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  • •The U.S. population is becomingmore and more culturally and ethnically diverse.•In the areas of health and illness, there are similarities and differences and dominant and variant cultural patterns among these populations.•To care for people holistically, nurses need to integrate culturally congruent care within their nursing practice.
  • [Fig. 9-1 from text p. 102 is shown. Note: From Chart text: *Hispanics may be of any race, so they are also included in applicable race categories; therefore total percentages are greater than 100%. †Includes Native Hawaiian, Pacific Islander, and people reporting two or more races.]•Approximately 33% of the population currently belongs to a racial or ethnic minority group.•Racial and ethnic minorities are more likely to have poor health and to die at an earlier age.•Racial and ethnic minorities often experience poor access to care.•Health disparities among ethnic and racial minorities continue to increase.•Eliminating disparities in the health status of people from diverse racial, ethnic, and cultural backgrounds has become one of the two most important priorities of Healthy People 2020.
  • •Culture is the context for interpreting human experiences such as health and illness and provides direction for decisions and actions.•Culture can be described as the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.•Culture has both visible and invisible components. •The invisible value-belief system of a particular culture is often the major driving force behind visible practices.•Ethnicity refers to the common sense of identity of a group of people based on their heritage.•People may declare their ethnic identity to be Irish, Vietnamese, or Brazilian. •Ethnicity is different from race.•Race is limited to the common biological attributes shared by a group such as skin color.•Examples of racial classifications include Asian and Caucasian.
  • •Ethnicity refers to the common sense of identity of a group of people based on their heritage.•People may declare their ethnic identity to be Irish, Vietnamese, or Brazilian. •Ethnicity is different from race.•Race is limited to the common biological attributes shared by a group such as skin color.•Examples of racial classifications include Asian and Caucasian.
  • [Present and briefly discuss the first section of the Case Study. You might ask the following question to get students thinking about what they would do if they were Jenny.] •If you were Jenny, how would you assist Mrs. Tao?[Ask students to think about Mrs. Tao’s needs as you proceed through these slides. This Case Study is presented in sections, which continue throughout the slide presentation.]
  • [You could play a Jeopardy© type game. Answers are in the boxes on the slide. You might start with: “Which concept shown in the boxes means an outsider’s perspective?” (Answer: Etic Worldview)][Definitions are as follows:]Culture: Thoughts, communications, actions, customs, beliefs, and institution of racial, ethnic, religious, or social groups.Subcultures: Represent various ethnic, religious, and other groups with distinct characteristics from the dominant culture.Ethnicity: A shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristicsEmic worldview: The insider, or native, perspective.Etic worldview: An outsider’s perspective.Enculturation: Socialization into one’s primary culture as a child.Acculturation: The process of adapting to and adopting a new culture.Assimilation: Results in varying degrees of affiliation with the dominant culture.Biculturalism: Also known as multiculturalism; occurs when an individual identifies equally with two or more cultures.
  • •Culturally congruent care is meaningful, supportive, and facilitative because it fits valued life patterns of patients.•Our goal is to provide culturally congruent care.•The process of providingculturally competent care puts us on the path to providing culturally congruent care.•The process of providing culturally competent care requires seeking support from the patient’s family.•It also requires seeking organizational support from inside the health care agency and from outside health care agencies.•Cultural conflicts can inhibit our learning and therefore inhibit our ability to provide culturally congruent care.•Cultural conflicts to avoid are ethnocentrism and cultural imposition.•Ethnocentrism occurs when people believe that their own way of life is superior to that of others. •Ethnocentrism causesbias and prejudice.•Cultural imposition can occurwhen people have cultural ignorance or cultural blindness about others. •Cultural imposition causes people to use their own values and lifestyle as the absolute guide in dealing with patientsand interpreting their behavior. [You can use the example in the book about the Apostolic Pentecostal woman to initiate a discussion about visible and invisible cultural components and how the process of culturally competent care, leading to culturally congruent care, could be achieved.]
  • Answer: D [Discuss.]
  • [The case study continues here. Ask students to keep in mind this part of this section of the case study as the presentation continues.]
