New Life College of Nursing Karachi Post RN - BScN 1st semester 2013 Faculty: - Sir Rameesh Kumar Subject: -Sociology Topic: - Special issues in the delivery of transcultural nursing care Group Member: - 1. Zahid Ali 2. Saima Naeem 3. Azra Noreen 4. Zainab Date: - 22-11-2013

Transcultural Nursing Special issues in the delivery of transcultural nursing care Transcultural Nursing

Objectives Define culture Identify the components of an accurate cultural assessment. Distinguish between primary and secondary cultural characteristics. Identify the advancement of transcultural nursing. List and define the key aspects of effective intercultural communication. Identify the future aspects of cultural diversity in nursing.

What is Culture? What is the transcultural nursing The sum total of the way of living; includes values, beliefs, standards, language, thinking patterns, behavioral norms, communications styles, etc. Guides decisions and actions of a group through time (Tappan, Weiss & Whitehead, 2007). Group’s acceptance of a set of attitudes, ideologies, values, beliefs, and behaviors that influence the way the members of the group express themselves What is the transcultural nursing Transcultural nursing is how professional nursing interacts with the concept of culture. Based in anthropology and nursing, it is supported by nursing theory, research, and practice. 

Characteristics of Culture Culture is considered a photocopy machine that makes duplicates of the original document with minor differences. Slight variation in the practices inevitably occurs when values, beliefs, and customs pass from one society to another. Subcultures develop when members of the group accept outside values in addition to those of their dominant culture. (Catalano 2009; Tappan, Weiss & Whitehead, 2007 ).

What is Diversity? Term used to explain differences between cultures such as: psychological, physical, and social differences that occur among any and all individuals. Example: race, ethnicity, nationality, religion, economic class, age, gender, sexual orientation, mental and physical ability, and learning styles. Primary Diversity: nationality, race, color, religious beliefs. Secondary Diversity: socioeconomic status, education, occupation ( powerful , but hard to identify). (Catalano 2009; Leininger & McFarland, 2002).

Major Factors in Transcultural Nursing Beliefs about illness, causes and cures Nutrition and dietary practices Disorders specific to a particular ethnic group Religious beliefs about illness and death

Asian Americans Demographics 4.3% of U.S. population (12.5 million) Asian Indians projected to become the dominant ethnic group within the next decade 2050 ethnic/racial groups will comprise close to 50% of U.S. population

Asian Religions Christianity-Philippines Islam-Middle East Asia Hinduism-India Buddhism-throughout Asia Judaism-Israel Taoism-China Shamanism-Thailand Shinto-Japan

Examples of Asian Healthcare Beliefs Yin and yang balance Respect for physician Limited concept of mental illness Traditional self-care, self-medication, self-dosing Fearful of blood work, excessive testing, surgery

More Asian cultural health care belief examples Self-restraint-may refuse pain medicine out of courtesy Do not touch the head-private and personal Modesty Eye contact Fasting (Ramadan) Visiting hours-large groups of family members Birthing beliefs

Examples of Asian Healthcare Practices Coining (Caogio) Cupping (Giac) Steaming (Xong) Acupuncture Patent Medicines

What is the role of the nurse? Provide care that is congruent with cultural values, beliefs and practices Perform transcultural assessments (communication, personal space, diet, religious beliefs, social orientation, what interventions have they already done?) Develop culturally competent interventions In-service staff on cultural competency Include teaching of transcultural nursing in school curriculum

Example of culturally sensitive interventions: Arrange nursing care so that it does not interrupt prayer session Try to schedule medication administration so that it does not interfere with fasting Try to accommodate dietary needs specific to culture Learn about alternative/complimentary medications

“Women who teach nursing in India must know the languages, the religions, superstitions and customs of the women to be taught… Florence Nightingale, 1894

Trans-Cultural Nursing A formal area of study and practice focused on comparative human-care ( caring) differences and similarities of the beliefs, values, and patterned life ways of cultures to provide culturally congruent, meaningful, and beneficial health care to people. (Leininger & McFarland, 2002)

Understanding Trans-cultural Nursing Care needs to be systematically studied to learn about human care ( caring) in diverse and similar cultures in the world and environments. Nurses are to be knowledgeable about their own cultural care heritage and of biases, beliefs, & prejudices to work effectively with clients. Nurses need to use trans-culture- specific and comparative knowledge to guide caring practices for culturally congruent care. Maintaining an open learning discovery process about care and culture is imperative. Nurses need creative ways to provide culturally congruent care practices. ( Leinniger & McFarland, 2002)

Advancement of Cultural Diversity in Nursing A hallmark behavior and action that focused on cultural diversity within nursing gave rise to the transcultural nursing movement. The early focus of the transcultural nursing movement was to bring sensitivity to the differences between nurses’ own culture and that of the people to whom they were providing care (Leininger, 1979). Successes of the transcultural nursing movement included incorporating culture to the nursing curricula and to the licensure and certification exams.

