Cultural Competence in Nursing Care PDF

INTRODUCTION The ethnic and racial composition of the United States is continually changing and nursing care must be culturally inclusive and sensitive for all populations. Cultural competence in healthcare is having the knowledge, abilities, and skills to deliver care congruent with the patient's...

INTRODUCTION The ethnic and racial composition of the United States is continually changing and nursing care must be culturally inclusive and sensitive for all populations. Cultural competence in healthcare is having the knowledge, abilities, and skills to deliver care congruent with the patient's cultural beliefs and practices. The lack of skills related to cultural competence can make it difficult for nurses to communicate with patients of cultures, races, and backgrounds that are different from themselves; therefore, knowledge of other cultures is imperative. When striving to provide culturally competent care, the nurse includes both the patient and the patient's family in the process, thereby providing care that respects the patient's social, cultural, and linguistic needs and preferences. In addition to awareness of other cultures, nurses must avoid being ethnocentric and remain free of bias. Ethnocentrism is a form of in-group bias that considers the views, ideas, and orientation of others as negative. Nurses must remain nonjudgmental to optimize relationships and maximize quality care for all patients. Moreover, viewing individuals as outsiders creates a power imbalance by marginalizing the patient. Respectful care is inclusive. The concepts of ethnicity, culture, race, bias, identity, and inclusion are potential influences on nurses' judgment and behaviors, affecting the ability to deliver culturally appropriate and person-centered care. Seeing the individual, the person, comes first. Person-centered care invites them in to the conversation and decision-making processes and acknowledges the support and influence of their family members. Moreover, person-centered care is respectful and inclusive. Person-centered care takes into consideration the cultural, linguistic, and social and environmental needs of the patient and the patient's family. Nurses have no way of knowing an individual's personal values and beliefs, national heritage, feelings about gender identity and sexuality, experiences within the healthcare system, or health literacy, based solely on appearance and demographic data. Nurses must develop essential skills in this area in order to work with and care for a cross-cultural and ethnically diverse workforce and patient population. Becoming a competent healthcare professional requires each individual to evaluate and assess their knowledge of other cultures and also requires an understanding of personal biases and stereotypes (generalized, oversimplified opinions and unfair and untrue beliefs about another person) that inhibit the ability to provide compassionate and person-centered care. Moreover, elimination of racial and ethnic disparities in healthcare is needed, and nurses are instrumental in developing care congruent with the principles of social justice and human rights. The provision of culturally appropriate care and sensitivity in developing care based on patients' beliefs and values are core competencies in nursing education. ETHNICITY, RACE, IDENTITY, CULTURE, AND CULTURAL BELIEF SYSTEM Race and ethnicity are related but different concepts. Both terms are associated with how individuals choose to self-identify (identify means how a person views themselves). Both race and ethnicity place individuals within a social category and begin to establish a personal and group identity. Race refers to a variety of features and characteristics that are shared by a group and may include skin color, facial features, and hair type. The U.S. Office of Management and Budget defines the racial categories that are used in many aspects of our daily lives, including employment applications, official census data, and even Medicaid applications. Self-reporting is the primary method of racial identification, using the following five categories from the U.S. Census Bureau: White---a person having origins in any of the original peoples of Europe, the Middle East, or North Africa Black or African American---a person having origins in any of the Black racial groups of Africa American Indian or Alaska Native---a person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment Asian---a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, Taiwan, and Vietnam Native Hawaiian or Other Pacific Islander---a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands In 2000, the U.S. census offered survey participants the option to select more than one race as the racial category to more accurately describe the changing demographics of the United States and account for the children born to parents of different races. For example, an individual may view themselves as multiracial and report their race as Asian and White or Native Hawaiian and Black. Our population is becoming much more diverse and multiracial. In fact, the 2020 census noted that respondents reporting two or more races increased by 276%. When a nurse views race as a negative characteristic, this is discrimination. Discrimination means taking actions that are unfair and damaging because an individual's beliefs, lifestyle, traditions, or preferences are different from yours or the cultural norms. One form of discrimination is racism, or a system of practices and actions that inhibit the equity, dignity, and respect of another person or another population. Discrimination, and specifically racism, places an individual or a population at a disadvantage, harming and marginalizing them as a result. When individuals are marginalized, their risk for poor health outcomes is