  • •Transcultural nursing is the comparative study and understanding of cultures to identify specific and universal caring constructs across cultures.•One way to begin understanding cultural context is to consider the differences in how health, illness, and caring are viewed in Western cultures and non-Western cultures.•A classic example of the differences between Western cultures and non-Western cultures:•The biomedical orientation of Western cultures emphasizes scientific investigation. •Non-Western cultures emphasize a holistic conceptualization of health and illness.[Table 9-1 from text p. 104, Comparative Cultural Contexts of Health and Illness,discusses specific examples of Western and non-Western cultural healing and healers.]
  • [Examples of Cultural Healers and Modalities are taken from Table 9-2 on text p. 105. ] •Two distinct categories of healers cross-culturally are naturalistic practitioners and personalistic practitioners. •Naturalistic practitioners attribute illness to natural, impersonal, and biological forces that cause alteration in the equilibrium of the human body. •For naturalistic practitioners, healing emphasizes the use of naturalistic modalities, including herbs, chemicals, heat, cold, massage, and surgery. •Personalistic practitioners believe that an external agent, which can be human (i.e., sorcerer) or nonhuman (e.g., ghosts, evil, or deity), causes health and illness. •For personalistic practitioners, healing emphasizes the importance of humans’ relationships with others, both living and deceased, and with their deities. [Ask the class: Which of these two types of practitioners would be considered “Western”? Which might be considered “non-Western”? Discuss.][For this slide and the next, you might ask students if they have personal knowledge of any of the healers in the table to initiate further discussion.]
  • [Examples of Healers are taken from Table 9-2 on text p. 105. As with the previous slide, you might ask students if they have personal knowledge of any of the healers in the table to initiate discussion.]
  • [The case study continues here. You might ask students what their thoughts and impressions are. Why might Mrs. Tao not follow Jenny’s suggestion to drink the ice water?]
  • •Cultures generally mark transitions to different phases of life by rituals that symbolize cultural values and meanings attached to these life passages. •Rites of passage are significant social markers of changes in a person’s life (Van Gennep, 1960).•Examining the practices surrounding these life events provides a view of the cultural meanings and expressions relevant to these transitions. •An example of a rite of passage is having a child. This rite of passage can be divided into four periods, as shown, each its own “rite of passage.”
  • •Examples of cultural practices for certain rites of passage: •Sending flowers and get-well greetings to a sick person is a ritual showing love and care for the patient in the dominant American culture in which privacy is valued. •In collectivistic groups such as the Hispanic culture, the physical presence of loved ones with the patient during illness demonstrates caring.•Cultures deal with significant life events in many different ways. •It is important for nurses to be aware of the cultural perspective of the patients they care for. •Nurses should consult the cultural assessment book used in the nursing program when caring for patients.[You might ask students if they can share their cultural experiences in these areas. Encourage students to participate by creating a safe environment for them to speak.]
  • [This information is taken from Box 9-1 on text p. 106: Evidence-Based Practice: Cultural Beliefs and Rituals Surrounding Death.]To provide culturally congruent care for patients who are preparing for death and for family members who are preparing for the death of a loved one, nurses need to:• Ask families about the rituals and ceremonies they use to help them cope with the death of a loved one.• Allow patients and families the ability to participate in planning which rituals will be performed at the patient’s bedside.
  • [You might ask students whether anyone expected that this might be the situation. Discuss how important cultural assessment is in the context of this Case Study.]
  • •Human groups create their own interpretations and descriptions of biological and psychological malfunctions within their unique social and cultural context (Dein, 2006). Examples: •In the United States “going postal,” which refers to extreme and uncontrollable anger in the workplace that may result in shooting people, is now considered a culture-bound syndrome. •Hwa-byung is a Korean culture-bound syndrome observed among middle-aged, low-income women who are overwhelmed and frustrated by the burden of caregiving for their in-laws, husbands, and children. Symptoms are generally somatic manifestations consisting of insomnia, fatigue, anorexia, indigestion, feelings of an epigastric mass, palpitations, heat, panic, feelings of impending doom, and dyspnea. Symptoms reflect the cultural definition of illness as imbalance between heat (yang) and cold (yin).
  • •Cultural assessment requires a comprehensive and thorough investigation of a patient’s cultural values, beliefs, and practices.•Make sure to look at Leininger’s Sunrise Model (Fig. 9-3 on text p. 108).•As students, you will perform a focused cultural assessment by selecting the most relevant problems that exist. [If you have culturally diverse students in your class, you might ask them to lead a discussion on these issues. You may also ask if students experience these issues, or if they occur with parents, grandparents, or elders in their family.]
