Transcript Slide 1

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
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Campinha-Bacote, 2008
Cultural Competence
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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…..
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Socioeconomic status
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Sexual Orientation
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Handicap/Disability
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Occupation
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Poverty
The Homeless
The Affluent/Wealthy
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Gay, Lesbian, Bisexual,
Transgender
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Deaf/Hearing Impaired
Blind/Visually Impaired
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Nurses, Military
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Adolescents, Elderly
Age
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
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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
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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.
Major World Religions
4%
3%
Christianity
4%
Islam
6%
33%
Hinduism
Nonreligious
16%
Buddhism
Chinese
Traditional
Primalindigenous
Other
16%
18%
U.S. Religions
 354,194
>
Congregations
1,200 Denominations
Yearbook of American & Canadian Churches, 2002
Spiritual & Religious Healers
Curandero/a
Shaman
Monk
Priest
Medicine
Man
Medicine
Woman
Elder
Bishop
Rabbi
Religion & spirituality
in healing….
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Prayer, Chants
Pilgrimages
Fasting
Amulets or talismans
Healing rituals
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Anointing with oil
Sacraments
Laying on of hands
Religion, Health & Culture
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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
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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
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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
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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?
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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?
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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
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Speak with Charge Nurse for
assistance
Call Operator to place call
1-800 number
Client code/ID
Request language
Directness in Clinical Encounters
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Americans value
directness:
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“Spit it out”
“Say what’s on your mind”
Languages that depend
on subtle contextual
cues:
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Infer meaning
Imply, but do not state, the
point
(Japanese, Arabic)
Directness and Subtlety
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“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
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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
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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.
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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
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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.
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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
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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.
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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
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Religious rules may apply to appropriate touch.
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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
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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
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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
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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
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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….
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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)
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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
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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
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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.
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The experience of pain can also be described in
physiologic, psychosocial, economic and
spiritual contexts.
What is Included in a Pain Assessment
Cross-Culturally?
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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.
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Pain Treatment and Cultural Factors
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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
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Typical barriers to a cultural sensitive pain
assessment and treatment by healthcare
providers include:
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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?
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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
Hypnotherapy
Ayurveda
Aromatherapy
Music
Therapy
Complementary
&
Alternative
Therapies
Acupuncture
Massage
Therapy
Reflexology
Chiropractic
Shamanism
Therapeutic
Touch
Complementary Therapies:
What is the Clinical Goal?
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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?
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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
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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
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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
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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
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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
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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
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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.
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Thank you for your time!