session 4.pptx

SESSION 04: CULTURAL AND
SPIRITUAL ISSUES IN CARING A
PATIENT WITH MENTAL ILLNESS
FACILITATOR : NDABILA
MICHAEL NDABILA,BSCN,RN ,TUTOR

Learning Objectives
• At the end of this session participants are
expected to be able:
• Define culture and spiritual
• Explain culture and spiritual issues
• Explain cultural and spiritual factors
influencing mental health and illness
• Identify client’s spiritual and religious needs

• Buzz…..
Define
• culture ……..
• Ethnicity (2minutes)

Definition of Culture and Spiritual
Culture
• Culture describes a particular society’s entire
way of living, encompassing shared patterns
of belief, feeling, and knowledge that guide
people’s conduct and are passed down from
generation to generation.
• Ethnicity is a some what narrower term and
relates to people who identify with each other
because of a shared heritage (Griffith,
Gonzalez, & Blue, 2003).

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Spirituality
• Spirituality is the human quality that gives
meaning and sense of purpose to an
individual’s existence. Spirituality exists within
each individual regardless of belief system and
serves as a force for interconnectedness
between the self and others, the environment,
and a higher power

Culture and spiritual issues in mental
health care
• Holistic psychiatric nursing care must take into
consideration a wide range of patient
characteristics in the assessment, diagnosis,
treatment, and recovery process.
• People live within social, cultural, and spiritual
contexts that shape and give meaning to their
lives. These characteristics are expressed as
beliefs, norms, and values and they can have
both direct and indirect influences on
patients’ perceptions of health and illness,
their help-seeking behavior, and their
treatment outcomes.

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• They are strong determinants of actual and
potential coping resources and coping responses,
and they influence all phases of an illness,
including treatment effectiveness.
• These social, cultural, and spiritual characteristics
can impact the person’s access to mental health
care, the risk for or protection against developing
a certain psychiatric disorder, the way in which
symptoms will be experienced and expressed, the
ease or difficulty of participating in psychiatric
treatment, and the ability to achieve recovery.
• Thus quality psychiatric nursing care must
incorporate the unique

Culture
• Knowledge related to culture and ethnicity is
important because these influences affect
human behavior, its interpretation and the
response to it.
• Many variations and subcultures occur within
a culture. These differences may be related to
status, ethnic background, residence, religion,
education, or other factors.
• Every individual must be appreciated for his or
her uniqueness

Cultural Competency
• Cultural competency is a necessary step in the
elimination of disparities in the diagnosis and
treatment of mental illness, and is essential in
patient-centered psychiatric nursing care.
• A specific competency for nurses, as defined
by the American Association of Colleges of
Nursing (2008), states that patient
assessment, treatment, and evaluation are
improved by applying knowledge of cultural
factors, using relevant data, promoting quality
health outcomes, advocating for social justice,
and engaging in competency skill
development. MICHAEL NDABILA,BSCN,RN ,TUTOR

continue
• Culturally competent nursing practice requires
far more than recording the patient’s age,
gender, ethnicity, and religion. It must first be
based in desire, awareness, and
understanding.
• Cultural competency is the ability to view each
patient as a unique individual, fully
considering the patient’s cultural experiences
within the context of common developmental
challenges faced by all people and the broader
social environment.

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• The nurse applies this information in nursing
interventions that are consistent with the life
experiences and values of each patient. Five
areas of cultural competency for nurses have
been identified
• Cultural desire—the motivation of the nurse to
want to engage in the process of becoming
culturally competent
• Cultural awareness—the conscious self-
examination and in-depth exploration of one’s
own personal biases, stereotypes, prejudices, and
assumptions about people who are different from
oneself MICHAEL NDABILA,BSCN,RN ,TUTOR

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• Cultural knowledge—the process of seeking and
obtaining a sound educational base about
different cultures including their health-related
beliefs about practices and cultural values,
disease incidence and prevalence and treatment
efficacy
• Cultural skill—the ability to collect relevant
cultural data regarding the patient’s presenting
problem and accurately perform a culturally
based assessment
• Cultural encounters—the deliberate seeking of
face to-face interactions with culturally diverse
patients

How Do Cultures Differ?
Giger (2013) suggests six cultural phenomena
that vary with application and use yet are
evidenced among all cultural groups:
• Communication,
• Space,
• Social organization,
• Time,
• Environmental control, and
• Biological variations.