increased. Ethnicity is related to race, but the terms are not synonymous. Ethnicity is the perception of oneself as belonging to one or more ethnic groups, including a commitment to cultural customs and rituals. For demographic purposes, the U.S. Census Bureau makes the distinction between people of Hispanic and non-Hispanic origin, and this information may be included in healthcare data. A Hispanic or Latinx person is of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. On an admission intake form, for example, the patient may select "Black, Hispanic," where "Black" is the race and "Hispanic" is the ethnicity. However, all patients who self-identify as the same ethnicity may not share all of the same practices or preferences. For example, individuals of Hispanic/Latinx ethnicity may share a common language (e.g., Spanish) and religion (e.g., Catholic), or they may share a language but not a religion. Another example is an individual who identifies as an Alaskan Native and may refer to themselves as a member of a particular tribal community and language group (e.g., Aleut or Eyak). Race and ethnicity are elements of a broader concept called culture. Culture is complex. At first, a person may simply explain that they are Irish or Jewish or African in relation to culture. However, that is a very limited view of culture. Culture relates to dynamic patterns of behaviors based on a collection of beliefs and values, communication, customs, language, roles, and relationships. These interrelated patterns influence expected behaviors associated with ethnic, racial, religious, or social groups that are shared and transmitted to following generations. Culture may also be by group membership or affiliation. When thinking about culture, individuals consider how much of self is visible to others and how much is kept hidden, yet everything about self---visible or hidden---interacts to create the individual's cultural belief system. Cultural belief systems are personally defined and unique to each individual; they reflect what is valuable and true to that individual, based on ideas and stories individuals tell themselves from a social and personal context. In healthcare, an individual's belief system influences information processing, including interactions with providers and the overall healthcare system. For example, food may be considered a medicine by certain individuals because food is used to restore health, whereas others may not see food and diet from such a holistic perspective. As caring professionals, nurses must develop their ability to provide culturally relevant and sensitive care---embracing a patient's belief system and preferences, ensuring that care is inclusive, just, and respectful. CULTURAL COMPETENCE, HUMILITY, AWARENESS, AND SENSITIVITY Cultural competence, humility, awareness, and sensitivity are similar yet different terms. Each term reflects critical knowledge, skills, and abilities that enable nurses to provide care that is appropriate for each patient's unique set of needs. Learning the differences between each term is the first step. Knowing that differences exist, having the ability to be open to and accepting of these differences, and choosing to avoid judging or assigning value to the differences is the goal. Cultural Competence The term competence is not new to nursing and healthcare. Competence refers to a person demonstrating proficiency, knowledge, and/or skill. Registered nurses learn how to take blood pressures and often must complete an annual validation to demonstrate competency for that essential skill, and they are then expected to complete that task correctly, every time. Cultural competence is the ability of healthcare providers and organizations to effectively deliver healthcare services that meet the social, cultural, and linguistic needs of patients. Culturally competent care means that nurses learn about each patient and tailor nursing actions to the individual patient and the patient's needs. For example, the nurse arranges testing or treatment appointments for a patient of Muslim faith so they would be free to participate in the five daily prayers. Culturally competent care is essential to all nursing interventions. In fact, it is a professional expectation set forth by the American Nurses Association (ANA) Standards of Professional Nursing Practice. Specifically, Standard 9, Respectful and Equitable Practice, explains that "the registered nurse practices with cultural humility and inclusiveness," which is demonstrated in a number of ways. The elements of Standard 9 explain how nurses apply knowledge of culture, diversity, and inclusion to develop care that is appropriate, sensitive, and reflective of current nursing practice (Box 3.1). Cultural competency requires the recognition that care must be equal, bias free, and respecting diversity. Diversity means difference and is one dimension that differentiates one person from another. As healthcare providers, nurse's actions must be inclusive, where patients and family feel valued, respected, and supported. Creating an environment in which all patients' perspectives and experiences are considered, valued, and acknowledged is important. Box 3.1 American Nurses Association Standards of Professional Nursing Practice: Standard 9 The registered nurse practices with cultural humility and inclusiveness. Competencies for the registered nurse: Demonstrates respect, equity, and empathy in actions and interactions with all healthcare consumers. Respects consumer decisions without bias. Participates in lifelong learning to understand cultural preferences, worldviews, choices, and decision-making processes of diverse consumers. Reflects on personal and cultural values, beliefs, biases, and heritage. Applies knowledge of differences in health beliefs, practices, and communication patterns