  • [You might start a discussion with these questions:]•Would you classify Jenny’s question as afocused question or as an open-ended question?•Why might it be important to form very focused, or specific, questions when assisting a patient of another culture?•When might you ask more general or open-ended questions?•Who can explain why Jenny’s last question is characterized as a contrast question?
  • •Consider some of the important points from Box 9-2 (on text p. 107),Cultural Aspects of Care: Understanding Cultural Safety.•How can you relate the experience that Jenny has with Mrs. Tao in the Case Study to the points shown?•What other important considerations will determine your approach to caring for a patient? [Discuss age and caring for elderly patients.]
  • [You might ask the following question to start a discussion on the implementation of culturally congruent care.]•After Jenny gives Mrs. Tao the cup of herbal tea, what does Jenny do next? [Jenny conveys the patient’s preferences to the cafeteria.]•It is very important thatnurses follow through with communicating specific culture-related information to all persons associated with giving a patient care.[For further discussion of patient dietary concerns, see Box 9-6 on text p. 111, Patient Teaching: Cultural Considerations in Healthy Food Choices.]
  • •Transcultural nursing refers to comparative study and understanding of cultures to identify specific and universal caring constructs across cultures.•Transcultural communication manages the impression the nurse makes on the patient to achieve desired outcomes of communication. •In a cultural assessment, the goal is to generate knowledge about the patient’s values, beliefs, and practices about nursing and health care. •If the nurse’s behavior is offensive to the patient, he or she will not likely participate in the interaction.•To provide safe and effective patient care, you need to develop and use transcultural communication skills and be able to work with interpreters.•Interpreters are more effective when they have knowledge of the culture of the patient. •Interpreters provide accurate accounts of what is said and, just as important, offer information regarding the cultural beliefs of the patient and family. •Interpreters tactfully formulate culturally sensitive questions that provide the health care provider with needed information (Dysart-Gale, 2007).[Discuss Box 9-4 on text p. 109, Rules of Impression Management.]
  • •Culturally competent care requires knowledge, attitudes, and skills supportive of implementation of culturally congruent care.•Several authors have proposed methods for conducting a cultural assessment.•In Fig. 9-3 (on text p. 108), you see Leininger’s Sunrise Model.•Three points will assist you when making a cultural assessment:•Census data: Knowing the population demographics of a particular community will help you formulate a plan of care. Remember to include the distribution of ethnic groups, education, occupation, and incidence of common illnesses.•Asking questions: Use open-ended questions and be focused. These types of questions encourage patients to describe their values, beliefs, and practices regarding health and illness. If needed, refer back to your speech or communication course taken as a prerequisite for entry into the nursing program. •Establishing relationships: Because language and communication difficulties may exist, it will be important to establish a relationship, so the patient and family feel comfortable discussing the patient’s illness.
  • [Discuss with students the following components and strategies of the outcome of this Case Study.]Outcome: Case StudyJenny institutes the following strategies:Teaching Strategies•Provides an interpreter or patient education information written in Chinese if needed•Fully assesses Mrs. Tao's diet and fluid preferences•Assesses the meanings of foods and fluids within Mrs. Tao’s cultural context•Explains that a breastfeeding mother requires more fluids than normal to produce milk•Providesbrochures that describe information about breastfeeding, including information regarding sufficient fluid intakeEvaluation Strategies•Monitorsfluid intake over the remainder of Mrs. Tao's hospitalization•Assesses hydration and nutritional status of Mrs. Tao's daughter (e.g., weight, sunken fontanels, moistness of mucous membranes)•Asks Mrs. Tao to list at least three fluids she will drink to promote lactation
  • [This information is taken from Box 9-3 on text p. 109: Nursing Assessment Questions. Review material by initiating a discussion of each bullet point. Have students consider which assessment components were important for Jenny and Mrs. Tao in the Case Study.]•Cultural assessment requires a comprehensive and thorough investigation of a patient’s cultural values, beliefs, and practices.
  • Answer: B[Discuss.]
  • •The competence of bilingual staff and interpreters providing language assistance must be ensured by the health care organization.•Unless requested by the patient, family, and friends, should not be used to provide interpretation services.•Interpreters are more effective when they have knowledge of the culture of the patient.•Patient-related information and signage must be posted in the service area of the health care organization in the languages of the groups that are commonly served.