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Communication
• All verbal and nonverbal behavior in
connection with another individual is
communication.
• Therapeutic communication has always been
considered an essential part of the nursing
process and represents a critical element in
the curricula of most schools of nursing.
• Communication has its roots in culture.
Cultural mores, norms, ideas, and customs
provide the basis for our way of thinking.

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• Cultural values are learned and differ from
society to society.
• Communication is expressed through language
(the spoken and written word), paralanguage (the
voice quality, intonation, rhythm, and speed of
the spoken word), and gestures (touch, facial
expression, eye movements, body posture, and
physical appearance). .

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• The nurse who is planning care must have an
understanding of the client’s needs and
expectations as they are being communicated.
• As a third party, an interpreter often
complicates matters, but one may be
necessary when the client does not speak the
same language as the nurse

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Territoriality
• refers to the innate tendency to own space.
• The need for territoriality is met only if the
individual has control of a space, can establish
rules for that space and is able to defend the
space against invasion or misuse by others.
• Density, which refers to the number of people
within a given environmental space, can
influence interpersonal interaction.

continue
• Distance is the means by which various
cultures use space to communicate.
• Hall (1966) identified three primary
dimensions of space in interpersonal
interactions in the Western culture: the
intimate zone (0 to 18 inches), the personal
zone (18 inches to 3 feet), and the social zone
(3 to 6 feet

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Social Organization
• Cultural behavior is socially acquired through
a process called enculturation, which involves
acquiring knowledge and internalizing values
(Giger, 2013). Children are acculturated by
observing adults within their social
organizations.
• Social organizations include families, religious
groups, and ethnic groups.

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Time
• An awareness of the concept of time is a gradual
learning process. Some cultures place great
importance on values that are measured by clock
time. Punctuality and efficiency are highly valued
in the United States, whereas some cultures are
actually scornful of clock time.
• For example, some rural people in Algeria label
the clock as the “devil’s mill” and therefore have
no notion of scheduled appointment times or
meal times (Giger, 2013).

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• They are totally indifferent to the passage of
clock time, and they despise haste in all
human endeavors.
• Other cultural implications regarding time
have to do with perception of time
orientation. Whether individuals are present
oriented or future oriented in their perception
of time influences many aspects of their lives

Environmental Control
• The variable of environmental control has to do
with the degree to which individuals perceive
that they have control over their environment.
• Cultural beliefs and practices influence how an
individual responds to his or her environment
during periods of wellness and illness.
• To provide culturally appropriate care, the nurse
should not only respect the client’s unique beliefs
but should also have an understanding of how
these beliefs can be used to promote optimal
health in the client’s environment.

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Biological Variations
• Biological differences exist among people in
various racial groups.
• These differences include body structure (both
size and shape), skin color, physiological
responses to medication, electrocardiographic
patterns, susceptibility to disease and
nutritional preferences and deficiencies.
• Giger (2013) suggests that nurses who possess
factual knowledge about biological variations
among diverse groups are better able to
provide culturally appropriate health care

Spirituality
• Spirituality is difficult to describe. Historically,
it has had distinctly religious connections,
with a spiritual person being described as
“someone with whom the Spirit of God
dwelt.”
• In the treatment of mental illness, some of the
earliest practices focused on including
spiritual treatment because insanity was
considered a disruption of mind and spirit
(Reeves & Reynolds, 2009).

continue
• Thus religion and spiritually have been
avoided rather than embraced as a valuable
aspect of treatment. More recently, the focus
is changing once again.
• Reeves and Reynolds note that the large
volume of contemporary research (more than
60 studies) demonstrating the value of
spirituality for both medical and psychiatric
patients is influencing this change.