without assigning value to the differences. Addresses the effects and impact of discrimination and oppression on practice within and among diverse groups. Uses appropriate skills and tools for the culture, literacy, and language of the individuals and population served. Communicates with appropriate language and behaviors, including the use of qualified healthcare interpreters and translators in accordance with consumer needs and preferences. Serves as a role model and educator for cultural humility and the recognition and appreciation of diversity and inclusivity. Identifies the cultural-specific meaning of interactions, terms, and content. Advocates for policies that promote health and prevent harm among diverse healthcare consumers and groups. Promotes equity in all aspects of health and healthcare. Advances organizational policies, programs, services, and practices that respect equity and values for diversity and inclusion. From American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). Author. Equal care means that every patient is treated the same, regardless of their values and preferences, and as a result, patient care outcomes are similar. For example, a nurse provides two different patients information about heart failure. One patient is a college graduate who possesses a high level of literacy, whereas the other patient has less education and a lower level of literacy. The nurse confirms that both patients fully understand the material and provides additional literacy support to either patient as necessary. This ensures that both patients receive equal access to the information. Cultural Humility Nurses must take time to learn about their own beliefs, cultures, and preferences while also taking time to learn about others' identities. Needing to learn more about a patient simply reflects humility in that nurses seek to better understand and embrace all patients. Cultural humility reflects a process rather than an endpoint. Cultural humility means that nurses embrace a lifelong commitment of self-evaluation, self-critique, and self-reflection to understand one's own biases and privileges. Knowing oneself affords the nurse to be flexible and open to creating relationships that improve patient interactions. This is in keeping with the ANA's definition of nursing as a caring profession and one that focuses on all of humanity, all patients, and all populations. Humility allows the nurses to take time to consider if actions are helpful and respectful. For example, a nurse realizes that they have no understanding of the food preferences of a patient who is of Muslim faith. Rather than order a "house diet," the nurse takes time to complete an admissions assessment. Once completed, the nurse spends more time discussing the types of diets available and learns more about the cultural preferences of the patient and religious doctrines embraced by the patient. Now the nurse has a better understanding about acceptable and prohibited Islamic foods. By taking time, including the patient in the conversation, and considering their personal and religious preferences, the nurse respects the patient's input and avoids a stereotypical response such as the patient would simply not eat pork. Rather the nurse understands foods that are considered profane and foods that are sacred. The dietary request is culturally sensitive, person-centered, inclusive, and respectful. Cultural Awareness Realizing that each patient sees and interprets things in their own way is the first step toward becoming culturally aware. Awareness may be defined as knowledge or understanding of a subject, issue, or situation, and cultural awareness is rooted in a desire to interact with the patient in a real and authentic fashion. Cultural awareness, therefore, is the realization and recognition that personal beliefs and values affect cultural health beliefs and potentially the view of those who are different. It is a critical starting point that nurses choose not to impose personal views on others. Awareness brings humility, further introspection, and empathy, which can help the nurse develop care that respects each patient's unique needs. To fully respect the differences of individual patients, nurses must actively create an environment and tone that are inclusive and without judgment. A nurse must be culturally aware to provide care that is appropriate for each patient and respectful of each patient's beliefs. For example, in some cultures, it might be appropriate and acceptable to physically stand very close to the person to whom you are speaking. In other cultures, physical space or distance between those in conversation is necessary, fostering comfort. Being culturally aware means that the nurse honors the patient's need for distance and does not force their own need to stand close to the patient. Awareness means the nurse is curious and mindful, wishing to know more, and choosing to act in a way that respects the patient's needs, not their own needs. Acknowledging and understanding the differences among patients and learning from them is the start of a nurse's cultural awareness. Cultural Sensitivity In order to provide culturally competent care, nurses must demonstrate cultural sensitivity: an understanding, thoughtfulness, and kindness that leads to inclusiveness and equity. Cultural sensitivity relates to an appreciation of one's personal needs and emotions, as well as to others' cultural practices, that lead to person-centered care. Sensitivity requires tact and thoughtfulness, allowing time and energy to consider the full complement of a patient's needs. This is especially important because, no matter the setting, nurses care for patients who come from diverse backgrounds. Lack of sensitivity may lead to undue harm and disrespect, which is counter to nurses' responsibility for