University of Chicago
Type of paper: Thesis/Dissertation Chapter
Culturally Competent Nursing Care
Culturally Competent Nursing Care
The United States is a diverse accumulation of cultural backgrounds which can often set the stage for feelings of confusion, anger, mistrust, and a host of other emotions when dissimilar cultures disagree. Cultural competence in nursing can help eliminate these barriers and provide a platform for nursing to follow in the quest to understand a patient’s culture and background. When a nurse takes the time to learn about a given culture prior to providing care, it conveys she respects the patient’s right to their beliefs, customs, and culture. It does not necessarily mean the nurse agrees with their practices but it does show that she is willing to be open minded and deferential. It is the responsibility of the health care provider to take the time to educate themselves on the various cultures they may be exposed to in their work (Purnell & Paulanka, 2003). Evidence of Culturally Incompetent Care
One act from the case study that exhibited cultural incompetence was the racial slur made by Connie when she referred to her clients as “This Mexican family”. If she would have taken the time to review the baby’s chart, she would have known that the family identified with the term Hispanic, not Mexican. Connie made a statement about the number of family members in the room and she gave the impression that the family was invading her work space unnecessarily. Connie identified that the family was speaking Spanish then stated she could not get them to understand her. Her tone indicated that the family was at fault for the lack of communication even though Connie did not bother to engage an interpreter.
Connie even went so far as to label the family’s inability to understand her as noncompliance. She also proceeded to go about her task of putting in and intravenous (IV) line without establishing autonomy and getting informed consent from the mother. Connie’s action of cutting the “ragged, old red string” off the baby’s wrist without asking for permission first is proof of her cultural insensitivity. Many cultures tie strings around various parts of the body to ward off evil, aid in healing, or as a symbol of faith. Connie knew she did something wrong because she admitted that the mother screamed at her when she cut the string. However, she did not take the time to understand why the mother was upset. She appeared to be more concerned with getting her nursing tasks done right away and with leaving for the day. Importance of Values, Beliefs, and Practices
The iceberg model splits the nursing skill set into two parts; technical and behavioral. The tip of the iceberg represents what can be easily seen or the technical skills and knowledge a person has that allows them to perform their job. Examples of technical skills demonstrated by Connie were obtaining IV access and identifying the signs and symptoms of dehydration. These particular skills are considered visible to others so they correlate with the upper portion of the iceberg in the model. The lower part of the iceberg is under water or invisible and is indicative of the behavioral aspects of self that demonstrate who we are as a person. Understanding one’s own values, beliefs and practices helps when trying to understand those same characteristics in a different culture. Nurses need to understand how they view themselves and others before they can achieve cultural competence (Buffalo, 2001).
The behavioral or lower portion of the iceberg is represented by social role, self-image, traits, and motives. The social role identifies with one’s image. It refers to how people want others to see them and how others actually do see them. The social role is important because it can establish how health care professionals determine what skill sets are important in their job. Self image is how people see themselves and once they understand themselves they can decide whether or not change is needed for personal growth. Another area on the hidden portion of the iceberg is traits or those characteristics and habits that determine how a person responds in a given situation. The last area of the iceberg is motives. Motives are formed early in life and are the driving forces behind personal actions. The status of the areas depicted in the lower part of the iceberg model also determine what characteristics are present on the visible portion of the model (Buffalo, 2001). Barriers to Healthcare
Communication is going to continue to be a huge barrier to healthcare for this family. They live in Texas which is very rich in Spanish culture and the Spanish language is common. Health care workers are often bilingual so this family should not have any trouble being understood when they go in for care in their home state. The general population of Texas has been exposed to the Hispanic culture and can relate to the beliefs and practices that are followed. However, this family migrates to Northern Minnesota, an area that is mostly comprised of white, non-Hispanic, English speaking people of European descent. From a transcultural nursing standpoint, nurses from the Northern areas of Minnesota may not even know they are lacking because the degree of interaction with the Hispanic population in the healthcare setting is minimal.
