Cultural Competence

1. Cultural Competence July 2008

2. 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)

3. Cultural Competence in Clinical Settings: An Introduction for New Nurses

4. 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)

5. 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

6. 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

7. Cultural Competence 1 2 Cultural Awareness Cultural Knowledge & Skill Campinha-Bacote, 2008 3 Cultural Encounter

8. 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

9. Socioeconomic status Sexual Orientation Handicap/Disability Occupation Age Poverty The Homeless The Affluent/Wealthy Gay, Lesbian, Bisexual, Transgender Deaf/Hearing Impaired Blind/Visually Impaired Nurses, Military Adolescents, Elderly Non-ethnic CulturesSelected Examples The Culture of…..

10. 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.

11. 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

12. 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!” “You’re right—It is because I got run down and then went outside without a coat yesterday. That’s why I’m sick.”

13. Explanatory Model Questions • What is the patient’s ethnic affiliation? • Who are the patient’s major support persons and where do they live? • With whom should we speak about the patient’s health or illness? • What are the patient’s primary and secondary languages, and speaking and reading abilities? • What is the patient’s economic situation? Is income adequate to meet the patient’s and family’s needs? (Lipson & Dibble, 2005)

14. Spirituality & Religion

15. Spirituality refers to a subjective experience of the sacred, whereas religion involves subscribing to a set of beliefs or doctrines that are institutionalized.

16. Major World Religions

17. U.S. Religions • 354,194 Congregations • > 1,200 Denominations Yearbook of American & Canadian Churches, 2002

18. Monk Spiritual & Religious Healers Curandero/a Shaman Priest Elder Medicine Man Medicine Woman Rabbi Bishop

19. Religion & spirituality in healing…. • Prayer, Chants • Pilgrimages • Fasting • Amulets or talismans • Healing rituals • Anointing with oil • Sacraments • Laying on of hands

20. 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

21. 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)

22. 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

23. Avoid scheduling medical appointments during holidays Avoid disruption to holy days (such as fasting during Ramadan) Religious, Cultural & Civic Holidays

24. Promoting Effective Cross-Cultural Communication..... Always ask, “By what name may I call you?”

25. What do Limited-English Speakers Want? Speaking one’s native language is…. • Easier when feeling ill • More comfortable • More accurate

26. 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)

27. 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.

28. Requirements in Using a Translator • Use approved Interpreter Services OR • Use the Interpreter Telephone

29. 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

30. Directness in Clinical Encounters • Americans value directness: • “Spit it out” • “Say what’s on your mind” • Languages that depend on subtle contextual cues: • Infer meaning • Imply, but do not state, the point (Japanese, Arabic)

31. 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

32. 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.

33. 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.

34. Smiling & laughter may be signs of embarrassment & confusion on the part of some Asians. Talking with one’s hands is more common in southern Europe than in northern Europe. A direct stare by an African American or Arab is not meant as a challenge to your authority, while dropped eyes may be a sign of respect from Latino or Asian patients & coworkers.

35. 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 one’s fingers at someone would be viewed in the United States.

36. American culture generally expects people to stand about an arm’s length apart when talking in a business situation. • Any closer is reserved for more intimate contact or seen as aggression. • In the Middle East, however, it is normal for people to stand close enough to feel each other’s breath on their faces.

37. 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

38. 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 child’s hair as an affectionate gesture, would be considered offensive by many Asians. • If you need to touch someone for purposes of an examination, explain the purpose & procedure before you begin.

39. 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.

40. Inappropriate Conversation Topics • Even a seemingly innocuous comment on the weather is off limits in the Muslim world, where natural phenomena are viewed as Allah’s will, not to be judged by humans. • This points to another aspect that relates to privacy. • To many newcomers, Americans seem naively open. Discretion and purposeful communication help us judge when to converse and when to be silent.

41. 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.

42. Saving face…. • In Asia, the Middle East, & to some extent Latin America, one’s dignity must be preserved at all costs. • Death is preferred to loss of face in traditional Japanese culture, hence the suicide ritual, hara-kiri, as a final way to restore honor. • Any embarrassment can lead to loss of face, even in the dominant American culture. • To be criticized in front of others, publicly snubbed, or fired, would be humiliating in most any culture. • Seemingly harmless behaviors can be demeaning to some patients.

43. 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.

44. Non-Verbal Communication All cultures have rules, often unspoken, about who touches whom, when & where.

45. Nonverbal Communication(~65% of all communication) • Touch • Facial expressions • Eye movements • Body posture

46. Modesty

47. 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)

48. Pain and Cultural Competence

49. 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

50. 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.