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Clinical Nursing Skills

5.1 Understanding Cultural Differences

Clinical Nursing Skills5.1 Understanding Cultural Differences

Learning Objectives

By the end of this section, you will be able to:

  • Identify cultural influences on beliefs of health and illness
  • Recognize health disparities among different cultures
  • Describe different healers among cultural variations
  • Explain how to counteract unconscious bias

Nurses encounter patients from a variety of backgrounds; therefore, it is essential they are able to provide culturally competent care. A lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes is known as cultural competence. It is a way of providing patient-centered, holistic nursing care.

A nurse who provides holistic care to patients will focus on healing the person as a whole rather than on one specific problem. In holistic nursing care, the interconnected aspects of a person’s life, including their physical, cognitive, social, emotional, and spiritual health, are taken into account. In culturally responsive care, an individual’s cultural beliefs are integrated into their health care. Culturally responsive care is required for a trusting, effective relationship with the patient.

Cultural Influences on Health and Illness

The United States is a nation characterized by a multitude of ethnic and cultural groups, with its diversity steadily increasing each day. A set of beliefs, attitudes, and practices shared by a group of people or community which is accepted, followed, and passed down to other members of the group is known as culture. Some groups of people have cultural beliefs that explain what causes illness, how illnesses are treated or cured, and who should be involved in the healing process. Culture also affects how people communicate with healthcare team members in terms of language or eye contact, or what can be discussed in terms of the person’s body, health, or illness. A person’s culture affects everything from how they think and feel about health and illness, to how receptive they are to treatment recommendations, to how, when, and from whom they receive care.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Safety and Procedure: Patient-Centered Care

Definition: Recognize the patient as a full partner in control of all decisions when providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs.

Knowledge: Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.

Skill: Communicate patient values, preferences, and expressed needs to other members of the healthcare team.

Attitude: Respect and encourage individual expression of patient values, preferences, and expressed needs.

Best practice standards include the nurse providing competent, effective care with each patient interaction. Conducting a cultural assessment is one way to ensure the patient’s preferences and cultural needs are met.

Physiological Differences

Some ethnic and cultural groups have a higher likelihood of experiencing specific diseases, particularly those with genetic conditions associated with their ancestry. Individuals belonging to these ancestral ethnicities are more prone to carrying recessive genes responsible for these illnesses. See Table 5.1 for a list of various ethnic groups along with some of the prevalent genetic diseases associated with each. For instance, there is potential susceptibility to certain cancers and rapid disease progression due to certain physiological diversity such as body structure, skin color, hair type, and metabolism (Perreira et al., 2019).

Ethnic Group(s) Associated Hereditary Conditions
African Sickle cell anemia, cystic fibrosis, thalassemia
Ashkenazi Jewish Tay-Sachs disease, cystic fibrosis, Gaucher disease
Asian Thalassemia
French Canadian, Cajun Tay-Sachs disease
Mediterranean Sickle cell anemia, thalassemia
Table 5.1 Ethnicities and Associated Hereditary Conditions

Psychological Differences

One main psychological distinction between cultures that affects how people think and make decisions is individualism versus collectivism. People from individualistic cultures focus on the individual. They are encouraged to make choices for their own benefit with an emphasis on independence and self-reliance, and health care tends to be viewed as a personal responsibility. Most Western countries, such as the United States, United Kingdom, and other parts of Western Europe are considered to have individualistic cultures (Fatehi et al., 2020).

In contrast, people from collectivistic cultures place an emphasis on community and cooperation. Decisions are made for the benefit of the collective. These cultures believe that it is best for society when everyone works together as a group, and the needs of the individual come secondary to the needs of the greater good. A patient from a collectivistic culture might entrust decisions about their treatment to their family, for example, reflecting the communal approach to decision-making and the importance of considering the broader impact on the group. Some countries that practice cultural collectivism include China, Japan, Indonesia, and some other Eastern countries.

Cultural Influences on Pain

Pain management can be a challenging task and can be made more complex by the cultural considerations particular to each patient. Pain is perceived differently across diverse cultures, including how to express it, how to treat it, and what it means. While pain is a universal physical sensation, its emotional and behavioral aspects are influenced by the cultural perspective of the individual (Givler & Bhatt, 2022). For instance, some research has shown that Black, Japanese, Hispanic, and East Asian cultures tend to be stoic about pain and may keep an unresponsive facial expression or believe that requesting pain medication is a sign of weakness. Others, such as those part of Muslim or Christian communities, can view pain as part of God’s plan. Chinese patients may view pain as an imbalance between yin and yang (Perreira et al., 2019). This does not mean that that these groups do not experience pain. Avoiding misunderstandings related to cultural differences in perceptions of pain is crucial in preventing either overtreating or undertreating the patient’s pain.

