Cultural Diversity and Community Health Nursing

Chapter 13

Cultural Competence

Cultural competence is respecting and understanding the values and beliefs of a certain cultural group so that one can function effectively in caring for members of that cultural group.

Culturally competent community health nursing requires that the nurse understand…

Lifestyle

Value system

Health and illness behaviors of diverse individuals, families, groups, and communities

Standards of Practice for Culturally Competent Nursing Care

Social Justice

Critical Reflection

Knowledge of Cultures

Culturally Competent Practice

Cultural Competence in Health Care Systems and Organizations

Patient Advocacy and Empowerment

Multicultural Workforce

Education and Training in Culturally Competent Care

Cross-Cultural Communication

Cross-Cultural Leadership

Policy Development

Evidence-Based Practice and Research

From: Expert Panel on Global

Nursing and Health (2010)

Population Trends

In 1970

Minority groups were 16% of population

By 2010

Minority groups increased to 36% of population

By 2025

More than half of all children will be minorities

By 2050

More than 54% of total population will be minorities

First time in U.S. history that minorities will make up a majority of the population

Population Trends (Cont.)

By 2060, projected demographic trends:

White 44%

Hispanic 30%

African American 15%

Asian 9%

American Indians & Alaska Natives 2%

Immigration to the United States

Since 1991, more than 13 million legal immigrants

In 2010, almost 40 million foreign-born individuals in the United States (12.9% of population) from:

Latin America 53.1%

Asia 28.2%

Europe 12.1%

Other regions 9%

Diversity Among Nurses

Minorities are generally underrepresented by nursing workforce (HRSA, 2009):

White/non-Hispanic 81.8%

African American 4.2%

Hispanic 1.7%

Asian and Pacific Islander 3.1%

Native American and Alaska Native 0.3%

Minority groups tend to be geographically distributed in the United States.

Cultural Perspectives and Healthy People 2020

Developed a set of national health targets…eliminating racial and ethnic disparities in health

Embraced and focused on ways to close the gaps in health outcomes

Focused on disparities among racial and ethnic minorities, women, youth, older adults, people of low income and education, and people with disabilities

Health Disparities

AHCRQ (2005) reveals that:

Cancer mortality rates are 35% higher in African Americans than in whites.

African Americans with diabetes are seven times more likely to have amputations and develop renal failure than are whites with diabetes.

30% of Hispanics and 20% of African Americans lack a usual source of health care (compared with less than 16% of whites).

Health Disparities (Cont.)

AHCRQ (2005) reveals that:

Hispanic children are nearly three times as likely as non-Hispanic white children to have no usual source of health care.

African Americans (16%) and Hispanic Americans (13%) are more likely to rely on hospitals or clinics for health care than are whites (8%).

Addressing Racial and Ethnic Disparities in Health Care

Disparities can be reduced or eliminated when adults have:

Health insurance and

A medical home

– Commonwealth Fund, 2007

Transcultural Nursing

“…a formal area of study and practice focused on a comparative analysis of different cultures and subcultures in the world with respect to cultural care, health and illness beliefs, values, and practices with the goal of using this knowledge to provide culture-specific and culture-universal nursing care to people.”

– Leininger (1978)

Transcultural Nursing Terminology

Culture specific refers to the “particularistic values, beliefs, and patterning of behavior that tend to be special, ‘local,’ or unique to a designated culture and which do not tend to be shared with members of other cultures”

– Leininger (1991)

Culture universal refers to the “commonalties of values, norms of behavior, and life patterns that are similarly held among cultures about human behavior and lifestyles and form the bases for formulating theories for developing cross-cultural laws of human behavior”

– Leininger (1978)

Transcultural Nursing Terminology (Cont.)

Ethnocentrism is a person’s tendency to view his or her own way of life as the most desirable, acceptable, or best, and to act in a superior manner toward another culture.

Cultural imposition is a person’s tendency to impose his or her own beliefs, values, and patterns of behavior on individuals from another culture.

Leininger’s Theory of Culture Care Diversity and Universality

Describes, explains, and projects nursing similarities and differences focused primarily on human care and caring in human cultures.