There will be language barriers, especially in the smaller, rural farming areas where the migrants tend to work. Many small rural hospitals do not have access to interpreters and it is common to have little to no cultural education provided to the employees. Unless there is a cultural change in this area of the country, communication will continue to be a problem. The disparity is one of population and geographic location relative to the Hispanic culture in Northern Minnesota (U.S., 2010). Cultural Sensitivity Information
Additional information that could have been added to the kardex was the preferred method of communication so the nurse would know right away if an interpreter would be needed. Family demographics could have been put on there so the nurse had information regarding the cultural background. Notes could have been put on the kardex that identified the family dynamics so other nurses would understand why so many family members were present. The religious preferences would also be significant because that would give the nurse insight to the possible importance of certain charms, icons, or beliefs. Another item that could have been on the kardex was the history of the patient from the perspective of the clinic nurse. She may have passed on more information to Connie but as flustered as Connie was, that information was more than likely minimized or forgotten because it was not written down. Connie only gave the bare facts during report, then hurried out of the workplace, leaving Gina with more questions than answers. Provisions of Culturally Competent Care
Gina recognized that she was lacking in cultural knowledge about this family and took the time to look up some information prior to interacting with them. She was respectful of the role of the elders and addressed each person accordingly, gaining some measure of respect in doing so. This helped her establish a mutually satisfying relationship with the family which in turn helped build trust. She also intervened and got an interpreter rather than allowing one of the younger teenagers to interpret. Gina also took the time to find out what interventions the family had provided and did not belittle them for their actions. Gina went from conscious incompetence to conscious competence and will more than likely advance into unconscious competence with time (Purnell & Paulanka, 2003). Transcultural Competency Model
The Camphina-Bacote competence model identifies cultural competence as a process that a healthcare worker goes through to enable themselves to work in a manner that falls within the cultural context of a client. The model has five constructs: Awareness, skill, knowledge, encounters, and desire. The first construct of the model, awareness, asks healthcare workers to question their own cultural consciousness by identifying biases and prejudices they may have toward other cultures. It is an attempt to help one understand just how sensitive they may or may not be toward other cultures. The second construct focuses on whether or not the healthcare worker has the necessary skills to conduct a cultural assessment in a manner that will insure insightfulness. This is important for insuring that the assessment is properly done and that it contains information necessary to others who may rely on it. Having the skills alone is not enough; the person conducting the assessment also needs to have knowledge of the culture.
The assessor needs to research the culture to understand the worldview. There are many blanket questionnaires available to use for the assessment if one does not care about personalization. However, understanding the culture is important before the interview begins if the person conducting the interview wants to develop questions that are more in-depth and of a personal nature. The Camphina-Bacote model also recommends that the person conducting the cultural assessment determine what type of encounter they wish to use for the interaction.
Some examples of encounters include face-to-face meetings, attending group cultural activities, phone interviewing, or any other type of communication method. Some people may be more comfortable filling out a questionnaire, others may want to meet in a relaxed, public environment and still others might want the professional atmosphere of an office setting. Whatever type of encounter is chosen, it is important that the comfort of the person being interviewed is taken into consideration and a mutual setting is agreed upon. The last construct of the model is desire. If there is no desire on behalf of the professional to learn about cultural differences then the process of attempting to become culturally competent will fail. At the very best, the information gained will be inadequate and could cause more misunderstand and mistrust (Ingram, 2012). Ladder of Cultural Competency
Based on the case study Gina was not being racists and was not blind to the patient and family’s needs or their culture. Purnell and Paulanka (2003) describe racism as a display of power in combination with prejudice: Gina did not exhibit either of these characteristics. She had a modest awareness and knowledge of the Hispanic culture and was sensitive to the family’s needs. Gina does not have the language proficiency yet so she would not be at the fifth step. Gina is on step four: Competence. She demonstrated her ability to provide culturally competent care for this family. Even though she did not already have all of the necessary information to care for this child, she knew where to go look for it and how to interpret it. She demonstrated that she valued the family’s cultural differences by taking the time to treat them with respect according to their beliefs. Utilization of an Interpreter
Gina knew that the patient and the family had a right to have an interpreter provided. She also knew that it would be disrespectful to allow a younger person to translate for an older person. In addition, the younger teenager who offered to translate stated she spoke very good English but indicated that she only attended summer school while in Minnesota. What the teenager considered good English more than likely would not have been adequate to translate medical terminology. Gina made a very good decision when she brought in an interpreter. She also obtained a resource for herself because the interpreter could have had additional knowledge about the culture. The Standards of Practice for Culturally Competent Nursing Care states that it “is critical that the healthcare system provides resources for interpretation when appropriate” (Douglas et al, 2009, p. 265). History of Present Illness
Gina could have asked the mother or family what they felt the cause of the illness was. This would have given her insight as to whether the family believed the cause was physical or spiritual. If it was believed to be spiritual in nature, the family may have wanted to call in a Hispanic healer to perform a ceremony for the child. She asked how many days the child had diarrhea and could have asked whether the child’s diet had changed before her diarrhea started. She also could have asked if any other family members had experienced the same symptoms. Coming to Minnesota may have precipitated a change in diet for the entire family with the possibility of contaminated food. Gina could have addressed the pathophysiology of the illness by asking whether or not the child had experienced any functional changes.
