Culturally Competent Care

1
Culturally Competent Care

• Chia-Ling Mao, Ph.D., RN.
• Associate Professor
• School of Nursing
• San Jose State University

2
Objectives

• Define ethnocentrism
• Discuss how the cultural background of the nurse
  influences the way in which care is delivered.
• Understand the variety of influences that culture
  and ethnicity have on theinterpretations of the
  concepts of health and illness.

3
Culture

• A set of standard for behavior which a group of
  people attribute to those around them and which
  they used to orient their behavior
• Meanings, values, and behavioral norms that are
  learned and transmitted in the dominant society
  and within its social groups.
• Culture powerfully influences cognitions,
  feelings, and the self concept, as well as the
  diagnostic process and treatment decision (DSM-IV)

4
Jewish

• Inter culture difference
• Ashkenazi from Russian, Eastern Europe
• Sephardic Spain, Portugal, the Mediterranean
  area
• Sabra Born in Israel black Jews from Ethiopia
• value the nuclear family and community
• Health seeking beliefs and behaviors are seen as
  a responsibility to maintain good health.
• Kosher diet no pork and shellfish dietary
  practices
• genetic disorders (especially Ashkenazi Jews)
  Tay-Sachs disease, Gaucher Disease and Canavan
  Disease
• Religion
• Torah Hebrew bible, tree of life,
• Sabbath no work
• Rabbi -
• The dying person should not be left alone, after
  the person dies the body should be wrapped and is
  put on the floor with the feet facing the door
  for a short period, a candle may be placed at the
  head no creamation

5
Vienamese

• Nodding is done out of respect and does not
  necessarily mean agreement or understanding.
  Direct eye contact is viewed as disrespectful as
  is a man touching a woman in public or anyone
  touching anothers head which is considered
  sacred
• It is inappropriate for women to discuss
  childbearing, sex, or contraception in the
  presence of men
• Causes of illness is viewed from Yin yang
  supernatural or spiritual influences, biomedical
  reasons
• Mental illness is stigmatized PTSD, depression,
  anxiety.
• SUNDS sudden unexpected nocturnal death syndrome

6
Race

• A number of broad division of the human species,
  based on a common geographic origin, certain
  shared physical characteristics and distinguished
  from other by a characteristic distribution of
  gene frequencies.

7
Ethnicity

• Collectively of people within a larger society
  defined on the basis of both common origins,
  shared symbols and standards for behavior

8
Population in the U.S.

• Year 2000
• Whites 69.4
• Black 12.7
• Hispanic 12.6
• Asian 3.8

• Year 2050
• Whites 50
• Black 14.6
• Hispanic 24.4
• Asian 8

US Census Bureau, 2004
9
US POPULATION

• 1998
• WHITE 72
• BLACK 12
• HISPANIC 11
• ASIAN 4
• NATIVE AMERICAN 1

• PROJECTED 2030
• WHITE 60
• BLACK 13
• HISPANIC 19
• ASIAN 7
• NATIVE AMERICAN 1

10
Sources US Census Bureau
11
Population in San Jose (2000)

• Whites - 47.5
• Hispanic - 30.2
• Asian - 26.9
• Black - 3.5
• U.S. Census Bureau (2006)

12
Minorities Receive Lower Quality Health Care Than
Whites

• Institute of Medicine, 100 studies reviewed over
  past 10 yrs.
• Full report www.nap.edu/books/030908265X/html
• Minorities less likely to receive sophisticated
  Txs for AIDS
• More likely to have leg amputations for diabetes
• Poorer relationships with MDs

13
Institute of Medicine

• Among 13,000 heart patients for every 100 whites
  who had a procedure to clear the heart arteries,
  only 74 blacks did
• Of 15,578 urban ER patients blacks were 1.5 times
  more likely to be denied authorization by managed
  care providers
• Differences exist even when insurance, income,
  age, and the severity of the disease are the same
  for both groups

14
Health Issues Cardiovascular

• Cardiovascular- death rate from heart attack 30
  higher in African Americans
• Heart attacks declined by 29 in whites vs 21
  for African Americans
• Death rates from stroke were 40 higher in
  African American adults

HHS Disparities Initiative, 9/24/2002
15
Health Issues Diabetes

• Diabetes is 2 times higher in African Americans
  and 1.9 times higher in Hispanics
• Native Americans have 2.6 times the rate of
  Diabetes and Pima Natives of Arizona have the
  highest known prevalence in the world

National Center for Health Statistics, 2002
16
Disparities Syphilis/Hepatitis

• Cases of primary and secondary syphilis in 1999
  with 30 times greater rate in African Americans
• Asian Americans represent 50 of those infected
  with Hepatitis B
• Minority teens with higher incidence of Hepatitis
  B and C