compassionate, stigma-free, and bias-free interpersonal relationships. The nurse might learn more about a patient by asking a few questions. For example, the nurse might ask, "How important is it for you to have your family members included in your discharge planning sessions?" As nurses, caring is a hallmark behavior that promotes actions, attitudes, and behaviors that respect all cultures and all patients as individuals. A caring mindset paired with consideration and appreciation for a patient's culture requires time and desire. These are attributes of a professional registered nurse and reflect the ANA's commitment to respecting the human rights of all persons and avoiding personal biases and stereotypes that lead to inequity (Box 3.2). Cultural respect is critical to reducing health disparities. Connection Check 3.1 Select the question that reflects a culturally sensitive response to a patient's question. A.  "Can you try to decrease your smoking while you work?" B.  "How do your religious beliefs affect your healthcare decisions?" C.  "What is the biggest barrier to you making a lifestyle change?" D.  "When do you think it is possible for you to decrease your salt intake?" HEALTH DISPARITIES AND HEALTH EQUITY Registered nurses must be committed to reducing health inequities and disparities by customizing patients' plans of care. Applying the current Nursing: Standards of Professional Practice ensures that the nurse's role is to fulfill a social contract, one based on social justice, by modifying care to respond to the needs of patients. Raising awareness is the first step in addressing barriers to health equity. As awareness is raised, nurses improve the ability to recognize actions that perpetuate unjust and unequal care and treatment that contribute to social injustice. Box 3.2 Applying Professional Nursing Standards in the Provision of Care The ANA's Nursing: Scope and Standards of Practice serves as a resource for nurses to use when examining how best to demonstrate culturally sensitive care. For example: Standard 1. Assessment. "Explores healthcare consumer's culture, values, preferences, expressed and unexpressed needs, and knowledge of the healthcare situation" (p. 75) Standard 5B. Health Teaching and Health Promotion. "Uses health promotion and health teaching methods in collaboration with the healthcare consumer's values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preferences, spirituality, culture, and socioeconomic status" (p. 85) Standard 7. Ethics. "Demonstrates that every person is worthy of nursing care through the provision of respectful, person-centered, compassionate care, regardless of personal history or characteristics" (p. 89) Standard 8. Advocacy. "Considers societal, political, economic, and cultural factors to address social determinants of health" (p. 91) Standard 9. Respectful and Equitable Practice. "Respects consumer decisions without bias" and "participates in lifelong learning to understand cultural preferences, worldviews, choices, and decision-making processes of diverse consumers" (p. 93) Standard 10. Communication. "Demonstrates cultural humility, professionalism, and respect when communicating" and "uses language translation resources to ensure effective communication" (p. 94) Modified from American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). Author. Health Disparities A disparity is a difference, an inequity, or a discrepancy that is considered as unfair. According to the Office of Disease Prevention and Health Promotion, a health disparity is a health difference that is closely linked with social, economic, or environmental disadvantages. Health disparities are real and preventable, and they exist in all age groups, cultures, races, ethnic groups, religions, and populations who are vulnerable by virtue of sexual identity. Any difference in a health outcome that is related to bias, injustice, exclusion, marginalization, and social determinants of health may be viewed as a health disparity. For example, a nurse might assume the reason a patient was unsuccessful in increasing the amount of fresh fruits and vegetables in their daily diet is simply related to the patient's choice to eat more processed foods. However, on inquiring about the patient's living situation, the nurse learns that the patient's neighborhood has only convenience stores, no grocery stores, and the patient is unemployed, limiting the amount of money they can spend on food. Both environment and financial factors contribute to the patient's health inequity. Taking time to learn about the patient affords the nurse the ability to understand what challenges the patient might be experiencing. An accurate understanding of all the challenges allows for an ability to customize interventions. Several other social factors might affect this patient (Box 3.3) or may result from the biases and discriminatory behaviors of providers. For example, the nurse might assume that a patient who identifies as lesbian is not at risk for sexually transmitted disease so does not address health promotion strategies. Or the nurse might feel that a man who identifies as gay does not deserve information concerning prostate cancer screening. For each patient, the degree of risk and vulnerability grows as the number of social factors increases. Box 3.3 Social Factors Affecting Healthcare Equity Age Disabilities Economic instability Education level Gender Income inequality Limited English proficiency Limited social support Mental health conditions Race Sexuality Social isolation Age A patient's age is an important consideration in the provision of culturally competent care. Age is one of many factors that informs the nurse's actions when developing a plan of care. However, assuming that patients of the same age, young or old, act and feel the same way is a misperception. Ageism, or