Chapter 2 Cultural Competence Copyright 2016 by Elsevier

Cultural Competency Questions Who are you meeting for the first time? Where does the patient come from? What is his or heritage? What is his or her cultural background: ethnicity and religion? Does the patient understand, speak, and read English? What language does he or she understand, speak, and read? What are his or health and illness beliefs and practices? Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 2

Objectives Demographic profile of United States National standards for culturally and linguistically appropriate services Background of heritage assessment Methods for conducting heritage assessment Traditional health and illness beliefs and practices Steps to cultural competence Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 3

Health and Illness Health Ø Balance of a person is a complex, interrelated phenomenon • Within one’s being: physical, mental, spiritual • In outside world: natural, communal, metaphysical Illness Ø Loss of a person’s balance • Within one’s being: physical, mental, spiritual • In outside world: natural, communal, metaphysical Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 4

Demographic Profile of United States Total population passed 311 million in 2011 Greater than one third of U. S. residents were other than non-Hispanic Whites Ø Minority, or emerging majority, populations total 114. 5 million people Ø Hispanics: largest and fastest growing group Ø Blacks: second largest population Ø Asians, American Indians, Alaska Natives, Native Hawaiians, and other Pacific Islanders make up the third largest part of the population Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 5

Emerging Minority Group Trends Differences noted in age, poverty level, and household composition Emerging majority groups tend to be as follows: Younger with lower median ages Ø Higher proportions under 18 years old Ø All ethnic and racial minority groups exceed the national poverty level Family size and multigenerational families are more evident in minority groups Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 6

Immigration and Health Care Concerns Status of immigrants entering the health care system Ø Ø Ø Many new immigrants have only minimal understanding of the following: Ø Ø Ø Legal permanent residents Naturalized citizens Undocumented aliens Refugees, requesting asylum, and parolees Legal nonimmigrant residents Modern health care delivery system Modern medical and nursing practices and interventions English language It is imperative that the nurse’s care be tailored to meet the person’s perceived needs Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 7

National Cultural and Linguistic Standards First and landmark standard Health care organizations should ensure that patients receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language* *Source: National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report, March 2001, Washington, DC: Office of Minority Health, DHHS Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 8

National Cultural and Linguistic Standard Components Effective care: positive outcomes and satisfaction for patient Respectful care: considers values, preferences, and expressed needs of patient Cultural and linguistic competence: congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 9

Linguistic Competence Title VI of Civil Rights Act of 1964 Ø In 2012, over 21% of Americans over 5 years of age speak a language other than English in their homes Ø Services cannot be denied to people of limited English proficiency Most common non-English language is Spanish Patients who have limited English proficiency (LEP) are at risk for poor health care outcomes due to the barrier that language presents during health care delivery interactions Ø Health care facilities may have established interpreters who can assist with therapeutic communication. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 10

Cultural Competence Culturally sensitive Ø Culturally appropriate Ø Possessing basic knowledge of and constructive attitudes toward diverse cultural populations Applying underlying background knowledge necessary to provide the best possible health care Culturally competent Ø Understanding and attending to total context of patient’s situation including the following: • Immigration status • Stress and social factors • Cultural similarities and differences Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 11

Steps to Cultural Competence Understand one’s own heritage-based values, beliefs, attitudes, and practices Identify meaning of “health” to patient Understand how health care system works Acquire knowledge about social backgrounds of patients Become familiar with languages, interpretive services, and community resources available to nurses and patients Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 12

Question What must the nurse assess first when providing culturally competent health care to an Asian American patient? 1. The tradition of the Asian American culture and the health care practices related to health and wellness 2. The nurse’s heritage-based cultural values, beliefs, attitudes, and practices 3. Any differences between the nurse’s culture and the Asian American culture 4. The attitudes of Asian American cultures to the health care system in the U. S. Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 13

Related Concepts Four basic concepts of culture Ø Race and ethnicity Ø Assimilation is one dimensional, and biculturalism/integration is bidimensional Acculturative stress Ø Self-identification and social group Acculturation Ø Learned, shared, adapted, and dynamic Losses and changes associated with integration of new beliefs Religion and spirituality Ø Organized system of beliefs versus individual’s unique experience Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 14

Culture Thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups Characteristics of culture Learned Ø Shared Ø Adapted Ø Dynamic Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 15

Ethnicity Describes a group united by the following: Common geographic origin Ø Migratory status Ø Religion Ø Race Ø Language Ø Shared values, traditions, or symbols Ø Food preferences Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 16

Religion Belief in divine or superhuman power, or powers to be obeyed and worshipped as creator/ruler of universe System of beliefs, practices, and ethical values Shared experience of spirituality Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 17

Socialization Process of being raised within a culture and acquiring characteristics of that group Related terms: Acculturation: process of adapting to and acquiring another culture Ø Assimilation: process of developing a new cultural identity and becoming like members of dominant culture Ø Biculturalism: dual pattern of identification and often of divided loyalty Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 18

Health-Related Beliefs and Practices Balance and beliefs about causes of illness Biomedical or scientific theory Naturalistic or holistic theory Yin and yang Ø Hot and cold Ø Magicoreligious perspective Traditional beliefs and health healers Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 19