AAP, Committee on Infectious Disease,
2000 National Center for HIV, STD, and TB
Prevention
17
Disparities Tuberculosis

• Of all tuberculosis cases reported in 1991-2001,
  80 were in racial and ethnic minorities
• Tuberculosis increased by 51 for Asian Americans
  and 30 for Hispanics
• Asian Americans and Pacific Islanders, 4 of the
  US population had 22 of the cases

NCHSTP Division of TB Elimination
18
Immunizations

• 48 African American and 56 Hispanic receive
  influenza vaccine compared to 67 Whites
• 31 of African American and 30 of Hispanics
  receive pneumococcal vaccine compared to 57
  Whites
• In 2001 African Americans and Hispanic aged 65
  and older were less likely to report having
  received vaccination

Morbidity and Mortality Weekly, 2002
19
Disparities Mental Health

• Native Americans disproportionate rate of
  depression and substance abuse
• Minorities have less access to mental health
  services and receive poorer quality services
• Under-represented in mental health research

National Center for Health Statistics, 2002
20
Other Cultural Domains

• Folk beliefs/religion - can be confused with
  religiosity
• Stereotyping labels - avoid generalizations
• Ethnopharmacology - genetic influence, effect,
  metabolism
• Herbal therapies - interactions with meds
• Folk healers treatment approaches, e.g..,
  hysteria, psychosis

21
Cultural competence impact on clinical outcomes

• Patients fear of being misunderstood or
  disrespected
• Providers are not familiar with the prevalence of
  conditions among certain minority groups
• Providers may fail to take into account differing
  responses to medication
• Providers may lack knowledge about traditional
  remedies, leading to harmful drug interactions
• Patients may not adhere to medical advice because
  they do not understand or do not trust the
  provider
• Providers may order more or fewer diagnostic
  tests for patients of different cultural
  backgrounds

22
Ethnic Disparities in Health Care

• African American women are more likely than
  European American women to die from breast
  cancer, despite having a lower incidence of the
  disease.
• Infant mortality rates are 2.5 times greater for
  African Americans and 1.5times greater for Native
  Americans than for European Americans.
• Influenza death rates are higher for African
  Americans and American Indian/Alaska
  Natives/Native Alaskans than they are for
  European Americans.
• Mortality for colorectal cancer is highest for
  African Americans, followed by Native Alaskans,
  and then Hawaiians.

23
Needs for cultural competence

• American nurses experienced a lack of cultural
  confidence in caring for culturally diverse
  populations - Coffman, Shellman, Bernal (2004)
  and Hagman (2006)
• There were gaps in healthcare providers
  knowledge of other cultures and how to care for
  them in culturally sensitive ways - Jones, Cason,
  and Bond (2004)

24
Other evidences

• Negative racial stereotypes - rate black patients
  as more likely to abuse drugs and alcohol, less
  likely to comply with medical advice, and less
  likely to participate in cardiac rehab than white
  patients - Van Ryn and Burke (2000)
• Less Dx test - physicians were less likely to
  recommend catheterization procedures for black
  female patients than white or black male patients
  if they experienced the same kind of symptoms.
  Schulman et al. (1999)

25
Cultural Competence is a Process

• American Nurses Association published its first
  guidelines on cultural diversity in nursing
  curricula in 1986 - understanding the concept of
  human diversity including cultural and racial
  variations
• The Board of Registered Nursing of California
  (2006) has required all nursing schools in
  California to include cultural diversity and
  competence into their curricula

26
Language barriers and disparity

• Utilization of health care services
• Fewer doctor visit and less preventive services
• More diagnostic test to compensate communication
  problems
• Satisfaction
• Less satisfied unless with interpreter
• Adherence
• Miss the appointment or drop out
• Outcomes
• Patient education

27
Health Disparities

• President Clinton (1998) set the goal reduce
  health disparities by the year 2010.
• Target areas (NIH, 2003)
• Infant mortality,
• Cancer screening and management,
• Cardiovascular disease,
• Diabetes,
• HIV/AIDS,
• Immunization

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Problems with Health Disparities- with cultural
factors

• Flaskerud, J. et al (2002) a review of 79
  articles in the past 5 decades
• Ignorance of certain groups (indigenous peoples)
• Inappropriate lump together
• Hispanic members of disparate groups with their
  own cultural identity eg., Puerto Ricans,
  Mexicans, Cubans, Dominicans
• Asian Pacific islanders

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Impact of Cultural Competency

• More successful patient education
• Increases in pts health care seeking behavior
• More appropriate testing and screening
• Fewer diagnostic errors.
• Avoidance of drug complications
• Greater adherence to medical advice
• Expanded choices and access to high-quality
  clinicians.