  • Review Box9-7 (on text p. 112)Focus on Older Adults: Culturally Sensitive Communication.In the United States, Americans often greet each other with a firm handshake. However, many Native Americans see this as a sign of aggression, and touch outside of marriage is sometimes forbidden in older adults from the Middle East. Generally, Eastern cultures value silence, whereas Western cultures are uncomfortable with it.In European American cultures, direct eye contact is a sign of honesty and truthfulness. However, eye contact with other groups such as older Native Americans is not allowed. Older Asian adults sometimes avoid eye contact with authority figures because it is considered disrespectful, and direct eye contact between genders in Middle Eastern cultures is sometimes forbidden except between spouses.
  • •Nurses achieve culturally congruent care through cultural assessment and the application of cultural preservation, accommodation, and repatterning.All three modes of professional decisions and actions assist, support, facilitate, or enable people of particular cultures.To provide culturally congruent care, it is important to identify potential conflicts between patients’ health care needs and their health care practices and cultural values.Nurses are able to use any or all of these action modes simultaneously. These actions require that nurses have knowledge of patients’ culture and willingness, commitment, and skills to work with patients and families in decision making.

Transcript

  • 1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Chapter 9Culture and Ethnicity
  • 2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Summary of U.S. Census Data, 2010Data from U.S. Census Bureau: State and county quick facts, 2010,http://quickfacts.census.gov/qfd/states/00000.html
  • 3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Culture Defined Culture affects how people value, evaluate,and categorize life experiences. The members of a cultural group sharevalues and ways of thinking and acting. These values and ways of thinking and actingare different from those of people who areoutside the group.
  • 4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Ethnicity Defined Members of an ethnic group feel a commonsense of identity. Ethnic identity is based on the language,geographic area, racial characteristics, andvalues of the group’s heritage.
  • 5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study Mrs. Tao is 27 years old and immigrated tothe United States from China 3 yearsago. She is in the hospital because she gavebirth to a baby girl yesterday. She isbreastfeeding her baby and plans to go hometomorrow. Jenny is a 23-year-old nursing studentassigned to care for Mrs. Tao. Jenny knowsthat it is important to provide education toMrs. Tao, so she will be able to take care ofher daughter at home.
  • 6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Understanding Cultural ConceptsCulture Subcultures EthnicityEmicWorldviewEtic Worldview EnculturationAcculturation Assimilation Biculturalism
  • 7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Cultural Care Concepts Culturally congruent care Fits the person’s valued life patterns and set ofmeanings Requires specific knowledge, skills, and attitudesin the delivery of care Culturally competent care Is the process of acquiring specific knowledge,skills, and attitudes to provide culturally congruentcare
  • 8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quick Quiz!1. Health disparities are unequal burdens ofdisease morbidity and mortality ratesexperienced by racial and ethnic groups.These disparities are often exacerbated byA. Bias.B. Stereotyping.C. Prejudice.D. All of the above.
  • 9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Jenny teaches Mrs. Tao that it is important todrink fluids to replace fluids lost during birthand to facilitate production of breastmilk. Jenny then gives Mrs. Tao a freshpitcher of ice water and suggests that Mrs.Tao drink at least 8 ounces of water everyhour.
  • 10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Cultural Context of Health, Illness,and Caring In every culture: Health, illness, and caring have meanings that areunique. Groups interpret and define experiences relevantto birth, illness, and death through a certaincontext.
  • 11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Examples of Cultural Healersand Modalities Chinese and Southeast Asians Herbalist, acupuncturist, fortune teller, Shaman Asian Indians Herbalist, acupuncturist, fortune teller, Shaman American Indians Shaman
  • 12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Healers African American “Granny midwife,” spiritualist, voodoo practitioner,hougan (male), mambo (female) Hispanics Cuarandero/a, yerbero, sabador, espiritsta,santero/a
  • 13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Several hours later, Jenny checks Mrs. Tao’swater pitcher and notices that Mrs. Tao didnot drink any of it. Jenny adds new ice to thepitcher and explains again to Mrs. Tao theimportance of drinking fluids. Mrs. Tao nodsthat she understands. Jenny leaves Mrs. Tao,expecting that she will drink the ice water.
