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Course: Pediatric Nursing

Topic: Cultural Competence

The Nurses International Community

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Module Goals

Learners will be able to:

Define cultural competence
Explain why a nurse should be culturally competent in providing care to children and families
Identify barriers to cultural competence in health care
Discuss strategies a nurse can utilize to overcome barriers to competence
Describe the steps of developing cultural competence

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Culture

Definitions:

‘...the shared patterns of behaviors and interactions, cognitive constructs, and affective understanding that are learned through a process of socialization. These shared patterns identify the members of culture group while also distinguishing those of another group.’ (University of Minnesota, 2019)

‘...shared knowledge and schemes created by a set of people for perceiving, interpreting, expressing, and responding to the social realities around them.’ (Lederach,1995, as cited in University of Minnesota, 2019)

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Culture

Components of culture:

Non-material culture: Values, beliefs, symbols, and language
Material culture: Society’s physical objects like tools/technology, clothing, eating utensils, means of transportation

Sociology: Understanding and changing the social world, 2010

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Contact info: info@nursesinternational.org

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Why Should Nurse Need to Know About Cultures?

There are variations between cultural groups regarding beliefs and behaviors related to:

Meaning of health, illness, and death
Causes of disease
How illness and pain are experienced and expressed
Decision making process to seek help from healthcare provider
Preference of the treatments

Mayhew, 2018

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Why Should Nurse Need to Know About Cultures? (Continued)

Globalization/migration has increased the exposure of nurses to caring for people from various cultures around the world.
Every client has the right to culturally acceptable and appropriate care.
Often client’s cultural beliefs and behaviors about health dictate their reception of health care services/information provided and their willingness to abide to medical prescriptions.

Mayhew, 2018

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Why Should Nurse Need to Know About Cultures? (Continued)

Demonstrating awareness of client/family’s culture and beliefs promotes:

Trust and respect between care provider and client/family
Acceptance of diagnoses and treatments by client/family
Client’s adherence to treatment
Adoption of healthy behaviors by client/family
Client/family willingness to seek health care in future
Ensure safety

Lack of cultural relevance may deflect the client/family from seeking appropriate healthcare or making healthy decisions!

Mayhew, 2018

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Critical Thinking Question

Think about the components of your culture (values, beliefs etc.) and how they affect your behaviors and beliefs related to healthcare.

If you had a nurse taking care of you who did not demonstrate that they understand or respected your culture, how might that affect your experience?

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Transcultural Nursing

Dr. Madeleine M. Leininger, founder of the theory ‘Transcultural Nursing’, stated that-

"Transcultural Nursing has been defined as a formal area of study and practice focused on comparative human care (caring) differences and similarities of the beliefs, values, and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people."

Transcultural Nursing Society, 2022

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Transcultural Nursing

An integral part of nursing practice
Provides nursing care to the clients whose cultural background is different to that of the nurse
Is aware of the self and client’s culture and beliefs, recognizes the differences, and provides care that remains respectful of the difference
Provides culturally competent nursing care

Understanding transcultural nursing, 2005

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Critical Thinking Question

Think about a cultural group that is different from your own that you might provide medical care to as a nurse. What are some ways you can use transcultural nursing to provide culturally competent care to this client population?

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Culturally Competent Care

Respects diversity in the client population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors
Respects the values of client’s/family’s health beliefs and practices
Require knowledge, attitudes, and skills that enable caring for people across different languages and cultures

Murphy, K., 2011

Palazzi, 2015

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Barriers to Culturally Competent Care

Lack of diversity in health care’s leadership and workforce
Systems of care poorly designed to meet the needs of diverse patient populations- hospitals’ poorly designed clients support systems for culturally diverse clients
Nurses’ own linguistic and culturally diverse backgrounds
Providers’ poor communication skills

Poor communication between providers and patients of different racial, ethnic, or cultural backgrounds

Betancourt et al., 2002

Twomey, 2014

Grandpierre, 2018

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Steps for Developing Cultural Competence

Self-assessment
Acquiring knowledge
Skills building

Murphy, K., 2011

de Guzman et al., 2016

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Steps for Developing Cultural Competence (Continued):

Self-Assessment

Realize everyone has biases
Personal biases cause one to inadvertently act in ways that are discriminatory
Awareness of one’s own beliefs, attitude, biases, prejudices through self-examination is essential
Acknowledging one’s own beliefs and biases is the first step to cultural competence
Reflect on how our beliefs and biases affect the care you provide to client/family