30
Negotiation Process

• Listen to the clients perspective
• Teach from your knowledge in language
  appropriate for client family
• Compare similarities differences, disagree but
  do not devalue clients view
• Compromise
• if client treatment not harmful, promote
• If harmful, explain harm and suggest alternatives

31
Ethnopharmacology
32
Ethnopharmacology

• Assumptions
• Ethnic culture affects beliefs about health,
  illness, medications, interactions with
  healthcare providers, comply with prescribed
  medications as well as response physiologically
  to medications.

33
Ethnicity affects drug responses

• Genetic and/or cultural factors make influence on
  
• Drugs absorption, metabolism, distribution, and
  excretion
• Drugs mechanism of action effects at the
  target site
• Patient adherence education

34
Beliefs about health, illness, medications

• White
• Intolerance to pain
• High expectation to be cured or well managed
  through technology, powerful drugs
• Management of microbes gt bolster resistance to
  them

• Asians
• Drugs safety profile gt its effectiveness
• Use lower doses and fewer reported side effects
• Quick remove of S/S does not equal to a permanent
  cure

35
Interaction with healthcare providers

• Language barrier
• Nonverbal communication
• Trusting relationships
• Attire, attitude
• Family involvement
• Decision maker

36
Adherence with prescribed medications

• Beliefs on the medication
• Discontinue the med when symptoms ease
• Thwart the acceptance of drugs with a delayed
  onset of action
• Stop taking the med if the diseases is not common
  in their original country

37
Culture preferences, rituals, or fears

• Ways of taking the med. ie. Oral, injection,
• Rituals ie. Fasting
• Concerns about addictive effects

38
Physiologic response to medications

• Genetic polymorphisms
• 3-5 of whites compare to 15-20 of Asians are
  poor metabolizers of drugs affected by
  mephenytoin polymorphism ie. Diazepam, imipromine
• Asians and Eskimos need lower doses of
  anxiolytics than white

39
Physiologic response to medications (II)

• Jewish Clozapine risk for agranulocytosis.
  20 as compared with the non-Jewish population of
  1.
• Asians, Indians, and Pakistanis require lower
  doses of lithium and antipsychotic drugs.
• Asians showed more EPS given same dose of Haldol.

40
Ethnicity and antihypertensive drugs

• Captopril found less effective in blacks than in
  whites
• Losartan is less effective in lowering BP in
  blacks.
• Thiazide diuretics is more effective in blacks.

41
Nursing implications

• Be knowledgeable about drugs varied responses in
  patients from different ethnic groups.
• Careful monitoring
• No two people are alike

42
Ethical dilemmas
43
Basic Theories

• Utilitarianism goal-based
• the greatest happiness for the greatest number
• Deontology duty based, love-based
• Autonomy human right self-determination
• Beneficence do good
• Justice - fairness
• Non-maleficence do no harm
• Veracity telling the truth
• Fidelity - keeping promise

44
Comparison of 2 major theories

• Utilitarian
• Consequences
• Who is the majority
• What is happiness

• Deontology
• Action motives
• Value
• knowledge

45
Ethical theory scientific theory

• Justify human action
• Acceptance of theory
• Action

• Explain phenomenon
• True or false
• Predict, control

46
Roles of the nurse

• Nurses fundamental responsibility- value,
  concern, goals
• Ethics of caring empathy, nurturing,
  commitment, being an advocate
• Participation of the family in decision making
  social assessment

47
Ethical Issues in Nursing

• Quantity vs. quality of life
• Pro-choice vs. pro-life
• Freedom vs. control
• Truth-telling vs. deception
• Distribution of limited resources
• Empirical knowledge vs. personal belief

48
Methods of moral reasoning

• Deductive code, creed,
• Inflexibility, value conflict, no motivation
• Inductive custom, cases,
• Static preventing progressive social change
• Intuition combination of subjective, objective,
  relativistic aspect
• Dialectical philosophical aspect, art

49
Cultural competence training

• Health care institutions
• Interdisciplinary programs
• Nursing service
• Orientation demographic data of the pop,
  ethical-legal consequences, appropriate resources
• In-service
• Interdisciplinary team
• Nursing education
• Undergraduate level core course
• Graduate level specialty areas

50
Factors to consider

• Time past vs. present, interpretation
• Circumstances setting, knowledge
• Religion beliefs, creation vs. revolution
• Science hard data vs. philosophy
• Technology change of nature

51
Leiningers Transcultural Care Theory Sunrise
Enabler

• Developed in the mid-1950s and early 1960s.
• To discover the meanings and ways to give care to
  people who have different values and lifeways.
• To guide nurses to provide nursing care that fits
  with those that are being cared for.
• Not only focuses on nurse-client interaction but
  also includes care for families, groups,
  communities, cultures and institutions.

