Cultural Competence

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Cultural Competence

• July 2008

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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)

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Cultural Competence in Clinical Settings An
Introduction for New Nurses
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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)

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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

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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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Cultural Competence
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Cultural Awareness
Cultural Knowledge Skill
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Cultural Encounter

• 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

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Non-ethnic CulturesSelected Examples
The Culture of..

• Poverty
• The Homeless
• The Affluent/Wealthy
• Gay, Lesbian, Bisexual, Transgender
• Deaf/Hearing Impaired
• Blind/Visually Impaired
• Nurses, Military
• Adolescents, Elderly

• Socioeconomic status
• Sexual Orientation
• Handicap/Disability
• Occupation
• Age

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Avoid STEREOTYPING
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.
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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
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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!
• Youre rightIt is because I got run down and
  then went outside without a coat yesterday.
  Thats why Im sick.

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Explanatory Model Questions

• What is the patients ethnic affiliation?
• Who are the patients major support persons and
  where do they live?
• With whom should we speak about the patients
  health or illness?
• What are the patients primary and secondary
  languages, and speaking and reading abilities?
• What is the patients economic situation? Is
  income adequate to meet the patients and
  familys needs? (Lipson Dibble, 2005)

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Spirituality Religion
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Spirituality refers to a subjective experience of
the sacred, whereas religion involves subscribing
to a set of beliefs or doctrines that are
institutionalized.
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Major World Religions
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U.S. Religions

• 354,194 Congregations
• 1,200 Denominations
• Yearbook of American Canadian Churches, 2002

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Spiritual Religious Healers
Curandero/a
Shaman
Priest
Elder
Medicine Man
Medicine Woman
Rabbi
Bishop
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Religion spirituality in healing.

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

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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

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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)

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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

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Religious, Cultural Civic Holidays

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

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Promoting Effective Cross-Cultural
Communication.....
Always ask, By what name may I call you?
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What do Limited-English Speakers Want?

• Speaking ones native language is.
• Easier when feeling ill
• More comfortable
• More accurate

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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)

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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.

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Requirements in Using a Translator

• Use approved Interpreter Services
• OR
• Use the Interpreter Telephone

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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

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Directness in Clinical Encounters

• Americans value directness
• Spit it out
• Say whats on your mind
• Languages that depend on subtle contextual cues
• Infer meaning
• Imply, but do not state, the point
• (Japanese, Arabic)

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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

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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.

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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.

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• Smiling laughter may be signs of embarrassment
  confusion on the part of some Asians.
• Talking with ones 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.

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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 ones fingers
  at someone would be viewed in the United States.

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• American culture generally expects people to
  stand about an arms 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 others
  breath on their faces.

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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

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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 childs 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.

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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.

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Inappropriate Conversation Topics

• Even a seemingly innocuous comment on the weather
  is off limits in the Muslim world, where natural
  phenomena are viewed as Allahs 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.

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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.

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Saving face.

• In Asia, the Middle East, to some extent Latin
  America, ones 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.

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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.

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Non-Verbal Communication

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

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Nonverbal Communication(65 of all
communication)

• Touch
• Facial expressions
• Eye movements
• Body posture

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• Modesty

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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)

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Pain and Cultural Competence
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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

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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.

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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.

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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

• 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.

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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.

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National Institutes of Health

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

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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

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Complementary AlternativeTherapies
Music Therapy
Aroma- therapy
Art Therapy
Acupuncture
Hypno- therapy
Massage Therapy
Ayurveda
Reflexology
Chiropractic
Therapeutic Touch
Shamanism
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Complementary Therapies What is the Clinical
Goal?

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

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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)

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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

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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

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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 drivers license or social
  security card to get a required number

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Meta-Communicative Cultural Competence

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

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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

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Meta-Communicative Cultural Competence

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

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Main Points Cultural Competence
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• 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.

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• 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.

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• 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!