The family did indicate the they brought the child to the clinic after she became listless. Getting a background on other functional changes may provide clues to other factors that might be making the illness worse. For example, was the child falling down, crying a lot before she became listless, et cetera. Another area to look at would be the course of the illness. Gina could have the mother describe how the illness started and give a timeline of signs, symptoms, and interventions up to the present time. This could include the treatments the family provided along with what the expected outcomes were.
Gina could ask the family whether or not they felt any of the interventions were successful, even if it was only mild success. It would also give Gina information about the remedies used so she could research and pass the information on to the health care provider. Two of the treatments supplied by the family were actually not conducive to good health. The manzanilla tea can cause diarrhea and the family was giving it to the child as a treatment for diarrhea. According to the CDC, greta is an orange powder used as a Hispanic remedy for stomach ailments. The powder contains concentrations of lead as high as 90% and contributes to lead poisoning (CDC, 2009). Getting the family’s perception on the illness is very important to increasing one’s awareness of how the family views the illness. Cultural Diversity Care Plans
Practice| Nursing Diagnosis| Goal| Interventions|
Gina provided care congruent with the culture via an interpreter. The family was unable to understand the plan of care for the child.| Knowledge deficit related to language barriers.| Patient will verbalize an understanding of the child’s condition and the need for the current treatment plan via an interpreter.| 1) Using an interpreter, explain the illness, causes, and treatment plan to the patient’s family.2) Have the primary care-giver demonstrate understanding by repeating back the plan of care and the potential benefits. 3) Allow for questions and answers.|
Practice| Nursing Diagnosis| Goal| Interventions|
Gina attempted to put the family at ease by using an interpreter to find out what the family understands about the child’s illness and the interventions that were tried in the home environment. She discovered that the red string was on the child for good luck and to keep her safe from spirits.| Anxiety related to cultural lack of understanding of the illness and the treatment plan practices.| Collaborate with the family to identify treatments that are culturally acceptable and that can be used in conjunction with western medicine to address the child’s medical needs.| 1) Allow a spiritual advisor to place new red strings on the child and support a ceremony if need be.2) Explain the need for an IV and make sure it does not violate the family’s beliefs.3) Praise family for their efforts thus far.|
Practice| Nursing Diagnosis| Goal| Interventions|
Gina found out the baby had been given manzanilla tea and greta. Neither of these remedies is a good choice. The manzanilla tea is used for constipation and the baby had diarrhea. According to the CDC, greta is high in lead content and causes lead poisoning.| Ineffective health maintenance related to lack of understanding.| Educate patient’s family on the illness and potential harm of some folk remedies and identify harmful remedies that the family needs to change.| 1) Provide family with culturally appropriate
educational material in whatever configuration they require.2) Work with the family to develop a plan of action and identify alternatives to the harmful remedies.|
Providing culturally competent care can be challenging at times and it requires nurses to be aware of their own limitations, strengths and beliefs. It was evident in the case study that Connie was not prepared to take on the task of developing her own cultural competence. Gina, however, showed good leadership ability and a willingness to learn about a culture different than her own in order to provide the best nursing care she could. Gina is the type of nurse that will continue to grow in her position and garner respect from her patients and co-workers. Her actions showed she was capable of doing what was in the best interest of the patient and family. Cultural competence does not just happen; nurses have to make it happen.
Buffalo State, (2001). Technical and behavioral success factors. Retrieved June 23, 2013, from The State University of New York: http://www.buffalostate.edu/offices/hr/pepds/sf/tb.asp. Centers for Disease Control and Prevention, (2009). Folk medicine. Retrieved July 17, 2013, from the National Center for Environmental Health: http://www.cdc.gov/nceh/lead/tips/folkmedicine.htm. Douglas, M., Pierce, J., Rosenkoetter, M., Callister, L., Hattar-Pollara, M., Lauderdale, J., & … Pacquiao, D. (2009). Standards of practice for culturally competent nursing care: a request for comments. Journal Of Transcultural Nursing, 20(3), 257-269. Ingram, R. (2012). Using Campinha-Bacote’s process of cultural competence model to examine the relationship between health literacy and cultural competence. Journal Of Advanced Nursing, 68(3), 695-704. doi:10.1111/j.1365-2648.2011.05822.x Purnell, L., & Paulanka, B. (2003). Transcultural health care: A culturally competent approach. Philadelphia, PA: F. A. Davis Company. Sitzman, K., & Eichelberger, L. (2004). Understanding the work of nurse theorists: A creative beginning. Sudbury, MA: Jones and Bartlett Publishers. U.S. Department of Health and Human Services, (2010). Disparities. In Healthy People 2020. Retrieved June
26, 2013, from U.S. Department of Health and Human Services:
http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx. Walsh, S. (2004). Formulation of a plan of care for culturally diverse patients. International Journal Of Nursing Terminologies & Classifications, 15(1), 17-26.