Cultural Competence

July 2008

The ACE Cultural Competence Committee

Margaret M. Andrews, PhD, RN, CTN, FAAN Lauren Clark, PhD, RN, FAAN Katherine Foss, MS, RN Sandie Kerlagon, MS, RN Jo Keuhn, RN, BS (Original Date: 2004)

Cultural Competence in Clinical Settings: An Introduction for New Nurses

What is Culture?

A definition: Leninger (1985) describes culture as: ‘the values, beliefs, norms, and practices of a particular group that are learned and shared and that guide thinking, decisions and actions in a patterned way’ Or more simply : the luggage each of us carries around for our lifetime (Spector, 2003)

Culture determines….

 Who is healthy & ill  What people think causes health & illness  What healers are sought to prevent and treat disease  What treatments are used  Appropriate sick role behavior  How long a person is sick & when he/she has recovered

Cultural and Linguistic Competence

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

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

1 2

Campinha-Bacote, 2008

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Cultural Competence

    Begins with understanding of own self Includes knowledge of various cultural characteristics Includes an understanding of cultural characteristics Requires application of cultural knowledge and understanding in the healthcare setting

Non-ethnic Cultures

Selected Examples

The Culture of…..



Socioeconomic status

   Poverty The Homeless The Affluent/Wealthy 

Sexual Orientation



Handicap/Disability

 Gay, Lesbian, Bisexual, Transgender   Deaf/Hearing Impaired Blind/Visually Impaired 

Occupation

 Nurses, Military 

Age

 Adolescents, Elderly

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

Cultural Assessment



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

Leininger & McFarland, 2006

Explanatory Models

 Explain why we are sick to other people and to ourselves to make sense of our misfortune  Example: “You have a terrible cold!” “You’re right—It is because I got run down and then went outside without a coat yesterday. That’s why I’m sick.”

Explanatory Model Questions

    

What is the patient’s ethnic affiliation?

Who are the patient’s major support persons and where do they live?

With whom should we speak about the patient’s health or illness?

What are the patient’s primary and secondary languages, and speaking and reading abilities?

What is the patient’s economic situation? Is income adequate to meet the patient’s and family’s needs?

(Lipson & Dibble, 2005)

Spirituality & Religion

Spirituality refers to a subjective experience of the sacred, whereas religion involves subscribing to a set of beliefs or doctrines that are institutionalized.

16% 6% 4% Major World Religions 3% 4% Christianity Islam 33% Hinduism Nonreligious Buddhism Chinese Traditional Primal indigenous Other 16% 18%

U.S. Religions



354,194 Congregations



> 1,200 Denominations Yearbook of American & Canadian Churches, 2002

Spiritual & Religious Healers

Monk Elde r Curandero/a Medicine Man Bishop Shaman Medicine Woman Rabbi Priest

Religion & spirituality in healing….

     Prayer, Chants Pilgrimages Fasting Amulets or talismans Healing rituals    Anointing with oil Sacraments Laying on of hands

Religion, Health & Culture

    Research demonstrates positive health outcomes for people with strong spiritual and religious beliefs Congruent with holistic philosophical beliefs about human nature Dietary & lifestyle practices often promote health & prevent disease (e.g., lower incidence of heart disease among Mormons & Seventh-day Adventists) Guides moral & ethical decision making

Symbols of Ethnoreligious Identity

     Shrines with Buddha, candles, incense, and various artifacts (Buddhist) Presence of prayer beads (Muslim) Amulets and talismans (charms) to ward off illness or bring good health (Mexican, Puerto Rican, & many African groups) Rosaries, religious medals, statues, votive candles (Catholics) Presence of mezuzza (small case containing torah passages on parchment--usually hung in doorway)

Include Religious & Spiritual Factors in Cultural Assessment

 Health-related beliefs & practices, e.g., diet, medications, medical & surgical procedures  Religious calendar & holy days  Healing practices  Religious network for providing spiritual & emotional support for sick & dying members.

 Spiritual & religious healers

Religious, Cultural & Civic Holidays

 Avoid scheduling medical appointments during holidays  Avoid disruption to holy days (such as fasting during Ramadan)

Promoting Effective Cross-Cultural Communication.....

Always ask, “By what name may I call you?”

What do Limited-English Speakers Want?

Speaking one’s native language is….

• Easier when feeling ill • More comfortable • More accurate

What is unsafe practice with Limited-English speakers?

 Using family members as interpreters  Recruiting

ad hoc

(or untrained) interpreters  Writing instructions in English

Interpreter errors cause medical errors

(Levine, JAMA, 2006)

Why not use a family member as an interpreter?

    Office for Civil Rights (OCR) Policy Guidance (2000) states that untrained “interpreters”: May not understand the concepts or official terminology they are asked to interpret or translate Obstruct the flow of confidential information to the provider.

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

Requirements in Using a Translator

• Use approved Interpreter Services OR • Use the Interpreter Telephone

Using Appropriate Interpreter Services in Clinical Care

 Speak with Charge Nurse for assistance  Call Operator to place call  1-800 number  Client code/ID  Request language

Directness in Clinical Encounters

 Americans value directness:  “Spit it out”  “Say what’s on your mind”  Languages that depend on subtle contextual cues:  Infer meaning  Imply, but do not state, the point (Japanese, Arabic)

Directness and Subtlety

 “Maybe” or “That would be difficult” is probably a polite “no”  Avoid yes/no questions  Phrase your inquiry as a multiple choice question

Nonverbal Communication

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

Gestures and Facial Expressions

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

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

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

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

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

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

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

Gestures

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

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

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

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

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

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

Touch

 Different rules about who can be touched & where.

 A handshake is generally accepted as a standard greeting in business, yet the kind of handshake differs.