stereotyping and discriminating based solely on the patient's age, marginalizes the patient and results in dehumanizing and inappropriate care. The following examples show how nurses may exhibit ageism: When admitting a 79-year-old female patient for elective surgery, the nurse avoids asking a question about alcohol intake because the likelihood of alcoholism is "pretty low" in her age group. The nurse assumes the patient does not drink alcohol and misses the opportunity to assess the patient for alcohol use disorder. During a health assessment, the nurse notices that the older adult male patient appears underweight and assumes the patient is malnourished. The nurse fails to ascertain that the patient is a long-distance runner whose weight has been stable for several years. Moreover, on finding this out, the nurse questions the importance of physical activity in "someone his age." The nurse dismisses the importance of exercise to the patient's social and spiritual well-being. Nurses must take steps to avoid judging and stereotyping patients based on age because these actions affect a patient's ability to receive the most appropriate care. These effects may be associated with health disparities because older adults may have limited access to healthcare, whereas in many older adults, the use of healthcare services increases. With the price of medications and other out-of-pocket costs, older adults are faced with the financial burden of prescription medication use, which may result in delayed healthcare and unmet healthcare needs. Nurses have the opportunity to assess patients using an age-relevant lens that supports the identification of appropriate resources to address patient needs. Race To support a healthcare workforce empowered to address and embrace the diversity in the patient population, the U.S. Congress formed the Office of Minority Health (OMH) in 1986. The OMH supports research, projects, and other initiatives to promote a better understanding of health risk factors and successful prevention and intervention strategies for racial minority populations. Despite the work done by the OMH, there are still problems with health equity for minority populations. The 2020 census noted an increase in racial and ethnic diversity within the United States. However, the burden of disease continues to be disproportionately borne by racial and ethnic minorities. For example, the COVID-19 pandemic revealed significant inequities in infection, hospitalization, and mortality rates among Black, Hispanic/Latinx, American Indian or Alaska Native, and other historically marginalized populations compared with Whites. As such, these populations experienced more health, social, and economic consequences. Gender and Sexuality Gender is a characteristic associated with an individual's sex and is associated with roles of men and women. However, how one identifies oneself may be different from how others describe the person. Gender identity is how one defines and sees oneself. For example, a patient may be assigned male/man at birth, yet the patient identifies as a woman/female or neither. Gender identity is personal and may lead to gender bias in the nurse. The nurse's actions can lead to inappropriate treatment of the patient, such as avoiding contact other than when it is necessary. Gender bias is the end result of negative stereotyping (e.g., assuming all patients who are transitioning to a different gender act in a certain way) and can lead to gender discrimination or the unequal treatment of the patient. Asking the patient what their preferred pronouns are allows the patient to self-identify. For example, a patient may reply with she/her/hers, he/him/his, or they/them/theirs based on the patient's gender identity. Nurses must be able to avoid gender bias and discrimination in order to establish a therapeutic relationship that is free from judgment, personal opinions, or the power to demoralize the patient and/or family. Nurses must develop care based on the acceptance of all patients for who they are, not how the nurse might think they should be, and that care should be both compassionate and equitable. Sexuality or sexual orientation is linked with gender identity and refers to which individuals a person chooses for romantic and sexual encounters. Both gender identity and sexual orientation are individually and personally defined and may be different from how others may "see" them. A nurse might hold the opinion that men "look" a certain way and women might "act" a certain way; these ideas reflect a broad generalization that is unacceptable and harmful. Holding on to one's personal perceptions regarding sexuality leads to behavior that negatively affects one's interactions with others, which is called gender stereotyping. The nurse's role is to ensure gender equality and facilitate care that respects all patients' rights and preferences. With an emphasis on addressing the health disparities within the LGBTQIA (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and agender) community, several organizations made advances to address systematic barriers to safe, affirming, and equitable care for LGBTQIA patients. Despite growing attention to LGBTQIA health in the past decade, knowledge gaps remain about the health disparities that affect this population. Noting that the research was limited concerning the vulnerable LGBTQIA populations, the National Institutes of Health established the Sexual and Gender Minority Research Office in 2015. In 2016, the National Institute on Minority Health and Health Disparities (NIMHD) designated sexual and gender minority groups as a health disparity population. This designation allows the NIMHD to specifically address the need for research among lesbian, gay, bisexual, and transgender populations, including those who may be questioning sexual