Uses world view, social structure, language, ethnohistory, environmental context, and the generic or folk and professional systems to provide a comprehensive and holistic view of influences in cultural care and well-being.

Leininger’s Sunrise

Model depicting the

theory of cultural

care diversity and

universality

Figure 13-1

From Leininger MM: Culture, care, diversity, and universality: a theory of nursing, New York, 1991, National League for Nursing Press.

Overview of Culture

Culture refers to the complex whole, including knowledge, beliefs, art, morals, law, customs, and any other capabilities and habits acquired by virtue of the fact that one is a member of a particular society (Tylor, 1871).

Culture represents a person’s way of perceiving, evaluating, and behaving within his or her world, and it provides the blueprint for determining his or her values, beliefs, and practices.

Overview of Culture (Cont.)

Four basic characteristics of culture—it is:

Learned from birth through the processes of language acquisition and socialization

Shared by members of the same cultural group

Adapted to specific conditions related to environmental and technical factors and to the availability of natural resources

Dynamic

– Sir Edward Tylor, 1871

Subculture

A fairly large aggregate of people who share characteristics that are not common to all members of the culture

Enables them to be a distinguishable subgroup

May be based on ethnicity, religions, occupation, health-related characteristics, age, gender, sexual preferences, or geographic location

Culture and Formation of Values

Common human problems related to values and norms:

What is the character of innate human nature (human nature orientation)?

What is the relationship of the human to nature (person-nature orientation)?

What is the temporal focus of human life (time orientation)?

What is the mode of human activity (activity orientation)?

What is the mode of human relationships (social orientation)?

Human-Nature Orientation

Innate human nature may be good, evil, or a combination of good and evil.

The dominant U.S. cultural group chooses to believe the best about a person until that person proves otherwise.

– Kohls (1984)

Person-Nature Orientation

Destiny, in which people are subjugated to nature in a fatalistic, inevitable manner.

Harmony, in which people and nature exist together as a single entity.

Mastery, in which people are intended to overcome natural forces and put them to use for the benefit of humankind.

Time Orientation

The focus may be on the past, with traditions and ancestors playing an important role in the client’s life.

The focus may be on the present, with little attention paid to the past or the future.

The focus may be on the future, with progress and change highly valued.

Activity Orientation

Being, in which a spontaneous expression of impulses and desires is largely nondevelopmental in nature.

Growing, in which the person is self-contained and has inner control, including the ability to self-actualize.

Doing, in which the person actively strives to achieve and accomplish something that is regarded highly.

Social Orientation

Lineal relationships: Exist by virtue of heredity and kinship ties. Follow an ordered succession and have continuity through time.

Collateral relationships: Focus primarily on group goals—and family orientation is important.

Individual relationships: Personal autonomy and independence dominate; group goals become secondary.

Culture and the Family

Cross-cultural differences may exist in:

Structural differences

Functional diversity

Socialization context

Sex roles and parenting values

Culture and Socioeconomic Factors

Socioeconomic status (SES) is a composite of the economic status of a family or unrelated individuals based on:

Income

Wealth

Occupation

Educational attainment

Power

Culture and Socioeconomic Factors (Cont.)

Poverty guidelines

Determined by comparing pretax cash income with the poverty threshold adjusted for family size and composition issued annually by USDHHS.

The U.S. Census Bureau (2012) reported that the poverty rate in 2011 was 15%

African American population—27.6%

Asian population—12.3%

Hispanic population—25.3%

Children under 6 years—24.5%

Culture and Socioeconomic Factors (Cont.)

Distribution of resources

Upper, middle, and lower classes

Total family income, occupation, and educational level

Age, sex, material possessions, health status, family name, location of residence, family composition, amount of land owned, religion, race, and ethnicity

A disproportionate number of individuals from the racially and ethnically diverse subgroups are members of the lower socioeconomic class

Outcome of social stratification is social inequality

Culture and Socioeconomic Factors (Cont.)

Education

Perhaps the single most important factor in SES.

Child’s educational development affected more by differences in levels of formal schooling than by cultural differences or economic indices.

Culture and Nutrition

Culturally competent nutrition assessment:

Cultural definition of food

Frequency and number of meals eaten away from home

Form and content of ceremonial meals

Amount and types of food eaten

Regularity of food consumption

Social contacts during meals

Beware of cultural stereotyping.

