Cultural Diversity

1. Cultural Diversity 1

2. 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. 2

3. What is Culture? 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 (Catalano, 2009). 3

4. 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. 4

5. 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). 5

6. 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) 6

7. 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) 7

8. 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. 8

9. 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. 9

10. 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). 10

11. 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 11

12. 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) 12

13. 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. 13

14. 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. 14

15. Language Differences in UAE In the United Arab Emirates, there are 800,000 local Emirati�s against 5 million expatriates, including Asians, Arabs, Americans, French, and Iranians among whom 10% only speak Arabic. 15

16. 16 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

17. 17 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)

18. 18 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

19. 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 19

20. 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. 20

21. b. Speech Patterns: The use of silence by some cultural groups has led to misunderstanding in the health-care setting. c. Personal patterns: some groups are less willing to disclose private matters or personal feelings than others d. Open-Ended language: when the client trusts the nurse, then it will be possible to answer open-ended questions. e. Touch Misinterpreted: it is inappropriate in some cultures and it will lead to miscommunication. f. Personal Space: Zone that individuals maintain around themselves in most casual social situations. g. Eye Contact: it communicates different messages to different cultures 21

22. 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. 22

23. Self Awareness � To learn to embrace diversity in individuals: Perform self-reflection of one�s own values/beliefs, incorporating feedback from peers. Identify cultural differences among clients and colleagues in the practice setting. Acknowledge one�s own feelings and behaviors toward working with clients, families and colleagues who have different cultural backgrounds, health behaviors, belief systems, and work practices. Identify and seek guidance, support, knowledge and skills from role models who demonstrate cultural proficiency. Recognize and address inequitable, discriminatory, and/or racist behaviors or institutional practices when they occur. Acknowledge the presence or absence of individuals from diverse cultural backgrounds at all levels in the workplace, reflecting the cultural makeup of the clients or community being served. 23

24. 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. 24

25. 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. 25

26. 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 26

27. Employee Orientation and Continuing Education Orientation and ongoing continuing education need to address cultural competence ranging from awareness to skill building. A competency-based diversity model provides the conceptual framework for an organization to organize structured cultural competence education while attending to diverse learning styles and teaching approaches for culturally diverse groups. Employees need to develop the relevant skills, including communication, conflict resolution and how to conduct a culturally appropriate assessment. It is important that appropriate funding is allocated for cultural competence employee orientation, continuing education, and ongoing access to cultural diversity training. The results need to be regularly monitored and acted upon as appropriate. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. 27

28. 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. 28

29. 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...� 29

30. 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. 30

31. 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). 31

32. 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). 32

33. The Future of Cultural Diversity in Nursing More curricular time and integration of cultural diversity concepts and content need to be considered. For instance, the anthropological perspectives of both emic (insider�s) and etic (outsider�s) viewpoints in patient care should be integrated to nursing curriculum, theory, and practice. Incorporating an emic�etic approach in patient care allows nurses to adhere to a culturally diverse approach that puts them in a culture-brokering position. (DeSantis, 1991). 33

34. 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� (p. 19). 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. 34

35. 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. 35

36. The Future of Cultural Diversity in Nursing The dynamics of culture on patient responses to health and illness and on physiological factors, cost of care, length of stay, and rates of compliance/adherence need to be studied. To enhance cultural diversity, nursing needs to study the effects of using culture on physiological, psychological, spiritual, and social factors. Nursing care could then be based upon a culturally informed nursing science. Outcome measures of the effects of culture on health seeking behavior and the response to illness could be developed. 36

37. It is because we are different that each of us is special. 37

38. Tutorial Activities. Part 1: Answer the following questions with discussion: 1- How culturally competent are you? Assess the extent do you think you are culturally sensitive? What areas need further development? 2- Is there racism in nursing? To what extent do you think nurses are transracial in their practice setting? 3- What do you see as the biggest danger in the use of alternative and complementary medicine? Elaborate. Part 2: Read the following two articles and discuss your impressions: 1- NURSING WORKFORCE: SHORTAGES AND DIVERSITY: Carol Bradley &Julia Pennbridge: Report to The California Endowment, March 2003. 2- Canadian Nursing Association: PROMOTING CULTURAL COMPETENCE IN NURSING: POSITION STATEMENT.October 2010 38

39. Extra Readings Branch, W.T. 2000. �The Ethics of Caring and Medical Education.� Academic Medicine 75:127-132. Carrillo, J.E., A.R. Green, and J.R. Betancourt. 1999. �Cross-Cultural Primary Care: A Patient-Based Approach.� Annals of Internal Medicine 130:829-34. Carrese J.A., and L.A. Rhodes. 2000. �Bridging Cultural Differences in Medical Practice. The Case of Discussing Negative Information with Navajo Patients.� Journal of General Internal Medicine 15(2): 92-96. https://cccm.thinkculturalhealth.org 39

40. 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. Cronin, P. & Anderson,K.(2004). Knowledge for contemporary Nursing Practice. Mosby. Tappan, Weiss, & Whitehead (2007), Essentials of Nursing Leadership and Management, 4th edition, F. A. Davis Company, Philadelphia. Marquis & Hustom (2003), Leadership Roles and Management Functions in Nursing: Theory & Application, 4th edition, Lippincott, Philadelphia. John , L. Cynthia , A. (2009)Cultural Diversity: The Intention of Nursing. Nursing Forum Volume 44, No. 1. 40

41. American Association of Colleges of Nursing [AACN]. (2008). Establishing a Culturally Competent Master�s and Doctorally Prepared Nursing Workforce. http://www.aacn.nche.edu/Education/pdf/CulturalComp.pdf Andrews, M., & Boyle,J. ( 2008). Transcultural Concepts in Nursing Care. 5th edition, Wolters Kluwer, Lippincott Williams & Wilkins. 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_Diversity.pdf The Emirates Center For Strategic Studies and Research http://www.ecssr.ac.ae/ECSSR_Index_en/ 41