organizations such as schools, churches, hospitals,
tribal councils, restaurants, taverns, and bars.
3. Know the specific areas to be focused on before beginning the cultural assessment.
4. Select a strategy for gathering cultural data. Strategies may include in-depth
interviews, informal conversations, observations of everyday activities or specific
events of the client, survey research, and a case-method approach to study certain
aspects of a client.
5. Identify a confidante who will help “bridge the gap” between cultures.
6. Know the appropriate questions to ask without offending the client.
7. Interview other nurses or health care professionals who have worked with the
specific client to get their input.
8. Talk with formal and informal community leaders to gain a comprehensive
understanding about significant aspects of community life.
9. Verify and cross-check the information that is collected before acting on it.
10. Avoid pitfalls in making premature generalizations.
11. Be sincere, open, and honest with yourself and the client.
B. Using an interpreter. When nurses do not speak or understand the client’s language,
they should make every effort to obtain assistance from an interpreter. Consider the
following when an interpreter is needed:
1. Use an interpreter who has knowledge of health-related terminology.
2. Use family members cautiously.
3. Some individuals prefer that questions about sexuality or childbirth be posed by a
translator of the same gender.
4. The age of the interpreter may be a concern. Children often have limited language
skills.
5. Watch for problems caused by differences in socioeconomic status, religious
affiliation, and educational level.
6. Identify the client’s birth origin and language or dialect.
7. Avoid using an interpreter from the same community to avoid a breach of
confidentiality.
8. Avoid using professional jargon, colloquialisms, abstractions, idiomatic
expressions, slang, similes, and metaphors.
9. Clarify roles with the interpreter.
10. Introduce the interpreter to the client, and explain what the interpreter will be doing.
11.
12.
13.
Observe the client for nonverbal messages, such as facial expressions, gestures, and
other forms of body language.
Increase accuracy in transmission of information by asking the interpreter to
translate the client’s own words and asking the client to repeat the information that
was communicated.
At the end of the interview, review the material with the client.
VI. Differences among cultural groups. Although all cultures are not the same, all cultures have
the same basic organizational factors. The organization of these factors within cultures
differentiates one group from another.
A. Communication. Understanding variations in patterns of verbal and nonverbal
communication is important in helping clients achieve therapeutic goals.
B. Space. Personal space is the area that persons need between themselves and others to
feel comfortable. Nurses should understand that spatial requirements vary and should
take cues from clients to place themselves in the appropriate spatial zone.
C. Social organization. Family significance varies across cultures. When working with
clients, nurses should be aware of family involvement in decision making and should
advocate that the individual’s needs also be considered.
D. Time perception. Nurses must recognize that time is perceived differently across
cultures. Individuals may be future, present, or past oriented. To increase benefits and
minimize misunderstanding, nurses should clarify the meaning of time before
instituting health promotion and disease prevention strategies.
E. Environmental control. This refers to the relationships between humans and nature.
Cultural groups may perceive humans as having mastery over nature, being dominated
by nature, or being in harmony with nature.
F. Biological variations. These distinguish one racial group from another. They occur in
areas of growth and development, skin color, enzymatic differences, and susceptibility
to disease. Other variations include eye shape, hair texture, thickness of lips, and body
configuration.
G. Nutrition. Dietary practices are an integral part of the assessment for families,
especially because they play a prominent role in all health problems. Knowing clients’
assimilative practices makes it possible to develop treatment regimens that will not
conflict with their cultural food practices.
H. Socioeconomic factors and culture. Members of minority groups are disproportionately
represented on the lower tiers in the socioeconomic ladder. Poor economic achievement
is also a common characteristic among populations at risk, such as those in poverty, the
homeless, migrant workers, and refugees. Nurses should be able to distinguish between
culture and socioeconomic class issues, and they should not interpret behavior as
having a cultural origin, when in fact it is attributed to socioeconomic class.