  • 14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Culture and Life TransitionsRites of PassagePregnancyChildbirthNewbornPostpartum Period
  • 15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Culture and Life Transitions (cont’d)Rites of PassageGrief and Loss
  • 16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Cultural Beliefs and RitualsSurrounding DeathApplication to Nursing Practice Be aware of religious and culturalpreferences when helping patients andfamilies prepare for death. Be sensitive to cultural perceptions regardingorgan donation, viewing the body, andpreparing for burial.
  • 17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Mrs. Taos husband comes in to visit his wifeat noon. Jenny decides to ask Mrs. Tao anopen-ended question. “Please help meunderstand why you aren’t drinking yourwater.” Mr. Tao replies, “My wife needs toavoid cold during the next 30 days to returnthe balance between yin and yang to herbody. She needs the warm energy force ofyang right now, so she cannot drink coldwater.”
  • 18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Culture-Bound Syndromes Culture-bound syndromes are illnesses thatare specific to one culture. They are used to explain personal and socialreactions of members of the culture. Culture-bound syndromes occur in anysociety.
  • 19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Selected Components of CulturalAssessmentEthnic Heritage andEthnohistoryBiocultural HistorySocial Organization Religious andSpiritual BeliefsCommunicationPatternsTime OrientationCaring Beliefs andPracticesExperiences WithProfessional HealthCare
  • 20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Jenny then asks a question, “According toyour beliefs, what beverages can youdrink?” Mrs. Tao replies that she prefers todrink hot tea right now. Jenny then asks acontrast question, “Would you prefer hotherbal tea, or is hot decaffeinated tea betterfor you?” Mrs. Tao replies, “I would like somehot herbal tea, please.”
  • 21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Implications for Nursing Practice Set culture care as a priority. Approach patients and families in a culturallysensitive manner. Engage in negotiated partnerships withpatients and families. Enable the families and social networks ofpatients to serve as backup support.
  • 22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Jenny gives Mrs. Tao a cup of herbal tea andconveys Mrs. Taos preferences to thecafeteria to make sure she continues toreceive the appropriate fluids on her mealtrays. Mrs. Tao drinks three cups of hot tea inthe next hour.
  • 23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Transcultural Nursing Transcultural communication requires: Linguistic skills Culturally congruent interpretation of behaviors ofothers Listening Observation skills Impression management facilitates: Culturally congruent communication Intercultural relationships
  • 24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Cultural Assessment A systematic and comprehensiveexamination of the cultural care values,beliefs, and practices of individuals, families,and communities Gathers information that will enable the nurseto provide culturally competent care
  • 25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Upon doing some reading about the Chineseculture, Jenny finds out that the yin-yang (hot-cold) theory is important and influences whata patient eats and drinks, especially duringpregnancy, following delivery, and in times ofillness. Jenny uses cultural care concepts toprovide education about breastfeeding toMrs. Tao.
  • 26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Assessment Questions Types of questions and question topics: Open-ended or focused Contrast Ethnohistory Social organization Socioeconomic status Bicultural ecology and health risks Language and communication Caring beliefs and practices
  • 27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quick Quiz!2. You are in the process of admitting anethnically diverse client. To plan culturallycompetent care, you will conduct a culturalassessment that includesA. Biocultural history.B. Ethnohistory.C. Negotiation.D. Ethnocentrism.
  • 28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Aids to Communication Language access services All health care organizations are required to offerfree language assistance, including bilingual staffor interpreter services to each patient with limitedEnglish proficiency. These services must beoffered in a timely manner at all hours of operationat all points of contact. Patients must be informed, in their preferredlanguage, of their right to receive languageassistance services both verbally and in writtenform.
  • 29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Aids to Communication (cont’d) Older adults Ask older adults how they like to be addressed. Ifin doubt, address them formally (e.g., Mr. Lin). Determine the patient’s preferences for touch. Investigate the patient’s preferences for silence. Be aware of the patient’s beliefs about eye contactduring conversation.
  • 30. 30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Culturally Congruent Care Cultural care preservation or maintenance—Retainand/or preserve relevant care values so patientsmaintain their well-being, recover from illness, or facehandicaps and/or death. Cultural care accommodation or negotiation—Adaptor negotiate with others for a beneficial or satisfyinghealth outcome. Cultural care repatterning or restructuring—Reorder,change, or greatly modify patients’ lifestyles for anew, different, and beneficial health care pattern.