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Application of Theory

• Care always occurs in a cultural context
• Culture is viewed as framework people use to
  solve human problems
• Culture is the lifeways of an individual or a
  group with reference to values, beliefs, norms,
  patterns, and practices (Leininger, 1997, p. 38)

54
Working with Interpreters

• Qualifications
• Bilingual, bicultural, understands English
  medical vocabulary
• Comfort in the medical setting, understands
  significance of the health problem
• Preserves confidentiality
• Multiple Roles
• Translator of Language
• Culture Broker
• Patient Advocate Convey expectations, concerns

55
Translation factors

• Language how are new words created?
• Navajo Penicillin the strong white medicine
  shot you get for a cold
• Minimize jargon, e.g., machine to look at your
  heart instead of EKG
• Nonverbal communication 60 of all
  communication
• Nodding may indicate politeness, not
  comprehension
• Bilingual interviewing takes at least twice as
  long as monolingual interviews!

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Caretakers Responsibilities in Using Translator

• Learn and use a few phrases of greeting and
  introduction in the patients native language.
  This conveys respect and demonstrates your
  willingness to learn about their culture.
• Tell the patient that the interpreter will
  translate everything that is said, so they must
  stop after every few sentences.

57
Caretakers Responsibilities (II)

• When speaking or listening, watch the patient,
  not the interpreter. Add your gestures, etc.
  while the interpreter is translating your
  message.
• Reinforce verbal interaction with visual aids and
  materials written in the clients language.
• Repeat important information more than once.
• Always give the reason or purpose for a treatment
  or prescription.
• Make sure the patient understands by having them
  explain it themselves.
• Ask the interpreter to repeat exactly what was
  said.
• Personal information may be closely guarded and
  difficult to obtain.
• Patient often request or bring a specific
  interpreter to the clinic.

58
Caretakers Responsibilities

• In some cultures it may not be appropriate to
  suggest making a will for dying patients or
  patients with terminal illnesses this is the
  cultural equivalent of wishing death on a
  patient.
• Avoid saying you must... Instead teach patients
  their options and let them decide, e.g., some
  people in this situation would...

59
Cultural Diversity and Health Care

• It is because we are different that each of us is
  special.

60
HEALTHY PEOPLE 2010

• Plan to eliminate disparities in health care
  provision and in health outcomes by 2010
• Addresses highly preventable conditions
• Requires participation by health care providers
  to be successful
• Includes issues of cultural and linguistic
  competence in access to care

61
Cultural Competency

• Defined as a set of congruent practice skills,
  behaviors, attitudes and policies that come
  together in a system, agency or among providers
  and professionals that enables that system,
  agency, or professionals to work effectively in
  cross-cultural situations.

Cross TL, Bazron BJ, et al. Towards a Culturally
Competent System of Care. CASSP Technical
Assistance Center, Georgetown University Child
Development Center, March 1989
62
Title VI-Civil Rights Act

• No person in the United States shall, on the
  ground of race, color, or national origin, be
  excluded from participation in, be denied the
  benefits of, or be subjected to discrimination
  under any program or activity receiving Federal
  financial assistance.

63
CULTURAL COMPETENCE

• Culturally appropriate, community-driven programs
  are critical
• Promote cultural awareness
• Encourage cultural competence inclusion in
  medical school and health careers curriculum
• Advocate for the needs of the patients by
  providing translators, culturally competent
  information and instructions in simple language

64
Impact of Cultural Competency

• More successful patient education
• Increases in pts health care seeking behavior
• More appropriate testing and screening
• Fewer diagnostic errors.
• Avoidance of drug complications
• Greater adherence to medical advice
• Expanded choices and access to high-quality
  clinicians.