Clinical Judgment Measurement Model

Take Action: Culturally Sensitive Nursing Interventions for Pain

Even though the ways in which patients experience and express pain are influenced by their cultural background, pain is an individual experience. It is important for the nurse to be aware of cultural differences so they can treat the individual in a way that best suits their pain. Culturally sensitive nursing interventions for pain include the following (Givler & Bhatt, 2022):

  • Providing an interpreter for patients with limited verbal or written English skills.
  • Asking the patient about their ideas and understanding of the concept of pain. Their beliefs may be representative of their cultural background, or they may not—be careful not to generalize without listening to the patient.
  • Providing thorough education to the patient on pain assessment and the importance of reporting pain. Self-reported assessments allow for a more accurate understanding of the patient’s pain, taking into account their personal perception and experience.
  • Assessing both observable behaviors and self-reported assessments to formulate a comprehensive approach to pain management. While observable behaviors can provide valuable insights into a patient’s condition, they may not capture the full range of pain experiences. Some individuals may not express pain through observable behaviors, while others may exaggerate their discomfort.
  • Being sensitive to traditional healing remedies, such as prayer or use of certain foods. Allow the patient to incorporate traditional remedies whenever possible. Make sure to gather a thorough history of all medicines, herbs, plants, and foods to avoid any possible interactions.
  • Assuring the patient that the healthcare team is there to help treat their pain in a way that is the most appropriate and suitable for them.
  • Adjusting the patient’s care plan to reflect their cultural needs.

Unfolding Case Study

Unfolding Case Study #1: Part 7

Refer to Chapter 3 Patient Communication and Interviewing and Chapter 4 Obtaining a Complete Health History for Unfolding Case Study Parts 1 through 6 to review the patient data. The medical-surgical nurse is providing care to a 28-year-old female patient who arrived to the hospital one hour ago from a walk-in medical clinic. The patient speaks only Spanish and is accompanied by her bilingual 10-year-old son.

Past Medical History Patient is a mother of one, who cares for her child and older mother in a small apartment. The mother is homebound and is not present at the hospital. Patient cleans houses to support her family, but income is inconsistent. Patient has an eighth-grade education and speaks no English. Medical history includes seasonal allergies, sinusitis, and two episodes of COVID-19 in the past two years.
Family history: Patient’s father is deceased, and patient’s mother has Alzheimer disease, stage II. Patient’s son is in good health, talkative, and attentive to his mother.
Social history: Patient is primary caregiver for mother and adolescent. No other support systems available. Patient has difficulty shopping and making doctor’s appointments due to lack of care for mother. Patient has difficulty communicating in English, but son translates for his mother.
No current medications and no known allergies.
Nursing Notes 2310: Assessment
History and assessment is difficult to obtain because patient does not speak English. Son reports that patient was seen at the clinic for a cough and was diagnosed with pneumonia and started on medication for it. Patient remains on 2 L oxygen via nasal cannula, breathing pattern appears normal without distress.
Flow Chart 2310: Assessment
Blood pressure: 135/75 mm Hg
Heart rate: 97 beats/minute
Respiratory rate: 22 breaths/minute
Temperature: 100.1°F (37.2°C)
Oxygen saturation: 97 percent on 2 L nasal cannula
Pain: 9/10—ear
Lab Results None
Diagnostic Tests/Imaging Results Chest x-ray: Bilateral infiltrates indicative of pneumonia.
Sputum culture pending.
Provider’s Orders Close observation.
Continue antibiotics.
Wean off oxygen as tolerated.
1.
Recognize cues: Which finding from the information provided is the highest priority at this time?
  1. patient does not speak English
  2. oxygen saturation 97 percent
  3. heart rate 97 beats/minute
  4. sputum culture results
2.
Analyze cues: The patient is reporting a 9/10 pain in the ear but does not show any other signs of being in pain such as grimacing or holding the ear. Which is the most likely rationale for this?
  1. The patient is lying about their pain level.
  2. The patient’s pain has improved since getting to the hospital.
  3. The patient’s culture may dictate how they show and process pain.
  4. The son stated the patient’s pain was a 9/10 so she would get pain medicine more quickly.

Health Disparities Related to Cultural Differences

The social determinant of health (SDOH) are the economic, social, and environmental factors that influence an individual’s health and well-being. The term health disparity describes the differences in health outcomes that result from SDOH. Various factors contribute to health disparities among various cultural groups. Socioeconomic class, race, educational level, and physical proximity to healthcare facilities are all factors related to health disparities. Black and American Indian populations have higher rates of obesity, diabetes, hypertension, and heart disease when compared to White populations (Perreira et al., 2019; National Academies of Sciences, Engineering, and Medicine, 2017a). Distrust of mainstream Western medicine in Black and American Indian communities due to a long history of systemic discrimination can further health disparities by preventing community members from seeking preventative care. This is another example of why it is important for the nurse to provide culturally sensitive care to all groups and foster a trusting relationship with the patient.

