Learning Objectives
By the end of this section, you will be able to:
- Describe nursing interventions to care for all persons assigned female at birth and their families during family-centered care
- Identify challenges to delivering the best care for all families and persons assigned female at birth across a range of cultures, religious backgrounds, and family structures
- Discuss barriers to care for LGBTQIA+, disabled, and culturally diverse persons and families that the nurse can help mitigate
In 1970, the sociologists Firth and Firth (2014) defined family and kinship as “a set of ties socially recognized to exist between persons because of their genealogical connection … relationships thought to be created between them by marriage and/or procreation of children” (p. 1). In 2023, family continues to be seen as a group of people related by kinship; however, kinship is now made of many different types of connections, such as adoption, surrogacy, friendship, cohabitation, and fostering. Other types of families are single-parent, dual-career, single adult, extended, and blended or binuclear families. The nurse cares for a person while considering their family’s role or influence on the person.
Communities and cultures include, but are not limited to, LGBTQIA+ persons, persons speaking other languages, religious communities, and persons with disabilities; these differences in social and ethnic backgrounds, gender, and sexual orientation represent a community’s diversity (Servaes et al., 2022). The nurse uses inclusive language and advocates for policies that allow all persons to feel included in the health-care process. The nurse should also find individual ways to care for those with disabilities to respect their autonomy yet provide needed assistance.
Care of Families
Nurses encounter people from a variety of backgrounds; therefore, it is essential that nurses provide culturally competent care. The 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 called cultural competence. The process of determining proper care and providing the best treatment for a person by understanding, respecting, and integrating a person’s cultural beliefs into their health care is called culturally responsive care. When people are valued for all aspects of their identity, background, and experiences, they feel safe, understood, and, most importantly, valued. Culturally responsive care is required for a trusting, effective nurse-patient relationship. Nurses must be intentional in learning about other cultures and belief systems.
Influence of Family Structure
Family structure includes the people considered family members, where the person falls in the birth/sibling order, how many parents are in the household, whether a parent is single by choice or by circumstances, nuclear or extended families, and the origin of the family. Family structure helps people determine their roles in society. Dysfunctional families lead to persons with mental health issues, trauma or abuse, abandonment, and neglect. Functional families lead to accomplishing tasks that lead to individual well-being, the ability to adapt to changes, and the ability to balance individual needs with family needs (Booysen et al., 2021).
Legal and Ethical Issues
Stepparents’ Rights and Responsibilities
In the United States, stepparents have limited legal rights and responsibilities. The legal authority for decision making belongs to the two biological parents. The stepparent can help their spouse, the biological parent of the child, but cannot make decisions regarding school, medical care, religion, or other important matters related to the child. If the stepparent and the biological parent divorce, some states will allow visitation rights to the stepparent.
Paperwork allowing the stepparent to seek care for patients may exist, for example, a signed consent-to-treat letter that is notarized and signed by both biological parents or legal guardian(s).
A stepparent can adopt the child if the other biological person agrees to terminate their parental rights. The courts state that a stepparent must be married to the biological parent for a year and live with the child for at least 6 months to be eligible to adopt the child (Law Offices of Hector A. Montoya, 2021).
Dual-Career Family
A dual-career family is defined as a household in which both parents work. In a survey of families from 2015 to 2017 (U.S. Bureau of Labor Statistics, 2020), dual-career families with children under 6 years of age brought in an income $53,873 higher than single-career families (not single-family households). In dual-career families, health insurance is usually available and affordable compared to households without employment. The issues or concerns of these families are related to time management, such as not having enough time to deal with family responsibilities. The increased stress of meeting all family members' needs plus career needs may create role conflict both professionally and in relation to the family. Women may experience more stress than men in a dual-career couple due to women still taking on most household tasks and childcare (Center for Equity, Gender, & Leadership [EGAL], 2020). When interviewing families, the nurse should focus on gathering information on how the family roles are assumed by each partner.
Single-Career Family
A single-career family is defined as a household in which one parent works and the other stays home. In the past, this pattern meant that the stay-at-home parent was the woman. Currently, 1 in 5 stay-at-home parents in the United States are fathers (Fry, 2023). When a parent is available for childcare, finances are not required for outside childcare, and significantly more family income is kept within the home. Future employment options for the stay-at-home parent may be limited when they return to the workforce because employers can view a significant gap in work history negatively.