65
Transcultural Nursing- Leininger, 1997

• Definition- A formal area of study and practice
  focused on comparative holistic culture care,
  health and illness patters of people with respect
  to differences and similarities in their cultural
  values, beliefs, and lifeways with the goal to
  provide culturally congruent, competent and
  compassionate care

66
Cultural needs

• Equal access to treatment and care
• Respect for cultural beliefs and practices
• Leininger, (1995) Narayanasamy, (2003)
• Religious beliefs, taboos, customs
• Dietary, personal care needs, daily routines
• Dying needs
• Communication needs
• Cultural safety needs,

67
Cultural needs (Contd)

• Pain
• Health practice
• Time orientation
• Space
• Family

68
Equal access to treatment and care

• Ethnicity
• racial discrimination,
• racial harassment and
• oppression
• Secondary problems
• stress
• psychological trauma

69
Communication needs

• Barrier
• Impede early detection
• delay prompt treatment and care
• Forms
• Language
• Non-verbal communication
• Translation services
• Interpreters
• Family interpreters
• Health condition acute illness crisis

70
Cultural safety needs

• Engage clients as partners
• Respect rapport -gt self-esteem
• Cultural negotiation culture compromise

71
Transcultural Care Practice

• Initiative
• Enthusiasm
• Commitment of individuals and groups
• Strategic planning
• Organization coordination of services
• Funding
• Education
• Recruitment research

72
Giger-Davidhizar (2004) - Assessment Model
Communication
Culturally Unique Individual
Space
Biological Variations
Social Organization
Environmental Controls
Time
Transcultural Nursing Assessment
Intervention. Mosby
73
ACCESS Model Narayanasamy, 2002

• Assessment
• Communication
• Culture negotiation and compromise
• Establishing respect and rapport
• Sensitivity
• Safety

74
Campinha-Bacotes Cultural Competence Model

• Cultural awareness
• Cultural skill
• Cultural knowledge
• Cultural encounters
• Cultural desire

75
Campinha-Bacote, J. (2003)
76
Cultural awareness

• Becoming appreciative, and sensitive to the
  values, beliefs, lifeways, practices, and problem
  solving strategies of clients' culture.
• Exam personal prejudices and bias, one's own
  cultural background

77
Cultural knowledge

• seeking and obtaining a sound educational
  foundation concerning the various world views of
  different cultures.
• obtaining knowledge regarding specific physical,
  biological, and physiological variations among
  ethnic groups

78
Cultural skill

• ability to collect relevant cultural data
  regarding the client's health histories and
  presenting problems as well as accurately
  performing a culturally specific physical
  assessment.

79
Cultural Encounter

• Engaging directly in cross-cultural interactions
  with clients from culturally diverse backgrounds.
  
• Being aware of the intra-ethnic variation, which
  refers to the fact that there is more variation
  within a cultural group than across cultural
  groups

80
Cultural desire

• the motivation of health care providers to "want
  to" engage in the process of cultural competence

81
Purnells Model

• Macro level global society, community, family,
  individual, health
• Cultural domains overview, communication,
  family roles, workforce issues, bioculturl
  ecology, high-risk behaviors, nutrition,
  pregnancy childbearing practices, death
  rituals, spirituality, health care
  practice/practitioners
• Cultural consciousness
• Unknown phenomenon

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Purnells Model for Cultural Competence
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Culturally Competent Organization

• US Census Bureau, 2000 total population
  281,421,906
• Latio 35.5 million 12.1
• African American 12.9
• Asians 4.2 (60 is foreign
  born)
• Multiracial 2.4
• Ethnic minorities accounts for one fourth of the
  nations population
• In 2020, it will be near to 40
• 10 of RNs in the US are from racial/ethnic
  minority background (2000)

85
Organizational Diversity Competence
Model(Frusti, Niesen, Campion, 2003)
Drivers
measurements
Linkages
Commitment
Culture
86
Ethic Conflicts

• Genetic counseling
• Family and community involvement in patient care
• Religious ritual ie Sabbath, fasting
• Delay in help seeking

87
Negotiation Process

• Listen to the clients perspective
• Teach from your knowledge in language
  appropriate for client family
• Compare similarities differences, disagree but
  do not devalue clients view
• Compromise
• if client treatment not harmful, promote
• If harmful, explain harm and suggest alternatives

88
Conclusion

• Culture is learned exists in a constant state
  of change
• Nursing is not culturally free but rather is
  culturally determined avoid ethnocentric
• Much diversity within a cultural group as across
  cultural groups.
• Culturally competence is a dynamic, fluid,
  continuous process.
• Goal discover culturally relevant facts about
  the client to provide culturally appropriate and
  competent care

89
Globalization Q How to define
globalization? A Princes Dianas death Q How
come? A An English princess with an Egyptian
boy- friend crashes in a French tunnel, in a
German car with a Dutch engine, driven by a
Belgian who was pissed on Scottish whiskey,
followed closely by an Italian paparazzi, on
Japanese motorcycles, treated by an American
doctor, using Brazilian medicines. And this is
sent to you by a Israeli, using Bill
Gates Technology which he stole from the
Taiwanese.