Advancement of Cultural Diversity in Nursing The advancement of cultural diversity is clear in the goal and mission of the ANA (1986, 1991), which is a commitment to serve the health needs of all people. In addition, the ANA has included cultural diversity as a priority in its strategic plans. Historically, cultural issues were addressed through the ANA’s interaction with minority organizations and minority leadership within the ANA. Cultural diversity issues have been addressed through ANA groups, such as the Committee on Intergroup Relations, Affirmative Action Task Force, and the Council of Cultural Diversity.

Advancement of Cultural Diversity in Nursing The Nursing Workforce Development programs were developed to increase opportunities for individuals who are from disadvantaged backgrounds, including economically disadvantage families, as well as racial and ethnic minorities underrepresented in the nursing profession (ANA, 2007).

The Need for Tran-Cultural Nursing! Leininger and McFarland (2002) discussed many reasons, but let us go through few: The steady marked increase in the migration of people worldwide. The rise in cultural identities with health consumers expecting that their cultural beliefs will be respected, understood, and appropriately responded to in health care. Increased signs of cultural conflicts and clashes, wars and violent acts among and between different cultures and nations influencing the health, survival, or death of people of diverse cultures. The marked increased number of nurses, physicians, and other health care providers working in many different places in the world

How do you feel about “your” ethnic and/or cultural and/or religious grouping stereotype? Stereotyping: is an oversimplified belief, conception, or opinion about another person based on limited amount of information. “Respect for cultural diversity and intercultural dialogue is one of the surest guarantees for development and peace”. UNESCO (2006)

Multiculturalism Many people cling tenaciously to their traditions (cultural practices) and language when they migrate to new country. Healthcare providers need to be aware of and learn ways to adapt their practices to allow for these differences.

Developing Cultural Awareness One of the most challenges for nurses who work in a culturally diverse environment is to understand client’s perspective of what is happening in the healthcare setting. Awareness starts with an understanding of one’s own cultural values and healthcare beliefs. Beliefs are based on knowledge and often religious beliefs. Ex, ‘knowledge of bacteria’. Try changing the client’s healthcare values by first, identifying his/her culture and practices that are similar or different from your practices, in order to decide whether it is desirable or possible to change. Tappan, Weiss, & Whitehead (2007); Marquis & Hustom (2003); Fawcett (2005).

Language Impact The problematic in UAE healthcare units larger due to the absence of enough professional medical interpreters 30% of the population are locals 70% divided between 10% (Arabs) and 90% (speakers of other languages) Poor communication is a barrier to good patient centered care. Non verbal communication taken for granted and can lead to false diagnosis In emergency cases , language barriers can be serious (The Emirates Center For Strategic Studies and Research, 2008)

Language and culture barriers result in: Poor patient-healthcare provider relationships Incorrect diagnosis Lack of informed consent Lower patient satisfaction Malpractice suits Marquis & Hustom (2003)

Solutions Needs for interpreters Respect privacy Cultural Competency: awareness and emphasis for all parties involved in the process Increase diversity of healthcare professionals (avoid bias/ethnocentrism/stereotyping Training to support cross-cultural care

Providing a Cultural Competent Care Cultural competence is the attitudes, knowledge, and skills necessary for providing quality care to diverse populations Becoming culturally competent is an ongoing process in which an individual or organization develops along a continuum until diversity is accepted as a norm and the nurse has acquired greater understanding and capacity in a diverse environment. Acceptance of various beliefs, behaviors, and values in determining a person’s physical and/or mental wellness/illness and incorporating those variables into the individual’s assessment and treatment (AACN, 2008)

Providing Culturally Competent Care Trans-cultural Understanding: The primary skills required for cultural competence include communication, understanding, and sensitivity. It is an ongoing process that continues throughout the nurse’s career. Trans-cultural Communication: It is a highly complex process that requires both verbal and non-verbal exchanges. a. Non-verbal Responses: nurses must be cautious when interpreting the nonverbal responses from some cultural groups. (Catalano, 2009)

Individual Recommendations The Registered Nurses’ Association of Ontario (2007) proposed that for each individual, embracing diversity means development of the following competencies and behaviors. Tools to assist in developing these skills are: 1. Self Awareness, To learn to embrace diversity in individuals. 2. Communication, To develop communication skills that promote culturally diverse settings. 3. New Learning, To attain cultural competence in individuals. The Registered Nurses’ Association of Ontario (2007)

Communication – To develop communication skills that promote culturally diverse settings. Are aware of different communication styles and the influence of culture on communication. Are aware of one’s preferred communication style, its strengths and limitations, and how it affects colleagues and recipients of care. Seek feedback from clients and colleagues, and participate in communication validation exercises (e.g. role-playing exercises, case studies). Use a range of communication skills to effectively communicate with clients and colleagues (e.g. empathetic listening, reflecting, non-judgmental open-ended questioning). Seek and participate in learning opportunities that include a focus on communication and diversity. The Registered Nurses’ Association of Ontario (2007)