Single-Parent Family
Single-parent families are defined as children living with one parent. Nearly 24 million children in the United States live in a single-parent home, and 14.5 million of those children live in a mother-only household (The Annie E. Casey Foundation, 2023). According to The Annie E. Casey Foundation (2023), nearly 30 percent of single parents live in poverty compared to only 6 percent of married couples; the children of these parents experience more physical, mental, and behavioral problems due to growing up poor. This foundation emphasizes that single-parent families also have strengths and benefits, such as the parent being able to focus on the children rather than dividing their attention between children and a significant other. In the case of divorce from a violent partner, violence or anger is resolved, and the stress of violence is greatly reduced (Ratini, 2023). In the health-care setting, the nurse should make sure that the parent who is present with the child is the legal guardian prior to discussing health-care information, and documentation should include this information.
Extended Family
An extended family consists of grandparents, aunts, uncles, and cousins. In some cultures, the nuclear family lives in the same house as their extended family. Many families struggling financially will live in one house to save money. Other families move grandparents into their home due to their failing health. Nurses caring for a person with extended family in the room should ask the person if they desire their extended family to be included in their plan of care prior to discussing private health-care information.
Blended or Binuclear Family
A blended family, also known as a binuclear or stepfamily, consists of parents and children who are not biologically related to the other parent. A blended family is usually created after a death or divorce but can also include those who have never married. According to the Step Family Foundation (n.d.), more than 50 percent of U.S. families are remarried or recoupled. Children of blended families may have trouble adjusting to their new parent and siblings. They may feel their new stepparent is trying to replace their other parent. Stepparents may feel the stepchild is not giving them a chance to be a family. Blended families can cause stress for the parents and children. Nurses should be aware of family stress as they are caring for a person.
Cultural Context
Foster Care: Children’s Aid
Foster care is a service provided by states that provides temporary homes to children who cannot live with their families. Different states offer different foster care programs. New York has a program called Children’s Aid foster care. This program is unique because it places children with families in their neighborhood to maintain relationships and familiar surroundings, such as school, church families, friends, and support systems. Children’s Aid currently has 500 to 600 children and young people in stable homes in their own neighborhoods across New York. If the birth family is unable to reunite with the child, Children’s Aid will help in the adoption process with a new family.
For more information, visit the Children’s Aid website.
Care of LGBTQIA+ Persons and Families
The biggest barrier to accessing culturally competent health care for LGBTQIA+ families is the lack of knowledge on the part of health-care providers. Providers and nurses may find themselves confused about pronouns, terminology, how to provide gender-affirming care, and what professional guidelines are specific to transgender and gender-nonconforming persons. Table 2.1 lists some current LGBTQIA+ terminology.
| Terminology | Definition |
|---|---|
| Transgender | An umbrella term for a person whose gender identity and gender expression may differ from the gender they were assigned at birth |
| LGBTQIA+ | Lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and any other identity |
| Bisexual | A person who is attracted to people with male and female gender identities |
| Cisgender | A person whose gender identity matches the sex they were assigned at birth |
| Gender affirmation | The process of aligning gender expression, social perception, and physical appearance with gender identity |
| Gender expression | The way a person communicates gender identity through behavior and/or appearance |
| Gender identity | A person’s internal sense of their gender; being male, female, or both male and female, neither male nor female, or something else |
| Gender nonconforming | People whose gender does not fit within traditional expectations of masculinity and femininity; this can include identities such as gender fluid, gender expansive, and gender queer |
| Queer | Any sexual orientation that is not straight or any gender identity that is not cisgender |
| Sexual orientation | A person’s emotional, romantic, or sexual attraction to other people |
| Transfeminine | A person assigned male at birth identifying as trans/nonbinary |
| Transgender man | A person with a male gender identity who was assigned female at birth |
| Transgender woman | A person with a female gender identity who was assigned male at birth |
| Transmasculine | A person assigned female at birth identifying as trans/nonbinary |
Historical Trauma
The cumulative trauma associated with a specific cultural, racial, marginalized, or ethnic group is called historical trauma. It provides a useful theory for the nurse to examine the experiences of LGBTQIA+ persons within the U.S. health-care system currently and in previous generations. When people who identify as LGBTQIA+ arrive for care, they carry the weight of discrimination that their family and friends have experienced, along with cumulative pain, bias, and mistreatment (Mirza & Roney, 2018). This leads to persons expecting to be treated with those same biases. In a 2018 survey, 8 percent of LGBTQIA+ respondents reported that a clinician refused to see them at an office visit due to their perceived sexual orientation, 7 percent reported that a clinician refused to recognize a child of a same-sex partner, 9 percent reported that a health-care provider used harsh or abusive language while treating them, and 7 percent reported experiencing unwanted physical contact from a health-care provider (such as fondling, sexual assault, or rape) (Mirza & Roney, 2018). For many LGBTQIA+ people, the health-care system continues to be perceived as an unsafe space. Using evidence-based resources, the nurse has the responsibility and power to provide culturally competent, supportive nursing care.