Murphy, K., 2011

Palazzi, 2015

de Guzman et al., 2016

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Steps for Developing Cultural Competence (Continued):

Acquiring Knowledge

Increasing cultural and global knowledge

Learn about other cultures, be aware of current events
Work and interact with people from different cultural backgrounds

Understand rules of interactions within cultures, helps understand different attitudes

Understand historical background of different cultures

Certain words/phrases that seem neutral evoke negative reactions in specific populations

Acquire knowledge on different cultural healthcare practices and beliefs

Murphy, K., 2011

de Guzman et al., 2016

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Steps for Developing Cultural Competence (Continued):

Skills Building

Learn:

New communication skills to simplify language for any client, regardless of primary language
Adapting to new and different situations in flexible way

Practice tolerance of different cultural backgrounds

Be appreciative and inclusive of all cultures

Make effort to identify verbal and non-verbal actions which are not appropriate in specific cultures

Murphy, K., 2011

de Guzman et al., 2016

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Steps for Developing Cultural Competence:

Skills Building (Continued)

Practice active listening

Focus on:

Content of what is being said

What is being demonstrated/expressed

Think about the feeling behind the content, emotions involved
Avoid making assumptions
Avoid jumping to conclusions

Practice empathy

Try putting oneself in the client/family’s position to understand their perspectives

Murphy, K., 2011

de Guzman et al., 2016

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Critical Thinking Question

One of the first steps in developing cultural competence is self-assessment.
Complete this cultural diversity and competence self-assessment (on pages 287-290) and then reflect on your results.
What areas could you improve on? How would improving these areas result in better patient care?

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Application of Cultural Competence

Important considerations:

People from same cultural background may not share same behaviors and views
There may be culture within a culture

Understanding transcultural nursing, 2005

Palazzi, 2015

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Application of Cultural Competence (Continued)

Gather information on client/family’s health beliefs, their perspective specific to the client’s health condition

Its cause
Treatment (home remedies)
If they have been using or plan to use home remedies

Home remedies that are harmful or obstructs the therapeutic effect of the medically prescribed treatment:

Inform client/family of its harmful effects on the client
Ask them how they feel about stopping its use

Palazzi, 2015

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Application of Cultural Competence (Continued)

Respecting family’s religious beliefs

Flexibility in choice of:

Medications (e.g., avoiding medications containing alcohol)
Diet
Timing for return visits or elective procedures in conflict with religious holiday

Dedicated place for meditation, worship
Consultation with leader of family’s faith or spiritual community

Ensure quiet environment during prayer/ritual (that is not harmful to the client), being performed by chaplain, spiritual healer

Palazzi, 2015

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Guiding communication techniques:

I see that the information I gave you is very upsetting to you. I would like you to know that I can help you contact someone from your family or your faith or spiritual community. Is there someone I may call for you?

Or

I can understand that you were not expecting to receive this news, and it is a lot to process. Would it be helpful for me to ask our hospital chaplain to come for a visit?

After visit from chaplain or spiritual leader/healer:

I saw that X came by to see you. How was your visit? Would you like me to notify our team that you want privacy when he (or she) comes again?

During prayer/ritual by spiritual leader/healer, interrupting with “I am sorry. When can I come back?” or “How long will you be here?” will likely be seen as disruptive and disrespectful.

(Palazzi, 2015)

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Application of Cultural Competence (Continued)

Ensure safety of the child who is wearing religious charm on a necklace or string around the neck

Explain safety concern to family
Offer alternatives like tying it around wrists, or placing it nearby the child avoiding strangulation or choking

Where family culture values presence of or interaction with extended family members

Separate room for family discussion
Emphasize client’s need for rest
Inform of visiting hours

Palazzi, 2015

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Example of a culturally competent communication:

Provider: Several people have come earlier today to visit with you and your child. I am sure that you appreciate all of their concerns and their support for you and your family. I want to make sure that you and they know that Joey must get enough rest each day.

Parent: Yes, they have all been wonderful.

Provider: I agree that it has been a wonderful experience for you. However, I am asking that we limit the number of visitors that come to the floor at one time since we have many patients who need to sleep during different times of the day.

Parent: I can’t ask my friends from church to stay away. They are like family.

Provider: I am not asking that they stay away, but I am here to help you decide who comes and how they can take turns visiting, so that Joey gets the rest and care he needs. Our hospital has the following policy: visiting hours are from __ to __, and there should be no more than __ people visiting at one time. The lower age limit for children to visit is generally __.