Disease Causation Theories Biomedical Assumes cause and effect Ø Views the body as a machine Ø Life can be divided into parts Ø Endorses germ theory Ø Naturalistic Forces of nature must be kept in balance Ø Embraces idea of opposing categories or forces Ø • Yin and yang, hot and cold Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 20

Disease Causation Theories (Cont. ) Magicoreligious Ø Supernatural powers predominate in area of health and illness • Examples include voodoo, witchcraft, and faith healing Healing and culture In addition to seeking help from health care providers, patients may also seek help from folk or religious healers Ø Hispanics or American Indians may believe that cure is incomplete unless healing is carried out for the body, mind, and spirit Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 21

Health-Related Behaviors Affected by Religion Meditating Exercising/physical fitness Sleep habits Vaccinations Willingness to undergo physical examination Pilgrimage Truthfulness about how patient feels Maintenance of family viability Hoping for recovery Coping with stress Genetic screening and counseling Living with a disability Caring for children Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 22

Differing Views Related to Health Beliefs Differing views of epilepsy Uganda: contagious, untreatable Ø Greece: source of family shame Ø Mexican-American community: evidence of physical imbalance Ø Hutterites: evidence of having endured trial by God Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 23

Developmental Competence Beliefs and values across life cycle Dominant culture beliefs Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 24

Traditional Treatments and Folk Healers Folk healers Hispanic: curandero, espiritualista, yerbo, or sabedor Ø Black: hougan, spiritualist, old lady Ø American Indian: shaman, medicine woman, medicine man Ø Asian: herbalists, acupuncturists, bone setters Ø Amish: braucher Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 25

Developmental Competence Culture affects choices parents make for children regarding the following: Presumed cause of illness Ø First treatment tried Ø Acceptability of treatments offered by clinicians Ø For older patients, culture is likely to do the following: Define their family responsibilities Ø Affect their view and knowledge of health care systems used by dominant culture Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 26

Transcultural Expression of Illness Transcultural expression of pain Expectations, manifestations, and management of pain are all embedded in a cultural context Ø Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person Ø Silent suffering has been identified as the most valued response to pain by health care professionals Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 27

Culture-Bound Syndromes Condition that is culturally defined Some have no equivalent in a biomedical, scientific perspective Ø Anorexia nervosa and bulimia are examples of cultural aspects of illness in dominant cultural population in North America Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 28

Steps to Cultural Competency Culturally sensitive Ø Culturally appropriate Ø Caregivers apply knowledge to improve health outcomes Culturally competent Ø Caregivers possess basic knowledge and understanding Caregivers apply a universal concept of understanding to all contextual aspects of care Cultural care Ø Provision of health care across cultural boundaries in consideration of context Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 29

Cultural Formation Model Categories Cultural identity of the individual Ø Cultural explanation of the individual’s illness Ø Cultural factors related to psychosocial environment and levels of functioning Ø Cultural elements of the relationship between the individual and clinician Ø impact of culture on diagnosis and care Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 30

Heritage Consistency Concepts Heritage consistency Ø Degree to which a person’s lifestyle reflects his or her traditional heritage Heritage consistency continuum Traditional: living within norms of traditional culture Ø Modern: acculturated to norms of dominant society Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 31

Indicators of Heritage Consistency Childhood occurred in country of origin or immigrant neighborhood of like ethnic group Ø Extended family support of traditional activities Ø Frequent visits to old country or old neighborhood Ø Family home within ethnic community to which they belong Ø Participation in ethnic cultural events Ø Raised in extended family setting Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 32

Indicators of Heritage Consistency (Cont. ) Regular contact with extended family Ø Name not anglicized Ø Educated in parochial school Ø Social activities primarily with members of ethnic community Ø Knowledge of language and culture of origin Ø Expresses pride in heritage Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 33

Traditional Treatments and Folk Healers Folk healers Hispanic: curandero, espiritualista, yerbo, or sabedor Ø Black: hougan, spiritualist, old lady Ø American Indian: shaman, medicine woman, medicine man Ø Asian: herbalists, acupuncturists, bone setters Ø Amish: braucher Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 34

Culture and Treatment First effort at treatment is often self-care Home treatment attractive for accessibility, particularly for people from rural or sparsely populated areas Home treatment may mobilize person’s social support network and provide a caring environment in which to convalesce Alternative or complementary interventions are gaining recognition from health care professionals in health care system Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 35

Culture and Disease Prevalence Disparity continues in deaths and illnesses experienced by racial and ethnic populations Ø Diseases are not distributed equally among all segments of population Abnormal biocultural variations may be genetic or acquired Information about disease prevalence for racial and ethnic groups provides focus for assessment regarding increased probability that particular conditions may occur Ø Nurses must be certain that they have gathered data needed to support or refute suspicions Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 36

Culture and Respect Realize you must know heritage of yourself and patient Examine patient within cultural context Select simple questions and speak slowly Pace questioning throughout exam Encourage patient to discuss meaning of health and illness with you Check patient’s understanding and acceptance of recommendations Touch patient within boundaries of his or heritage Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 37

Question Which of these is a necessary tool for building cultural competence? 1. Cultural Competency Assessment Tool 2. Health Risk Assessment Tool 3. Ethnic Identity Tool 4. Heritage Assessment Tool Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 38