Using Affirming and Inclusive Language
There are many evidence-based gender-affirming interventions the nurse can implement in the clinic to improve patient outcomes and create safer spaces for the LGBTQIA+ community. Language that accurately describes a person’s gender identity, called gender-affirming language, is imperative in the health-care setting. Using inappropriate or inaccurate language to describe a person’s gender can be detrimental to the patient’s mental health, causing them to be distrustful of the nurse, health-care providers, and the health-care system as a whole (Dawson & Leong, 2020). Health-care offices and hospitals can add gender-affirming language to intake forms, ask which pronouns the patient prefers, ask the patient’s gender identity, or ask how they identify. Nurses can introduce themselves and provide the pronouns they prefer, then ask the patient their preferred pronouns. Nurses should remember that words can heal. By using appropriate gender-affirming language, the nurse can establish trust and provide supportive care.
Safe Health-Care Spaces
Health-care offices and hospitals must consider if the environment they provide is inclusive of all persons. Language used in electronic health records or office paperwork should also be gender affirming or gender neutral. Check-in logs should provide choices beyond male or female for gender identity. Relationship status should also be inclusive. Nurses can advocate for safe spaces for all patients, including having a private physical space to allow private disclosure of a person’s gender identity, sexual orientation, sex assigned at birth, and preferred pronouns. The nurse can also advocate for independent electronic health record tablets to be used independently by the patient to disclose this information (Deutsch & Buchholz, 2015). The nurse can play an important role in advocating for and integrating diverse, equitable, and inclusive care throughout the office and hospital.
LGBTQIA+ Images in Offices and Hospitals
Another way to ensure diverse, equitable, and inclusive care for all patients is by including images of people and families that look like them. The nurse can advocate for updated illustrations and educational materials reflecting gender-affirming language and LGBTQIA+-friendly materials. In 2014, the Gay & Lesbian Medical Association released a guideline for clinicians to create safer spaces for LGBTQIA+ persons. The guidelines stated that LGBTQIA+ persons often “scan” the office for cues that they are welcome; those cues include rainbow flags, unisex bathrooms, and even small LGBTQIA+ stickers or symbols. The guidelines also recommended exhibiting posters of racially and ethnically diverse same-sex couples or transgender people, along with posters from nonprofit LGBTQIA+ and HIV/AIDS organizations. Brochures about LGBTQIA+ health related to breast cancer, safe sex, hormone therapy and treatment, mental health, sexually transmitted infection (STI) testing and treatment, and a posted nondiscrimination statement are recommended.
Affirmative Language in Charting Systems
The electronic health record (EHR) is one of the biggest areas of discrimination for LGBTQIA+ patients. Most EHRs contribute to microaggressions long before the person even meets the clinician. EHRs are not programmed to accommodate diverse options for a person’s gender identity, chosen name, or preferred pronouns. Imagine a transgender man giving birth in a labor and delivery unit, repeatedly asking that the gender on his wristband be changed to male and being told that the EHR could not accommodate that. Deficits like this cause people to feel invisible to clinicians and deny them access to the care they desire and deserve. Additionally, being misidentified can cause a patient posttraumatic stress, depression, and anxiety.
The EHR should also be updated to allow patients to choose or enter the descriptors that apply to them. Recently, the Human Rights Campaign (2018) found that less than 50 percent of health-care facilities in the United States have specific policies ensuring appropriate, welcoming interactions with transgender persons. Nurses can advocate for their hospital to provide LGBTQIA+ persons appropriate care in a safe, protected environment such as maternal health units.