Unfolding Case Study

Unfolding Case Study #1: Part 8

Refer back to Unfolding Case Study #1: Part 7 to review the patient data.

Nursing Notes 0100:
Patient given one dose of acetaminophen and reports that ear pain is now 4/10. Interpreter has arrived and plans to stay on the unit until morning rounds so they can translate when the provider comes in. Patient resting comfortably, son sleeping on couch at the bedside.
3.
Prioritize hypotheses: Based on the information provided in the patient’s social history, the nurse is concerned that the patient may be experiencing health disparities. How are the SDOH linked to an increased risk of health disparities?
4.
Generate solutions: What actions can the nurse take to address the SDOH that are contributing to the health disparities being experienced by the patient?

Healer Variations Among Different Cultures

Every culture develops its own ways of dealing with health and illness. The various medicines and healing practices around the world that differ from the modern, Western healthcare system are referred to as traditional healing (World Health Organization, n.d.) (Table 5.2). The term encompasses a vast range of traditions and practices that differ across diverse regions and cultures.

Traditional healing has long been used to promote health and fight disease and is still used today by many people around the world because traditional healers tend to be accessible, affordable, and knowledgeable of the language and culture. Some people rely on traditional healers instead of Western medicine, while others may choose to incorporate traditional healing practices into Western medical care.

Healing Tradition Chief Characteristics
Traditional Chinese Medicine (TCM) Belief in the idea of balance as the root of health; based in concepts of Qi and yin and yang; practices include acupuncture, cupping, herbs, tai chi
Ayurveda Hindu form of medicine from India, based on idea that disease is caused by imbalance; seeks to cure imbalances using Ayurvedic medicine including diet, herbal medicines, yoga, and meditation
African Traditional Healing Extremely diverse and varies by tribe; some many believe that ancestral spirits are closely involved in the lives of the living; offer spiritual education and care, and function as counselors and social workers
American Indian Traditions Belief in spiritual and physical health as intertwined; the healer’s role is to help the individual as they help themselves; ritual and ceremony have key roles in healing
Hispanic Traditions Curanderismo is a holistic practice rooted in beliefs that health is achieved through the right balance of mind, body, and spirit; healers focus not only on the individual’s physical health but also on their mental health, diet, personal relationships, and more; use various healing methods including prayer, oils, herbs, special diets, and other spiritual rituals
Western European Traditions Role of patient at the center of the patient-healer relationship is crucial; strong foundation in using medicines created from natural elements, including herbs, plants, minerals, and animals
Table 5.2 Healing Traditions

Asian Traditions

Asian healing traditions are rooted in the concept of balance. Two of the more well-known traditions are Traditional Chinese Medicine and Ayurveda. Both Traditional Chinese Medicine and Ayurveda have become increasingly popular in recent years as complementary therapies to Western medicine.

Traditional Chinese Medicine (TCM) is an ancient practice based on the ideas of Qi and yin and yang. Qi is the life force that runs through one’s body; yin and yang are the qualities of Qi that must be in balance for optimal health (Johns Hopkins Medicine, 2019b). TCM consists of such practices as acupuncture, acupressure, cupping, herbs, tai chi, and others (Figure 5.3). The Accreditation Commission for Acupuncture and Oriental Medicine is a federally recognized organization that accredits schools in the United States that teach acupuncture and TCM.

A photograph shows a person standing at table with various herbs used in traditional Chinese medicine.
Figure 5.3 Various herbs shown here are used in Traditional Chinese Medicine. (credit: “Chinese prescription,” by Tim Wilson/Flickr, CC BY 2.0)

Ayurveda is a traditional Hindu form of medicine from India that is based on the idea that disease is caused by an imbalance in the body. Ayurvedic medicine seeks to cure this imbalance through a combination of diet, herbal medicines, yoga, and meditation. In India, Ayurvedic medicine is considered equivalent to conventional Western medicine, and providers receive formal training; however, there is no licensing process for Ayurvedic practitioners in the United States (Johns Hopkins Medicine, 2019a). Ayurvedic medicine consists of herbs, spices, minerals, and other substances that can interfere with conventional drugs (medications that are widely accepted and commonly used in mainstream medical practice); a thorough list of all medicines and supplements is an important part of the nursing assessment for this reason.

African Traditions

African healing traditions have their foundations in practices dating back thousands of years. Although specific religious traditions vary by tribe, traditional African healing is rooted in the idea that ancestral spirits are closely involved in the lives of the living and act as “mediators” between the living and God (Mokgobi, 2014). As Christianity and Islam began to spread across the continent, many people converted from traditional religions. However, they often retained traditional practices alongside embracing Westernized health care.