Cultural food preferences are often interrelated with religious dietary beliefs and practices.

Culture and Religion

Culturally competent nursing care and religious factors:

Gain a general understanding of religious calendars.

Know the customary days of religious worship.

Learn about special days of observance or celebration.

Ask clients what religious practices they follow.

Religious beliefs may influence a client’s belief about the cause of illness, perception of its severity, choice of healer, and source of consolation.

Assess spiritual needs of clients.

Know the difference between religion and spirituality.

Remember that various religions have shared beliefs.

Culture and Aging

Different cultures view older adults in very different ways.

Tasks of older adults

To achieve a sense of integrity in accepting responsibility for their own lives

To have a sense of accomplishment

Older adults develop their own means of coping with illness through self-care, assistance from others, and social support groups.

Cross-Cultural (Intercultural) Communication …

… between a nurse and client attempts to understand the other’s point of view from a cultural perspective.

Nurse-client relationship

Space, distance, and intimacy

Overcoming communication barriers

Nonverbal communication

Language

Touch

Gender

Health-Related Beliefs and Practices

Understand personal culturally based values, beliefs, attitudes, and practices.

Include the client’s beliefs about the cause of illness:

Biomedical perspective

Naturalistic perspective

Magicoreligious perspective

Understand the role and value of folk or religious healers.

Health-Related Beliefs and Practices (Cont.)

Cultural variations exist in how symptoms and disease conditions are perceived, diagnosed, labeled, and treated.

Expression of pain is culturally determined.

Some conditions are culturally defined—a culture-bound syndrome.

Management of Health Problems: A Cultural Perspective

First effort at treatment is often self-care.

Mobilizes client’s social support network

Provides a caring environment

Cultural negotiation is used when conceptual differences exist between client and nurse.

Same words but different meanings

Same phenomenon; different notions of causation

Different memories or emotions associated with the term and its use

Cornerstones of Public Health Nursing

Focus on health of entire population

Reflect communities’ priorities and needs

Establish caring relationships

Remain grounded in social justice

Provide care for the whole person

Promote health based on epidemiological evidence (evidence-based practice)

Collaborate with community resources

– Keller, Strohschein, & Schaffer, 2011

Management of Health Problems in Culturally Diverse Populations

Providing health information and education

Delivering and financing health services

Developing health professionals from minority groups

Enhancing cooperative efforts with the nonfederal sector

Promoting a research agenda on minority health issues

Providing Health Information and Education

Developing programs to increase public awareness about health problems.

Plan health information campaigns:

Be sensitive to cultural factors.

Involve community leaders.

Acknowledge existing cultural beliefs and practices.

Involve families, churches, employers, and community organizations as support systems.

Use lay volunteers to organize community support networks.

Client education should be interpersonal; carefully use credible printed materials and audiovisuals.

Role of the Community Health Nurse

Conduct a “culturological” assessment.

Conduct a cultural self-assessment.

Seek knowledge about local cultures.

Recognize political issues of culturally diverse groups.

Provide culturally competent care.

Recognize culturally based health problems.

Culturological Assessment

Brief history of ethnic and racial origins of the cultural group with which the client identifies

Values orientation

Cultural sanctions and restrictions

Communication

Health-related beliefs and practices

Nutrition

Culturological Assessment (Cont.)

Socioeconomic considerations

Organizations providing cultural support

Educational background

Religious affiliation

Cultural aspects of disease incidence

Biocultural variations

Developmental considerations

Resources for Minority Health

U.S. Department of Health and Human Services and Public Health Service

Office of Minority Health

Disadvantaged Minority Health Improvement Act of 1990

Indian Health Service

Indian Self-Determination Act of 1975

National Institutes of Health

National Center on Minority Health and Health Disparities (NCMHD)

Federally Sponsored Initiatives to Improve Health of Minority Groups

HRSA Health Disparity Collaboratives (HDC)

Racial and Ethnic Approaches to Community Health (REACH 2010)

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

Ryan White Comprehensive AIDS Resources Emergency (CARE) Act B

National Center on Minority Health and Health Disparities (NCMHD)