Family Planning for the LGBTQIA+ Family
All people who have a uterus should be offered full reproductive care including preconception, pregnancy, contraceptive, and abortion care (Dawson & Leong, 2020). One issue faced by LGBTQIA+ persons is that few facilities provide care specific to their community, including fertility preservation services (Dawson & Leong, 2020). Fertility preservation is the process of freezing embryos, eggs, ovarian tissue, sperm, or testicular tissue for future reproduction. According to a study conducted by Jones et al. (2020) on nonhospital facilities providing abortion care, estimates suggest 462 to 530 transgender people obtained abortions primarily at facilities that did not provide transgender-specific health care. Additionally, recent surveys suggest that in most states, 20 to 30 percent of LGBTQIA+ persons are raising children (Movement Advancement Project, 2024). Nurses may care for LGBTQIA+ persons who are making a family via adoption, use of a surrogate, or pregnancy through artificial insemination.
In addition to planned pregnancies, LGBTQIA+ patients can experience unplanned pregnancies as a result of consensual sex and sexual assaults. Data suggest that LGBTQIA+ people experience sexual assault at higher rates than cisgender and heterosexual people (Human Rights Campaign, 2022.). Therefore, sexual assault nurse examiners (SANE) and emergency department staff must be culturally competent to care for survivors who are LGBTQIA+.
Link to Learning
The National LGBT Health Education Center, a part of the Program of the Fenway Institute, is an interdisciplinary center for research, education, training, and policy development for LGBTQIA+ people. They have created best practices that nurses can use to update guidelines in clinics and hospitals for transgender and gender-nonconforming patients in a free downloadable document.
Challenges in Caring for Families
Clear and effective communication between the patient and the nursing professional is essential. Communication can be hindered by a language barrier. Quality nursing care can be negatively affected by not supplying language-appropriate resources in the form of medical interpreters and printed health information in a patient’s native language.
Different Languages
Culturally and linguistically appropriate services (CLAS) are “respectful of and responsive to the health beliefs, practices and needs of diverse patients” (Culturally and Linguistically Appropriate Services, 2023, p. 1). Language-appropriate health care provides care in the person’s native language. The Agency for Healthcare Research and Quality defines linguistic competence as “providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators” (“What Is Cultural and Linguistic Competence?” 2019, p. 1).
All educational materials, instructions, and consent forms should be offered in the patient’s preferred language. When caring for a person whose primary language is not English and who has a limited ability to speak, read, write, or understand the English language, the nurse should seek the services of a trained medical interpreter. The Joint Commission (2021) requires that interpretative services be provided by trained bilingual staff, contracted interpreting services, or employed language interpreters. The requirement states that if the health-care provider is bilingual and communicates with the patient in their preferred language, an interpreter is not needed.
Nurses should refrain from asking a patient’s family member to act as an interpreter. The patient may withhold sensitive information from them, or family members may possibly edit or change the information provided. Unfamiliarity with medical terminology can also cause misunderstanding and errors.
Medical interpreters may be on-site or available by videoconferencing or telephone. The nurse should also consider coordinating patient and family member conversations with other health-care team members to streamline communication, while being aware of cultural implications such as who can discuss what health-care topics and who makes the decisions. When possible, the nurse should obtain a medical interpreter of the same gender as the patient to prevent potential embarrassment if a sensitive matter is being discussed.
Cultural Context
Guidelines for Working with a Medical Interpreter
- Allow extra time for the interview or conversation with the patient.
- Whenever possible, meet with the interpreter beforehand to provide background.
- Document the name of the medical interpreter in the progress note.
- Always face and address the patient directly, using a normal tone of voice. Do not direct questions or conversation to the interpreter.
- Speak in the first person (using “I”).
- Avoid using idioms, such as, “Are you feeling under the weather today?” Also avoid abbreviations, slang, jokes, and jargon.
- Speak in short paragraphs or sentences. Ask only one question at a time. Allow sufficient time for the interpreter to finish interpreting before beginning another statement or topic.
- Ask the patient to repeat any instructions and explanations given to verify that they understood.