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• Nursing has embraced this new focus by the
inclusion of nursing responsibility for spiritual
care in the International Council of Nurses’
Code of Ethics and in the American Holistic
Nurses Association’s Standards for Holistic
Nursing Practice.
• The inclusion of spiritual care is also
evidenced by the development of the nursing
diagnosis category “Spiritual Distress” by
NANDA International (Wright, 2005).

continue
• Spirituality is the recognition or experience of
a dimension of life that is invisible, and both
within us and yet beyond our material world,
providing a sense of connectedness and
interrelatedness with the universe

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Spiritual Needs
• Smucker identified the following factors as
types of spiritual needs associated with
human beings:
o Meaning and purpose in life
o Faith or trust in someone or something
beyond ourselves
o Hope
o Love
o Forgiveness

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Meaning and purpose in life
• Humans by nature appreciate order and
structure in their lives.
• Having a purpose in life gives one a sense of
control and the feeling that life is worth living.
• Each nurse’s exploration of their own
spirituality and efforts to grow spiritually are
foundational to being responsive to those
needs in others.

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• Walsh (1999) describes “seven perennial
practices” that he believes promote
enlightenment(to give spiritual insight) aid in
transformation and encourage spiritual
growth. He identified the seven perennial
practices as follows:
Transform your motivation: Reduce craving
and find your soul’s desire.
Cultivate emotional wisdom: Heal your heart
and learn to love.
Live ethically: Feel good by doing good.

continue
Concentrate and calm your mind: Accept the
challenge of mastering attention and
mindfulness.
Awaken your spiritual vision: See clearly and
recognize the sacred in all things.
Cultivate spiritual intelligence( understanding
and reasoning): Develop wisdom and
understand life.
Express spirit in action: Embrace generosity
and the joy of service

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Forgiveness
• “Essential to a spiritual nature is forgiveness—
the ability to release from the mind all the
past hurts and failures all sense of guilt and
loss”.
• Feelings of bitterness(grievious) and
resentment(anger) take a physical toll on an
individual by generating stress hormones(
stressor hormone called cortisol ) which if
maintained for long periods can have a
detrimental effect on a person’s health.

continue
• Forgiveness enables a person to cast off
resentment and begin the pathway to healing.
Forgiveness is not easy.
• Individuals often have great difficulty when
called upon to forgive others and even greater
difficulty in attempting to forgive themselves.
• Many people carry throughout their lives a
sense of guilt for having committed a mistake
for which they do not believe they have been
forgiven or for which they have not forgiven
themselves.

continue
• To forgive is not necessarily to condone or
excuse one’s or someone else’s inappropriate
behaviour.
• Holding on to grievances causes pain,
suffering and conflict.
• Forgiveness (of self and others) is a gift to
oneself. It offers freedom and peace of mind.
• It is important for nurses to be able to assess
the spiritual needs of their clients.

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• Nurses need not fulfil the role of professional
counsellor or spiritual guide but because of
the closeness of their relationship with clients
nurses may be the part of the healthcare team
to whom clients may reveal the most intimate
details of their lives

Cultural and Spiritual Factors
Influencing Mental Health and Illness
• Patient-centered care requires knowledge of
how social, cultural, and spiritual life
experiences and personal characteristics may
influence mental health, psychiatric nursing
care and treatment outcomes without bias,
assumptions or overly simplistic views of
complex life experiences.
• Nurses who routinely ask patients questions
about these aspects of their lives convey
concern about their well-being and avoid
stereotyping.

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• The concept of risk factors and protective
factors is important to understanding how
people acquire experience and recover from
illness (Carpenter-Song et al, 2007).
• They develop over time and may change with
personal circumstances. These factors are the
same as the predisposing factors that nurses
assess

• Six patient characteristics influenced by social
norms, cultural values, and spiritual beliefs,
have been shown to be predisposing factors
related to mental health and mental illness.
• These factors are age, ethnicity, gender,
education, income, and spirituality.

• They influence the patient’s exposure to
stressors, appraisal of stressors, coping
resources and coping responses
• For example, poverty is a risk factor for many
psychiatric disorders, such as depression and
anxiety and numerous psychosocial problems
such as divorce and abuse

Age
• Age influences an individual’s experience of
life stressors, variations in support resources,
and coping skills.
• From school age, to young adult, to retirement
and fragile old age, individuals are faced with
challenges and changes in their life.

