1. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Professional Nursing Practice Concepts and Perspectives Seventh Edition Chapter 21 Nursing in a Culturally Diverse World

2. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved 21.1 Analyze concepts related to cultural diversity in nursing. 21.2 Discuss components of culture pertinent to nursing care. 21.3 Describe the components of Leininger’s Sunrise Model. 21.4 Describe the components of Purnell’s Model of Cultural Competence. 21.5 Describe barriers to cultural competence. 21.6 Assess clients from a cultural perspective. 21.7 Plan and implement culturally competent care. Learning Objectives

3. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Hallmark Features A focus on foundational knowledge related to professional nursing –Includes nursing history, nursing theory, ethics, and legal aspects, etc. An overview of professional nursing roles, issues, and changes in the profession –Discusses nurses as healthcare providers, learners and teachers, and leaders

4. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Challenges and Opportunities Become open to differences in beliefs about health and illness and unscientific approaches Establishing trust Numerous health disparities associated with race, ethnicity, and socioeconomic status Opportunity to enrich own lives through the understanding of differences of others Working toward health equity

5. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.1 Analyze concepts related to cultural diversity in nursing.

6. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Nursing in a Culturally Diverse World Diversity in America has changed Refer to Table 21–1

7. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Nursing in a Culturally Diverse World TABLE 21–1 Population Diversity of the United States, Projections for 2015 through 2055 *Beginning with the 2000 census, for the first time participants could select multiple races if they were of mixed racial heritage; therefore, the total can exceed 100%. **Persons of Hispanic origin may be of any race; thus projections are determined by race and then separated into categories of non-Hispanic. Source: Projections of the Population by Sex, Hispanic Origin, and Race for the United States: 2015 to 2060,” by the U.S. Census Bureau, Population Division, 2014. Retrieved from http://www.census.gov/population/projections/data/national/2014/http://www.census.gov/population/projections/data/national/2014/ summarytables.html Race2015(%)2025(%)2035(%)2045(%)2055 (%) One race* White77.375.473.471.469.4 African American/Black13.213.413.713.914.2 American Indian and Alaska Native01.2 01.3 Asian05.406.407.308.209.0 Native Hawaiian/Other Pacific Islander00.2 00.3 Two or more races02.603.203.904.805.7 Hispanic or Latino **17.720.322.325.327.6

8. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Nursing in a Culturally Diverse World Cultural mosaic describes the way in which other cultures retain their cultural identity for generations Healthcare professionals must understand their own cultural beliefs and biases Healthcare professionals need to develop an awareness of the cultural belief systems prevalent in their communities

9. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Nursing in a Culturally Diverse World Five competencies essential for culturally competent care –Apply knowledge of social and cultural factors –Use relevant data sources and best evidence –Promote achievement of safe and quality outcomes of care for diverse populations –Advocate for social justice –Participate in continuous cultural competence development

10. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Culture universals –Commonalities of values, norms or behavior; life patterns that are similar among different cultures Culture specifics –Values, beliefs, and patterns of behavior that are unique to designated culture

11. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Material culture –Dress –Art –Cultural artifacts –Religious artifacts –Eating utensils

12. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Nonmaterial culture –Beliefs –Customs –Languages –Social institutions

13. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Culture –Culture, diversity, ethnicity, and race often used interchangeably, but they are not synonymous –Culture is “the learned, shared and transmitted values, beliefs, norms, and lifeway practices of a particular group that guide thinking, decisions, and actions in patterned ways” –Cultural patterns are learned

14. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Subculture –Comprises people who have a distinct identity and are also related to larger cultural group Bicultural –Integration of two cultures within the individual

15. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Diversity –“State of having people who are different races or have different cultures in a group or organization” –Is all-inclusive –Comprises differences between oneself and others regardless of affiliation

16. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Ethnic –Group of people who share a common and distinctive culture –Subgroup of a larger social system with different experiences from those of the dominant culture –Characteristics of group give individual a sense of identity

17. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Race –Classification of people according to shared biological characteristics, genetic markers, or features Acculturation –Process of “becoming a competent participant in the dominant culture” –Also referred to as assimilation

18. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Nursing ethnoscientists –Study the health beliefs of cultures Transcultural nursing –Study of different cultures and subcultures with respect to nursing and health, illness, caring practices, beliefs, and values –Madeleine Leininger, nurse theorist, anthropologist, and founder of transcultural nursing

19. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Cultural awareness –Recognition of differences and similarities between varied cultural or ethnic groups Cultural sensitivity –Respect and appreciation for cultural behaviors

20. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Cultural competence –Knowledge, abilities, and skills to deliver care congruent with client’s cultural beliefs and practices Cultural and linguistic competence in health care –Congruent behaviors, attitudes, and policies –Enables effective work in cross-cultural situations

21. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Culture shock –Occurs when members are abruptly moved to another culture or setting –Disorder that occurs in response to transition from one cultural setting to another –Signs of culture shock range from silences and immobility to agitation and distress

22. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Characteristics of culture –Everyone has culture –Culture is learned –Culture is taught –Culture is social –Culture is adaptive –Culture is satisfying –Culture is difficult to articulate –Culture exists at many levels

23. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.2 Discuss components of culture pertinent to nursing care.

24. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Concepts Related to Culture Components of culture relate to all aspects of life Many facets of culture have an effect on nursing practice –Social structures and gender relationships –Health and illness practices –Attitudes about touch, territory, privacy –Childbirth and child-rearing practices –Death and dying practices

25. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Culture and Health Care Two transcultural healthcare systems –Indigenous healthcare system  Folk healthcare methods  Home treatments  Older, referred to as unscientific or primitive

26. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Culture and Health Care Two transcultural healthcare systems –Professional healthcare system  Structured system maintained by individuals who have engaged in formal program of study  Few professional healthcare workers are knowledgable about indigenous healthcare systems or practitioners –Goal of health care should be to use the best of both systems

27. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Culture and Health Care Complementary or integrative –Using nonmainstream approach together with conventional medicine Alternative –Using nonmainstream approach in place of conventional medicine

28. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.3 Describe the components of Leininger’s Sunrise Model.

29. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Leininger’s Sunrise Model Sunrise Model depicts a theory of cultural care diversity and universality See Figure 21–1

30. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved FIGURE 21–1 Leininger’s Sunrise Model Source: From Culture Care Diversity and Universality: A Theory of Nursing (Publication No. 15-2402, p. 43), by M. Leininger (Ed.), 1991, New York: National League for Nursing Press. Reprinted with permission.

31. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Leininger’s Sunrise Model Emphasizes that health and care are influenced by elements of the social structure, such as –Technological factors –Religious and philosophical factors –Kinship and social systems –Cultural values

32. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Leininger’s Sunrise Model Emphasizes that health and care are influenced by elements of the social structure, such as –Political and legal factors –Economic factors –Educational factors

33. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Leininger’s Sunrise Model Social factors are addressed within –Environmental context –Language expressions –Ethnohistory Each system is part of the social structure of any society

34. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.4 Describe the components of Purnell’s Model of Cultural Competence.

35. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Purnell’s Model for Cultural Competence More complex and provides greater specificity about factors that influence healthcare practices and decision making Consists of concentric circles, moving from outer rim to inner most ring –Global society –Community –Family –Individual person

36. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Purnell’s Model for Cultural Competence Within the circle are 12 pie-shaped wedges representing 12 cultural domains –Overview/heritage –Communication –Family roles and organization –Workforce issues –Biocultural ecology –High-risk behaviors

37. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Purnell’s Model for Cultural Competence Within the circle are 12 pie-shaped wedges representing 12 cultural domains –Nutrition –Pregnancy –Death rituals –Spirituality –Healthcare practices –Healthcare practitioners All domains are interrelated in how person perceives and receives health care

38. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Purnell’s Model for Cultural Competence Provides framework for assessing clients from comprehensive cultural perspective Enables healthcare provider to assess own knowledge, skills, beliefs, values related to cultural competence

39. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Integrating Cultural Knowledge in Care Strategies to understand one’s own culture as well as culture of another –Become aware of one’s own cultural heritage –Become aware of the client’s culture as described by the client –Become aware from the client of adaptations made to live in North American culture –Develop a plan of care with the client that incorporates his or her culture

40. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.5 Describe barriers to cultural competence.

41. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Integrating Cultural Knowledge in Care Barriers to integrating culture and care –Ethnocentrism  Individual’s belief that his or her culture’s beliefs and values are superior to those of other cultures –Stereotyping  Assuming that all members of a culture or ethnic group are alike

42. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Integrating Cultural Knowledge in Care Barriers to integrating culture and care –Prejudice  Negative beliefs or preferences generalized about a group –Discrimination  Differential treatment of one person or group based on race, ethnicity, gender, age, social class, disability, sexual preference, or other distinguishing characteristics

43. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Integrating Cultural Knowledge in Care Conveying caring to diverse groups –Address clients by title and last names –Introduce yourself by name and position, where appropriate –Be authentic –Use language that is culturally sensitive

44. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Integrating Cultural Knowledge in Care Conveying caring to diverse groups –Assess whether client information on health problems is congruent with the dominant healthcare culture –Do not make any assumptions –Respect the client’s values, beliefs, and practices –Show respect of the client’s support people –Make an effort to obtain trust

45. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.6 Assess clients from a cultural perspective.

46. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Health beliefs and practices –Magicoreligious health belief view  Health and illness controlled by supernatural forces  Illness is a result of “being bad” or opposing God’s will –Scientific or biomedical health belief view  Life and life processes controlled by physical and biochemical process manipulated by humans  Illness caused by germs, viruses, bacteria, or breakdown of human body

47. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Health beliefs and practices –Holistic health belief view  Forces of nature must be maintained in balance  When natural balance or harmony is disturbed, illness results  Medicine Wheel in indigenous cultures  Concept of yin and yang in Chinese culture  Hot/cold theory in Hispanic/Latino cultures

48. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Health beliefs and practices –Sociocultural forces (politics, economics, geography, religion) and predominant healthcare system influence client’s  Health status  Health-seeking behaviors  Healthcare behaviors

49. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Health beliefs and practices –Folk medicine  Healing derived from cultural traditions  More humanistic  Less expensive  Less frightening

50. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Health beliefs and practices –Important for nurse to obtain information about folk/cultural or family healing practices that may have been used prior to seeking Western scientific medical treatment  Clients reluctant to share home remedies

51. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Family patterns –Patriarchal versus matriarchal –Shared decision making –Value placed on children and elderly –Cultural and religious norms about sex-role behavior –Extent of family’s involvement in the client’s care –Naming systems

52. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Communication style –Culture is transmitted through communication –Critical to providing culturally competent nursing care

53. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Verbal communication –Differences in  Vocabulary  Grammatical structure  Voice qualities  Intonation  Rhythm  Speed  Pronunciation  Silence

54. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Verbal communication –Initiating verbal communication influenced by cultural values –Guidelines for communicating with someone who speaks another language  Avoid slang, medical terminology, and abbreviations  Augment conversation with gestures  Speak slowly, at a normal volume  Validate understanding  Translators or interpreters may be necessary

55. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Using an Interpreter Avoid asking a member of the client’s family, especially a child or spouse, to act as interpreter. The client may not wish family members to know about his or her problem, therefore, may not provide complete or accurate information if a family member is interpreting. Be aware of gender and age differences; it is preferable to use an interpreter of the same sex as the client to avoid embarrassment and faulty translation of sexual matters. Children should not be used as interpreters. Avoid an interpreter who is politically or socially incompatible with the client. Address questions to the client, not to the interpreter. Face the client, not the interpreter; you want to see the nonverbal message while the client is speaking. Ask the interpreter to translate as closely as possible to the words and meaning used by the healthcare provider. Speak slowly and distinctly. Do not use metaphors; for example, do not say “Does it swell like a grapefruit?” or “Is the pain stabbing like a knife?” It is better to ask, “Describe the pain.” Observe the facial expressions and body language that the client assumes when listening and talking to the interpreter.

56. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Nonverbal communication –Nurse needs to be aware of  What nonverbal behaviors mean to client  What nonverbal behaviors mean to client’s culture

57. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Nonverbal communication –Includes  Silence  Touch  Eye movement  Facial expressions  Body posture  Space orientation and distance

58. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Communication –Essential part of establishing relationship with client and family –Important for developing effective working relationships with colleagues

59. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Space orientation –Includes the individual, the body, surrounding environment, and objects within the environment –Relationship is learned and influenced by culture  Intimate zone – smallest area  Personal zone  Social zone  Public zone – largest area

60. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Time orientation –Individual’s focus on the past, present, or future –Most cultures combine all three, with a particular focus on one –Be aware of the meaning of time for clients

61. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Nutritional patterns –Staple foods of different cultures –Way food is prepared and served –Food-related cultural behaviors  Breast-feed versus bottle-feed infants –Food can be considered part of the remedy for illness

62. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Pain responses –Related to actual perception of pain and the meaning of pain to the client and family; in some cultures pain is  Punishment for bad deeds  Sign of mourning or grief  Sign of strength or endurance  Worthy of attention and sympathy –Client’s responses to pain should be assessed within context of client’s culture

63. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Childbirth and perinatal care –Prenatal care  Some equate prenatal exams with problems  For many cultures, pregnancy and childbirth are exclusive realm of women  People in several cultures emphasize equilibrium model of health

64. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Childbirth and perinatal care –Labor and delivery; differences vary by culture in the following areas  Choice of laboring and birthing location  Choice of primary healthcare provider  Who’s allowed to be present  Positions for delivery  Responses to labor pain

65. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Childbirth and perinatal care –Postpartum care  Many cultures focus on restoring harmony  Confinement periods vary  Extended family play essential role –The newborn  Breast- or bottle-feeding

66. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Selected Cultural Parameters Influencing Nursing Care Death and dying –Universal experience  Various practices associated with death, dying, and grieving  Dying in solitude unacceptable in most cultures  Different approaches regarding who to tell and when  Beliefs about cause of death and the soul vary  Specific rituals may be required prior to or immediately after death

67. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Learning Objective 21.7 Plan and implement culturally competent care.

68. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Providing Culturally Competent Care Providing culturally competent care is essential to quality nursing All phases of nursing process affected by client’s and nurse’s cultural values, beliefs, behaviors Nurses must also consider cultural values of healthcare setting

69. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Providing Culturally Competent Care Cultural assessment –Use broad statements and open-ended questions –Encourage client’s full expression –Client is teacher and expert regarding his or her culture –Make no conclusions

70. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Providing Culturally Competent Care Cultural assessment –Process of assessment is critical to understanding client –Trust must first be established –Assessments take time –Nurse must recognize own cultural values and beliefs –Assessment includes observation of behaviors, nonverbal responses, and verbal responses to questions

71. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Providing Culturally Competent Care Cultural assessment –Determine the client’s language and degree of fluency in English before assessment begins –Refer to the box titled “Examples of Open-Ended Questions for a Cultural Assessment”

72. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Examples of Open-Ended Questions for a Cultural Assessment Cultural Affiliation I am interested in learning about your cultural heritage. Can you tell me about your cultural group, where you were born, and how long you have lived in this country? Beliefs About Current Illness What do you call your problem? What name do you give it? What do you think has caused it? Why did it start when it did? What does your sickness do to your body? How severe is it? What do you fear most about your sickness? What are the chief problems your sickness has caused for you personally, for your family, and at work? Healthcare Practices What kinds of things do you do to maintain health? For example, what types of food do you eat to maintain health? What foods do you eat during illness, and how is food prepared? What other activities do you or your family do to keep people healthy (e.g., wearing amulets, religious or spiritual practices)? How do you know when you are healthy? Illness Beliefs and Care Practices What kinds of things do you do to treat illnesses? Do you use traditional healers (shaman, curandero, sabador, priest/priestess, espiritualista, herbalist, acupuncturist)? Who determines when a person is sick? How would you describe your past experiences with cultural healers and Western health professionals? What special remedies are generally used for the illness you have? What remedies are you currently using (e.g., herbal remedies, potions, massage, wearing of talismans, copper bracelets, or charms)? What remedies have you used in the past, and which did you find helpful? What remedies or treatments are you considering now, and how can we help? Family Life and Support System I would like to learn about your family. Who are the members of your family? What family duties do women and men usually perform in your culture? Whom do you consult when making healthcare decisions (e.g., other family member, cultural or religious leader)? Who will be able to help you during and after treatment? Do you need help to contact these people?

73. Copyright © 2016, 2012, 2009 Pearson Education, Inc. All Rights Reserved Providing Culturally Competent Care Cultural assessment –Leininger identifies three modes to guide nursing judgments, decisions, and actions  Cultural care preservation and/or maintenance  Cultural care accommodation and/or negotiation  Cultural care repatterning or restructuring