Healers vary among tribes; for example, the Bapedi tribe has diviners (Ngaka ya ditaola), Sanusi (or Sedupe), traditional surgeons, and traditional birth attendants. Diviners and Sanusi can diagnose and prescribe treatment for mental, physical, and spiritual afflictions (Zuma et al., 2016). Surgeons have been trained to perform circumcisions, along with the duties of diviners and Sanusi. Older women who have experience assisting with births over many years become traditional birth attendants. However, African traditional healers do more than help with physical illness and injury. They also offer spiritual education and care and have special knowledge of traditional culture, which allows them to function as counselors and social workers (Zuma et al., 2016).

American Indian Traditions

In American Indian and Alaska Native cultures, physical and spiritual health are interconnected. The belief is that in order for the body to heal, the soul must heal as well. American Indian healers believe the individual is the source of most of the healing and is responsible for their own health, wellness, and behavior. The healer’s role is to help the individual as they heal themselves, although the individual’s family and community play an important part as well (National Institutes of Health [NIH], n.d.).

Ritual and ceremony hold a key role in traditional American Indian healing. Purifying and cleansing the body, whether through sweating or purging, is an important practice in some American Indian healing rituals. Smudging is another practice that involves cleansing a place or person with the smoke of certain sacred plants. Some healing ceremonies can involve whole communities. These ceremonies can include music, painting bodies, dancing, exorcisms, sand paintings, stories, and use of mind-altering substances. These ceremonies are a way to seek spiritual assistance and physical healing (NIH, n.d.).

Members of the Native American Church are legally allowed to use peyote, a hallucinogen, during religious ceremonies. It can cause hallucinations and alterations in perceptions of space, time, and self. Physical symptoms include nausea, vomiting, dilated pupils, increased heart rate, elevated blood pressure, perspiration, headaches, muscle weakness, and impaired motor coordination. In rare cases, large doses have been reported to cause bradycardia, hypotension, and respiratory depression (Department of Justice, 2020). Peyote has been used for centuries by American Indians and is considered a sacred plant.

Hispanic Traditions

Traditional Hispanic medicine is known as curanderismo, with the healers called curandera (women) or curandero (men). The holistic practice of curanderismo is rooted in beliefs that health is achieved through the right balance of mind, body, and spirit. A curandero focuses not only on the individual’s physical health but also on their mental health, diet, personal relationships, and more. Curanderos use various healing methods including prayer, oils, herbs, special diets, and other spiritual rituals. They also act as counselors and social workers, listening to individuals talk about their problems and helping them build an emotional support network (Cruz et al., 2022).

Western European Traditions

The central role of the patient in the healer/patient relationship is foundational to modern Western European healing culture. There is also a strong emphasis on technology and scientific evidence of healing practices.

Traditional European medicine has a strong foundation in using medicines created from natural elements, including herbs, plants, minerals, and animals (Firenzuoli & Gori, 2007; Hosseinzadeh et al., 2015). Homeopathy (an alternative medicine system based on the principle of “like cures like,” utilizing highly diluted substances to treat similar symptoms) and naturopathy (focusing on the body’s self-healing abilities through holistic approaches like dietary changes, herbal medicine, and lifestyle counseling) both have roots in European tradition. Individuals who rely on herbal and plant-based remedies tend to either use them in conjunction with conventional Western medicine or view them as alternatives to harsher methods of treatment. Examples of these remedies are discussed later in this chapter, in 5.3 Cultural Practice in Nursing. Nurses should provide quality education to their patients about clinical evidence of the effectiveness of these complementary and alternative therapies (Leonti & Verpoorte, 2017).

Counteracting Implicit Bias

Everyone holds biases that reflect their own personal belief systems. An explicit bias is a consciously held set of beliefs about a person, situation, or group based on certain characteristics (Sabin, 2022). Explicit bias is what we typically think of when we see or hear the word bias. A person might be openly biased against someone due to their age, gender, race, sexuality, or another reason. An overtly racist comment is an example of explicit bias (Sabin, 2022).

In comparison, implicit bias refers to all our unconscious biases. Implicit bias is an automatic reaction toward a person, situation, or group involving subconscious feelings, perceptions, attitudes, and stereotypes. You may hold conscious beliefs about equality and fairness while still having unconscious, implicit biases that contradict these beliefs.

Bias negatively affects the patient-provider relationship, leading to poorer quality care and worse outcomes for certain groups. For example, research studies have shown that implicit bias regularly leads to the undertreatment of pain in Black patients (Sabin, 2022). Implicit bias can be difficult to change because it operates at an unconscious level, making individuals often unaware of these biases. The first step in overcoming implicit biases is to become aware of them; training in diversity and inclusiveness can also help identify problematic feelings, thoughts, and behaviors.

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