Age continue
• Age-related increases and decreases in the use
of mental health services can reflect emerging
trends in the physical, social, cultural, and
spiritual domains of life.
• Young adolescents can face many social
stressors such as bullying at a time when they
have not yet developed effective coping skills.

Age cont
• Such social stressors can be distressing at any
age. However, when they are experienced
during transition age periods, such as early
adolescence, new parenthood, or recent
retirement, they can seem more
overwhelming if at the same time the
individual must develop new skills and
resources to cope effectively.

Age cont.
• Many expect to be able to remain active,
healthy, and independent. Their expectations
can mean greater demands on all health care
services, including mental health care
• Although age alone can be a determining
personal characteristic, age interacts with all
other characteristics and therefore can be
somewhat less predictable

Age cont
• For example, different interactions of age and
income, age and gender, and age and ethnicity
can yield different effects. Culturally
competent practice requires asking the
patient about specific age-related experiences
and concerns

Ethnicity
• Ethnicity is a cultural characteristic based on
racial, national, tribal, genetic, linguistic, and
family origins. Individual members of
culturally intact groups can have more shared
beliefs and values and less variation between
communities.
• However, because ethnicity is largely a cultural
characteristic, persons who have similar
physical features can have important cultural
differences and distinctions

Gender
• As a predisposing factor, gender is similar to
ethnicity in that at first glance there appears
to be distinctive male and female patterns of
risk and protection. However, when all
psychiatric disorders are included, the
prevalence of mental illness among males and
females is approximately equal.

Gender cont.
• The difference between the two groups is in
the type of disorder that is most commonly
diagnosed. Substance abuse and antisocial
personality disorder are the most prevalent
psychiatric disorders among males, whereas
affective disorders and anxiety disorders are
most prevalent among females

Gender cont.
• In contrast, the prevalence of schizophrenia
and manic episodes for males and females is
about equal.
• These findings suggest that male and female
role socialization plays a part in the perception
of health and illness, and that the risk of
psychiatric disorders may be gender typed by
socio cultural factors, including the way they
perceive and cope with life stressors.
• For example, women are more likely to
ruminate about distressing life experiences,
whereas men are more likely to seek
distractions MICHAEL NDABILA,BSCN,RN ,TUTOR

Education
• Education is a coping resource that can
decrease the risk of developing stress-related
psychiatric disorders or increase the
probability of a recovery. For example, it has
been shown that more years of schooling is
associated with decreased risk for developing
psychiatric disorders, better treatment
outcomes, and more complete recovery.

Education cont.
• Education is more important than income in
determining the use of mental health services,
with those with the highest educational level
using mental health services most often.
However, education is more than the number
of completed years of schooling

Education cont.
• it is important to remember that patients with
less education could have the ability but lack
opportunity, family and community support,
or self-confidence.
• Patients with less education also may also
have limited income. The close interaction of
education and income requires that they be
assessed as related characteristics.
• Perhaps the most consistent impact of
education has to do with problem-solving
capacity

Income
• The profound negative impact of poverty as a
risk factor for psychiatric illness is evident
regardless of age, ethnicity, gender, or
education.
• The relationship of poverty and severe
financial stressors to poor health has been
well documented.
• Poverty seems to multiply the impact of other
risk factors. Alternatively, poverty might
undermine the impact of protective factors.

Beliefs
• Personal beliefs touch all aspects of life. A
person’s belief system, world view, religion, or
spirituality can have a positive or negative
effect on mental health.
• Adaptive belief systems can enhance health
and wellbeing, improve quality of life, and
support recovery from psychiatric disorders.

