Chapter 9 Foundations

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Culture and Ethnicity

•The U.S. population is becoming more 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.

Summary of U.S. Census Data, 2010

•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 Defined

•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.
Culture affects how people value, evaluate, and categorize life experiences.
The members of a cultural group share values and ways of thinking and acting.
These values and ways of thinking and acting are different from those of people who are outside the group.

Ethnicity Defined

•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.
Members of an ethnic group feel a common sense of identity.
Ethnic identity is based on the language, geographic area, racial characteristics, and values of the group's heritage.

Culture

the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

Emic Worldview

insider or native perspective

subculture

ethnic and religious groups with characteristics distinct from the dominant culture

ethnicity

refers to a shared identity related to social and cultural heritage such as values, language, geographic space, and racial characteristics

etic worldview

outsider perspective

enculturation

socialization into one's primary culture as a child

acculturation

a second culture learning that occurs when the culture of a minority is gradually displaced by the culture of the dominant group in the process of assimilation

assimilation

members of an ethnocultural community are absorbed into another community and lose their unique characteristics such as language, customs, and ethnicity

bicultureism/multiculturalism

occurs when an individual identifies equally with two or more cultures

Culturally congruent care

Fits the person's valued life patterns and set of meanings
Requires specific knowledge, skills, and attitudes in the delivery of care
•Culturally congruent care is meaningful, supportive, and facilitative because it fits valued life patterns of patients.
•Our goal is to provide culturally congruent care.

Culturally competent care

Is the process of acquiring specific knowledge, skills, and attitudes to provide culturally congruent care
•The process of providing culturally 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 causes bias and prejudice.
•Cultural imposition can occur when 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 patients and interpreting their behavior.

In every culture:

Health, illness, and caring have meanings that are unique.
Groups interpret and define experiences relevant to birth, illness, and death through a certain context.
•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.

Examples of Cultural Healers and Modalities

Chinese and Southeast Asians
Herbalist, acupuncturist, fortune teller, Shaman
Asian Indians
Herbalist, acupuncturist, fortune teller, Shaman
American Indians
Shaman
•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.

Culture and life transitions/ rites of passage

pregnancy, childbirth, newborn, postpartum period, grief and loss
•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.

Cultural Beliefs and Rituals Surrounding Death

Be aware of religious and cultural preferences when helping patients and families prepare for death.
Be sensitive to cultural perceptions regarding organ donation, viewing the body, and preparing for burial.
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.

Culture-Bound Syndromes

Culture-bound syndromes are illnesses that are specific to one culture.
They are used to explain personal and social reactions of members of the culture.
Culture-bound syndromes occur in any society.
•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).

Selected Components of Cultural Assessment

1. Ethnic heritage and ethnohistory
2. biocultural history
3. social organization
4. religious and spiritual beliefs
5. communication patterns
6.time orientation
7. caring beliefs and practices
8. experiences with professional health care

Implications for Nursing Practice

Set culture care as a priority.
Approach patients and families in a culturally sensitive manner.
Engage in negotiated partnerships with patients and families.
Enable the families and social networks of patients to serve as backup support.
•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?

Transcultural communication requires

Linguistic skills
Culturally congruent interpretation of behaviors of others
Listening
Observation skills

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

Cultural Assessment

A systematic and comprehensive examination of the cultural care values, beliefs, and practices of individuals, families, and communities
Gathers information that will enable the nurse to provide culturally competent care

Culturally competent care requires `

knowledge, attitudes, and skills supportive of implementation of culturally congruent care.

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.

Nursing Assessment Questions

Open-ended or focused
Contrast
Ethnohistory
Social organization
Socioeconomic status
Bicultural ecology and health risks
Language and communication
Caring beliefs and practices

Language access services

All health care organizations are required to offer free language assistance, including bilingual staff or interpreter services to each patient with limited English proficiency. These services must be offered in a timely manner at all hours of operation at all points of contact.
Patients must be informed, in their preferred language, of their right to receive language assistance services both verbally and in written form.

Cultural care preservation or maintenance

Retain and/or preserve relevant care values so patients maintain their well-being, recover from illness, or face handicaps and/or death.

Cultural care accommodation or negotiation

Adapt or negotiate with others for a beneficial or satisfying health outcome.

Cultural care repatterning or restructuring

Reorder, change, or greatly modify patients' lifestyles for a new, different, and beneficial health care pattern.

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