New Learning – To attain cultural competence in individuals: Acquire knowledge of the range of cultural norms, beliefs and values relevant to clients and colleagues as a starting point to foster understanding – and further inquiry. Are aware of the disparities (e.g. health outcomes, access to care, economics, job opportunities) that exist for diverse populations and understand the factors and processes that contribute to them. Recognize how culture and diversity influence behaviors and interactions. Develop and apply cultural competence knowledge and skills in the areas of communication, care planning, conflict resolution and change management. Access, utilize, and partner with cultural resources. The Registered Nurses’ Association of Ontario (2007)

Anticipated Outcomes: A workforce composed of nurses who are open-minded, inclusive, and respectful of all colleagues and recipients of nursing services. Individual members of the workforce identify and are co-operative with one another to address barriers to equity and diversity, and build practice environments in which every person’s contribution is valued thus allowing the full potential of all to be maximized. These individuals refuse to participate in discrimination, harassment or bullying and address the issue in a way that will effect change The Registered Nurses’ Association of Ontario (2007)

Healthcare Workers Responsibilities Learn and use a few phrases of greeting and introduction in the patient’s 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. 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 client’s language. Repeat important information more than once. Tappan, Weiss, & Whitehead (2007); Marquis & Hustom (2003); Fawcett (2005).

Healthcare Workers Responsibilities 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. 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...” Tappan, Weiss, & Whitehead (2007); Marquis & Hustom (2003); Fawcett (2005).

The Future of Cultural Diversity in Nursing To evaluate the movement of nursing’s cultural diversity intention, the attitudes and beliefs about cultural diversity should be examined for its impact on behavior and actions that have resulted in the operational definition and actualization of cultural diversity. In process, reflection, and practice, nursing science should embody characteristics of cultural diversity; in that way, the science would serve as a process for understanding all aspects of cultural diversity.

The Future of Cultural Diversity in Nursing Nursing as a profession and discipline can conceptualize cultural diversity as more than just an awareness of diverse cultures through basic nursing curricula. The curricula need to go beyond simply teaching categories of cultural content where categories of beliefs and practices of cultural characteristics are developed and implemented for nursing assessment and intervention purposes. According to Zoucha and Housted: “the health care provider ought to treat a patient who happens to be from a particular culture, as an individual from a particular culture rather than, in effect, to treat the culture through the patient” (2000, p. 326).

The Future of Cultural Diversity in Nursing Future nurses need to be taught how to apply culture and diversity in the clinical setting. This will begin when nursing faculty are prepared in the cultural diversity dimension and are fully persuaded/ passionate about the cause. Increasing the diversity among nursing faculty within nursing’s educational programs is needed so that students have diverse role models. Diversity among nursing faculty can also help to disseminate and interpret cultural knowledge and needs of diverse nursing students. Additionally, nursing curricula need to reflect culturally diverse learning styles . .(Crow, 1993; Lowe, 2002).

The Future of Cultural Diversity in Nursing Chalanda (1995) described culture brokering as “the act of bridging, linking, or mediating between groups or persons through the process of reducing conflict or producing change” Through culture brokering, patients will be able to mediate between their beliefs and practices and the beliefs and practices promoted by Western biomedicine about how they should resolve their particular health or illness situation. (Chalanda (1995) Nurses in clinical practice have been expected to use a recipe or formula approach to delivering culturally competent patient care.

The Future of Cultural Diversity in Nursing Often, this approach does not adequately address cultural diversity because of preconceived and prescribed stereotypical notions and assumptions. Patients must be viewed as individuals outside of stereotypical characteristics and categorized to a particular cultural group. In this way, it would become clear that there are views and practices that conceptualize diversity between and within cultures. Nursing, from a cultural diversity approach and perspective, has been more descriptive in nature. Research approaches need to move from descriptive research to applied, programmatic, or biocultural in nature.

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

References Putsch III RW. Cross-cultural communication: The special case of interpreters in health care. JAMA 1985;254(23):3344-48 Fawcett, J.(2005). Contemporary Nursing Knowledge analysis and evaluation of Nursing Models and Theories. 2nd edition. F.A.Davis company. Philadelphia. John , L. Cynthia , A. (2009)Cultural Diversity: The Intention of Nursing. Nursing Forum Volume 44, No. 1. Leininger, M., McFarland, M., (2002). Transcultural Nursing. Concepts, theories, research, & practices. 3rd edition. McGraw Hill. The Registered Nurses’ Association of Ontario. (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence http://www.rnao.org/Storage/29/2336_BPG_Embracing_Cultural_Diversi ty.pdf

ACKNOWLEGEMENT SIR RAMESH KUMAR