Disability
Culturally competent care also applies to those with physical and intellectual disabilities. For pregnant or laboring persons with disabilities, the nurse must work with the person to determine a plan of care that meets their needs and respects their uniqueness (Schnaith et al., 2021). For example, among U.S. women aged 18 to 39, approximately 4.7 percent experience hearing loss; pregnant persons who are hard-of-hearing can experience adverse health outcomes due to inadequate communication (Mitra et al., 2020). Nurses should be aware that this population has higher rates of chronic conditions and pregnancy complications (preterm birth and low birth weight) (Mitra et al., 2020). The nurse needs to determine if the patient is verbal and, if not, determine how the patient best communicates. If the patient is deaf, the nurse should use an American Sign Language interpreter to discuss health history and expectations for labor and birth.
For people who are visually impaired, pregnancy brings different challenges. To assist the person, the nurse can provide a tour of the labor and birth unit, allowing the person to become familiar with the surroundings. Health-care providers and nurses should always introduce themselves due to the patient’s inability to read their name tag. Other actions to consider are to warn the patient you are about to touch them, announce yourself when entering the room, and announce that you are leaving the room (Jillings, 2017). Written information should be available in Braille or by audio. To assist with care of the newborn, the nurse can describe the newborn’s facial expressions or behaviors in response to certain interventions.
Nursing care for persons with physical disabilities is tailored for their specific needs. Hospitals, offices, and clinics should have wheelchair access to the facility, bathrooms with bars and wheelchair access, wide doors, and exam tables that are easily accessible for those with physical disabilities (Figure 2.2). The nurse should ask the person which activities require assistance and which do not, respecting the person’s independence but providing help when needed. The nurse can also order special equipment such as a bedside commode or shower chair to make daily activities easier for the person. During birth, the nurse can assist the person into a position that is easiest and most comfortable to the birthing person.
Link to Learning
Mayo Clinic provides information regarding care of the pregnant person with disabilities for patients. The website provides information on navigating the health-care system, finding support before and after birth, getting financial help, and understanding the rights of parents with disabilities.
Culture
The set of norms, attitudes, and beliefs that a group of people accept and pass along to the next generation is called culture. Many cultures have beliefs that explain what causes illness, how illnesses can be treated or cured, and who should be involved in the process. Culture also affects how people communicate with providers 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.
Spirituality and Religion
Throughout history, spirituality, religion, and health have often gone together. Spirituality and religion are not the same, however. Spirituality is what a person feels and believes that brings that person peace and understanding of the meaning of life. It is important to ask the patient how they nurture their spirit. Religion is a belief system that is practiced as a group or community. In many healing traditions, healers also serve as religious leaders. Many people rely on their religious and spiritual beliefs when making medical decisions. For instance, Jehovah’s Witnesses believe that it is against God’s will to accept blood products and will therefore not allow blood transfusions. A person’s religious beliefs can affect their dietary intake. For example, many people following the religions of Hinduism, Jainism, and Buddhism are vegetarian (Tesfamariam, 2020). Health-care providers must be prepared to take patients’ religious and spiritual preferences into account as an important part of the treatment plan (Swihart et al., 2022). A thorough cultural assessment should include information on a patient’s religious and spiritual beliefs that might affect their care.
Cultural Context
Adolescent Parenthood in Western Cultures versus Other Cultures
According to the National Vital Statistics Reports (Centers for Disease Control and Prevention [CDC], 2022), the U.S. teen birth rate was 15.4 per 1,000 females ages 15 to 19 in 2020, which was down 8 percent from 2019 and 75 percent from 1991. Factors associated with teen pregnancy and birth in the United States are having a mother who gave birth as a teen and had lower levels of education; not feeling connected with family; living in communities with higher rates of substance misuse, violence, and hunger; and being Black or Hispanic and having less access to family planning services and information and more distrust due to mistreatment by the medical community (U.S. Department of Health & Human Services, n.d.-a).
In other countries, such as Ghana, where 20 percent of girls become pregnant before the age of 18, adolescent pregnancy is associated with health risks and social and economic hardships for adolescents, families, the community, and society (Amoadu et al., 2022). An estimated 21 million adolescent girls become pregnant annually in developing countries, and 12 million below the age of 16 give birth (Amoadu et al., 2022). In Ghana, confounding factors include lack of knowledge about or accessibility of contraception. Sexuality is a taboo subject, sex education in schools is restricted to abstinence messages, and child marriage is prevalent (Amoadu et al., 2022). Adolescent pregnancies in the United States are associated with higher incidences of violence in marriage, decreased education and employment opportunities, social stigma, and rejection from parents and communities.