 North America = hearty grasp  Mexico = softer hold  Asia = soft handshake with the second hand brought up under the first is a sign of friendship & warmth

Touch

  Religious rules may apply to appropriate touch.

 Touching between men & women in public is not permitted by some orthodox religions, so a handshake would not be appropriate.

Ideas about respect are conveyed through touch  Touching the head, even tousling a child’s hair as an affectionate gesture, would be considered offensive by many Asians.

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

Topics Appropriate for Discussion

 What is acceptable for nurse and patient to discuss?

   Many Asian groups regard feelings as too private to be shared.

Latinos generally appreciate inquiries about family members, while most Arabs & Asians regard feelings as too personal to discuss in business situations.

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

Inappropriate Conversation Topics

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

This points to another aspect that relates to privacy.

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

Privacy

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

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

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

Saving face….

     In Asia, the Middle East, & to some extent Latin America, one’s dignity must be preserved at all costs.

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

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

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

Seemingly harmless behaviors can be demeaning to some patients.

The Culturally Competent Clinician

Attitudes of the Culturally Competent Clinician

Understanding

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

Empathy

: Being sensitive to the feeling of being different.

Patience

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

Ability:

To laugh with oneself and others.

Trust:

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

Non-Verbal Communication

All cultures have rules, often unspoken, about who touches whom, when & where.

Nonverbal Communication (~65% of all communication)

 Touch  Facial expressions  Eye movements  Body posture

Modesty

Cultural Perspectives on Modesty

 Patients may prefer clinicians of the same gender  May be taboo for males to examine or treat females (e.g., Middle Eastern groups)  In some Asian & Hispanic cultures, older adults may believe that hospital gowns cause disease by exposing them to cold drafts (related to yin/yang & hot/cold theories of disease)

Pain and Cultural Competence

Pain and Culture

 Pain is an abstract concept which can be referred to as: A personal private sensation A stimulus that signals harm A pattern of behavior to protect from harm

Pain Experience

 Pain is a universal human experience, but pain reactions are unique to the individual and includes thoughts, feelings, reactions, expectations and past experiences associated with pain.  The experience of pain can also be described in physiologic, psychosocial, economic and spiritual contexts.

What is Included in a Pain Assessment Cross-Culturally?

    

Pain Expression

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

Pain Language

: Word(s) used to describe pain.

Language

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

Religious Beliefs

: Meaning of pain or suffering.

Rituals

and taboos associated with pain or pain treatment.

Pain Assessment and Cultural Factors 

Social Roles: Ethnic identity and degree of acculturation: such as primary language used, identification of social support networks.

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

 

Gender and Age Influences.

Perception of the healthcare system: Trust vs. suspicion. Use of traditional/lay remedies.

Past experience with the healthcare system .

Pain Treatment and Cultural Factors   

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

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

Also elicit patient beliefs about:

  

Meaning of pain or illness.

Expectations of healthcare providers.

Therapeutic goals.

Barriers

 Typical barriers to a cultural sensitive pain assessment and treatment by healthcare providers include:  Stereotyping.

 Lack of empathy.

 Ethnocentrism.

 Language.

 Experience or expertise of practitioner and time constraints.

National Institutes of Health

 Facilitates research and evaluation of complementary and alternative practices  Provides information about a variety of methods

What is complementary and alternative medicine?

 Includes a broad range of healing philosophies, approaches & therapies  A therapy is called

complementary

when it is used

in addition to

conventional biomedical/scientific treatments  An alternative therapy is used

instead of

conventional biomedical/scientific treatments.

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

Art Therapy Music Therapy Aroma therapy Hypno therapy Ayurveda

Complementary & Alternative Therapies

Acupuncture Massage Therapy Chiropractic Shamanism Therapeutic Touch Reflexology

Complementary Therapies: What is the Clinical Goal?

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

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

 Check for drug interactions with prescription or over-the-counter medications  Assess for harmful side effects  Discourage over-reliance on traditional healing if it delays necessary biomedical treatment (for example, conditions for which an antibiotic is needed)

Meta-Communicative Cultural Competence

 Pay attention to body language, facial expressions & other behavioral cues; much information may be found in what is not said  Avoid yes/no questions; ask open ended questions or ones that give multiple choices; remember that a nod or yes may mean: “Yes, I heard” rather than “Yes, I understand” or “Yes, I agree”

Meta-Communicative Cultural Competence

 Consider that smiles & laughter may indicate discomfort or embarrassment; investigate to identify what is causing the difficulty or confusion  Make formal introductions using titles (Mr., Mrs., Ms., Dr.) & surnames; let the individual take the lead in getting more familiar

Meta-Communicative Cultural Competence

 Greet patients with “Good Morning” or “Good Afternoon” and when possible, in their language  If there is a language barrier, assume confusion; watch for tangible signs of understanding, such as taking out a driver’s license or social security card to get a required number

Meta-Communicative Cultural Competence

 Take your cue from the other person regarding formality, distance, and touch  Question your assumptions about the other person’s behavior; expressions & gestures may not mean what you think; consider what a particular behavior may mean from the other person’s point of view  Explain the reasons for all information you request or directions you give.

Meta-Communicative Cultural Competence

    Use a soft, gentle tone and maintain an even temperament Spend time cultivating relationships by getting to know patients & coworkers Be open to including patients’ family members in discussions & meetings with patients Consider the best way to show respect, perhaps by addressing the ”head’ of the family or group first

Meta-Communicative Cultural Competence

 Use pictures & diagrams where appropriate;  Pay attention to subtle cues that may tell you an individual’s dignity has been wounded  Recognize that differences in time consciousness may be cultural & not a sign of laziness or resistance

Main Points: Cultural Competence

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

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

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

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

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

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

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

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

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

 Thank you for your time!