(Children’s hospitals, including Texas Children’s, typically have unrestricted visiting for parents and siblings, except in special care units.)

(Palazzi, 2015)

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Application of Cultural Competence (Continued)

Ask client/family their preferred language

Use resources for language interpretation (interpreter or interpretation service through telephone)
Communication aids like spoken or visual aids
Speak directly to the client/family, pausing for interpreter to translate
Talk in short bites
Pay attention to the body language of client/family (confused, anxious, angry, distracted, etc.)
Repeat important information
Consent documents written in client/family native language

Palazzi, 2015

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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What Should the Nurse Do?

A family brought an infant to the emergency department to be evaluated for a high fever. The infant is bundled in a sweater and two blankets, which the family refuses to remove.

The nurse knows that this is a common practice in the family’s culture. However, the nurse also knows that removing the blankets and sweater will help to reduce the infant’s fever.

How should the nurse proceed in this situation?

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While the nurse might be tempted to lecture, berate, or shame the family for using a practice that is different from what is done in the nurse’s culture and that the nurse knows is not scientifically founded, the more appropriate and culturally competent approach would be to gently explore and seek to understand the family’s health beliefs that have led them to bundle their febrile infant. For example, the nurse might ask, “What do you feel will happen if we remove these blankets?” This kind of question can help the nurse to understand the family’s health beliefs, after which the nurse can provide information about how these beliefs will effect the child. In this situation, after sharing information with the family, the nurse could then ask, “How would you feel if we removed some of these blankets?”.

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Red Flags

Negative feelings toward client/family

Client/family looking confused, lost in translation, or upset

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References:

Agency for Healthcare Research and Quality. (2020 September). Consider Culture, Customs, and Beliefs: Tool #10. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Betancourt,J. R., Green, A. R., Carrillo, J. E. (2002). Cultural Competence in Healthcare: Emerging Frameworks and Practical Approaches. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf

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References:

de Guzman, M.R.T., Durden, T.R., Taylor, S.A., Guzman, J.M., & Potthoff, K. L. (2016, June 7). Cultural Competence: An Important Skill Set For The 21st Century (G1375). NebGuide. https://extensionpubs.unl.edu/publication/9000017519635/cultural-competence-an-important-skill-set-for-the-21st-century-g1375/

Grandpierre, V., Milloy, V., Sikora, L., Fitzpatrick, E., Thomas, R., & Potter, B. (2018). Barriers and facilitators to cultural competence in rehabilitation services: a scoping review. BMC health services research, 18(1), 23. https://doi.org/10.1186/s12913-017-2811-1

Mayhew, M. (2018, March). How culture influences health. Caring for Kids New to Canada, Canadian Pediatric Society. https://www.kidsnewtocanada.ca/culture/influence

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References:

Palazzi, D.L., Lorin, M.I., Ward, M.A., & Cabrera, A.G. (2015). Communicating with Pediatric Patients and their Families: The Texas Children’s Hospital Guide for Physicians, Nurses and other Healthcare Professionals. Texas Children’s Hospital. https://cdn.bcm.edu/sites/default/files/2015/13/pcg-v21.pdf

Sociology: Understanding and changing the social world. (2010). Available under the terms of a Creative Commons Attribution-NonCommercial-ShareAlike license. https://open.lib.umn.edu/sociology/chapter/3-2-the-elements-of-culture/

Transcultural Nursing Society. (2022, March 14). Dr. Leininger. https://tcns.org/madeleineleininger/

Contact info: info@nursesinternational.org

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References:

Twomey, T.C. (2014). Pediatricians and pediatric nurses in the delivery of culturally competent care: A scoping literature review to investigate progress and issues around culturally diverse care in paediatrics. Pediatr Neonatal Nurs Open Journal, 1(1): 19-25. doi: 10.17140/PNNOJ-1-105

Understanding Transcultural Nursing (2005, January). Nursing,35, p- 14,16,18,21,23. https://journals.lww.com/nursing/fulltext/2005/01001/understanding_transcultural_nursing.3.aspx#:~:text=Transcultural%20nursing%20means%20being%20sensitive,and%20related%20health%20care%20practices.

University of Minnesota, The Center for Advanced Research on Language Acquisition[CARLA]. (2019). What is Culture? https://carla.umn.edu/culture/definitions.html

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