Beliefs cont.
• Maladaptive belief systems can contribute to
poor health status, refusal of necessary
treatment, nonadherence with treatment
recommendations, or even self-injury.
• Beliefs help people make sense of their lives
and the world in which they live.
• Beliefs can provide answers to questions
without answers solutions to problems that
cannot be solved and hope when hope is all
that remains. Personal beliefs can have many
different sources

Client’s Spiritual and Religious Needs
• Religion - a set of beliefs, values, rites, and
rituals adopted by a group of people. The
practices are usually grounded in the
teachings of a spiritual leader.
• Religion is one way in which an individual’s
spirituality may be expressed. There are more
than 6,500 religions in the world (Bronson,
2005).

continue
• Some individuals seek out various religions in
an attempt to find answers to fundamental
questions that they have about life and
indeed, about their very existence. Others,
although they may regard themselves as
spiritual, choose not to affiliate with an
organized religious group.
• Brodd (2009) suggested that all religious
traditions manifest seven dimensions:
experiential, mythic, doctrinal, ethical, ritual,
social, and material.

• He explains that these seven dimensions are
intertwined and complementary and,
depending on the particular religion, certain
dimensions are emphasized more than others.
For example, Zen Buddhism has a strong
experiential dimension, but says little about
doctrines. Roman Catholicism is strong in both
ritual and doctrine

• The social dimension is a significant aspect of
religion as it provides a sense of community
of belonging to a group such as a parish or a
congregation which is empowering for some
individuals.
• Affiliation with a religious group has been
shown to be a health-enhancing endeavor
(Karren et al, 2010).

• A number of studies have been conducted
that indicate a correlation between religious
faith/church attendance and increased chance
of survival following serious illness, less
depression and other mental illness, longer
life, and overall better physical and mental
health

• In an extensive review of the literature,
Maryland psychologist John Gartner (1998)
found that individuals with a religious
commitment had lower suicide rates, lower
drug use and abuse, less juvenile delinquency,
lower divorce rates, and improved mental
illness outcomes.
• It is not known how religious participation
protects health and promotes well-being.
Some churches actively promote healthy
lifestyles and discourage behaviour that would
be harmful to health or interfere with
treatment of disease.

• But some researchers believe that the strong
social support network found in churches may
be the most important force in boosting the
health and well-being of their members. More
so than merely an affiliation, however, it is
regular church attendance and participation
that appear to be the key factors

Key Points
• Culture encompasses shared patterns of belief,
feeling, and knowledge that guide people’s
conduct and are passed down from generation to
generation.
• Cultural groups differ in terms of communication,
space, social organization, time, environmental
control, and biological variations.
• Culture-bound syndromes are clusters of physical
and behavioral symptoms that are considered as
illnesses or “afflictions” by specific cultures, but
do not readily fit into the Western conventional
diagnostic categories.

• Spirituality is the human quality that gives
meaning and sense of purpose to an
individual’s existence.
• Individuals possess a number of spiritual
needs that include meaning and purpose in
life, faith or trust in someone or something
beyond themselves, hope, love, and
forgiveness.
• Religion is a set of beliefs, values, rites, and
rituals adopted by a group of people.

• Religion is one way in which an individual’s
spirituality may be expressed.
• Affiliation with a religious group has been
shown to be a health-enhancing endeavor.
• Nurses must consider cultural, spiritual, and
religious needs when planning care for their
clients

Session Evaluation
• What is culture
• What is spirituality
• What are culture and spirituality issues?
• What are cultural and spiritual factors
influencing mental health and illness?
• What are client’s spiritual and religious needs

Reference
• Keltner N.K, & Steele D, (2015) Psychiatric Nursing 7th ed. St Louis,
Missouri: Mosby
• Blashki. G, Judd. F, Piterman. L, (2007) General Practice Psychiatry,
Australia: McGraw-Hill companies
• Halter MJ. (2014). Varcarolis’ Foundation of Psychiatric Mental Health
Nursing 7th ed. St. Louis: Elsevier Sounders
• Townsend M C. (2011), Essentials of Psychiatric Mental Health and
Nursing: Concepts of Care in Evidence –Based Practice.5th ed. Philadelphia.
F.A Davis
• Puri, B. K., Laking, P. J., &Treasaden, I. H.( 2011). Textbook of psychiatry
(3rd ed.). London UK, Churchill Livingstone
•
• Stuart GW.,(2013) Principles and practice of psychiatric nursing.(10th ed).
St Louis Missouri. Mosby

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Editor's Notes