orientation, identity, and expression. Research studies have shown that the social stigma associated with transgender patients plays a role in the degree of patient engagement with medical care. For example, COVID-19 vaccine hesitancy in LGBTQIA populations was associated with past experiences of provider discrimination. Moreover, transgender populations experience a greater proportion of human immunodeficiency virus (HIV) infection and other sexually transmitted disease (STDs), yet HIV and STD risk among transgender persons remains understudied. Provider bias may lead to missed care and services in the LGBTQIA populations, leading to poor health outcomes. Evidence-Based Practice Culturally Affirming Care---LGBTQIA Patients Best Practice: The Encounter Best Practice: The Suggested Actions When addressing patients, avoid using gender-specific terms such as "sir" or "ma'am." Ask, "How may I help you today?" When talking about patients, avoid pronouns or other gender-specific terms. If you have a record of the name used by the patient, use it in place of pronouns. Consider saying, "Your patient is here in the waiting room." Or, "Max is here for a 3 o'clock appointment." Politely ask if you are unsure about a patient's name or pronouns used. "What name do you go by, and what are your pronouns?" "I would like to be respectful---how would you like to be addressed?" Ask respectfully about names if they do not match those in your records. "Could your chart be under another name?" "What is the name on your insurance?" Did you goof? Politely apologize. Own the misstep. Consider saying, "I apologize for using the wrong pronoun--- I didn't mean to disrespect you." Only ask information that is necessary for providing care. What information is critical? Ask yourself: What do I know? What do I need to know? How can I ask in a sensitive way? National LGBT Health Education Center. (2020, Winter). Affirmative services for transgender and gender-diverse people. Best practices for frontline health care staff. Fenway Institute. Economics The possession of adequate financial resources for day-to-day living expenses and to pay for healthcare services greatly affects an individual's ability to obtain healthcare. The high costs of healthcare services and health insurance create a financial barrier for patients with limited resources. Information related to both past and present financial resources is useful in determining gaps in healthcare or deterioration in health status and function that may be attributable to economic factors. Through a better understanding of the patient's financial needs, the nurse identifies the support services (e.g., patient assistance programs for prescription medications, free community clinics) that are appropriate for the patient. When patients face economic and financial barriers to accessing healthcare, there may also be delays in receiving care and/or accessing primary care services that potentially prevent definitive care and hospitalization. For example, for patients suffering from a fractured ankle, time between injury and presentation to hospital is longer in uninsured patients compared with insured patients. Additionally, the uninsured patients are more often lost to postoperative follow-up care, placing them at greater risk for surgical site infections. Often, income level and employment are associated with health insurance access. Health insurance increases a patient's access to primary care and preventive care. As a nurse, understanding the financial barriers and supporting access to healthcare services for all patients is a vital part of helping patients achieve the highest possible level of health. Language and Literacy Communication is a vital part of any patient encounter. The concepts of literacy and health literacy are essential components of providing person-centered care. Literacy is the ability to read, write, speak, and compute and solve problems, and health literacy is the ability to appropriately locate, comprehend, and use health information and services. Patients must have an adequate understanding of their treatment plan, medications, and health status in order to make informed decisions. When given teaching materials, patients must be able to read and understand the content accurately, as well as to be able to read printed materials and contact the healthcare provider if experiencing unusual symptoms. Patients with language barriers or poor levels of health literacy use healthcare services differently compared with patients with higher health literacy and may experience poorer outcomes. Patients with lower health literacy are less likely to access health information on the internet, participate in advanced care planning, and follow a medication routine. Health literacy is critical to enabling patients to make the best decisions to meet their needs and prevent negative health outcomes. Geography When nurses consider the health of the individual or the population, they must consider the environment in which the patient lives. Where a person lives may create health disparities because an individual's health is directly affected by elements that increase or decrease wellness; a person's immediate neighborhood influences their health. Consider the phrase "place matters." When a neighborhood has plenty of green space and parks, crime is low, and streets and sidewalks are in good working order, individuals might feel compelled to enjoy the outside space, embrace exercise, and spend time talking to neighbors. Compare that scenario to a neighborhood where crime is high, city services are marginal, and many homes are vacant and boarded up. Physical safety might be a concern that encourages an individual to stay inside, avoid public spaces, and limit outside hobbies. Consider a neighborhood that has limited public transportation and the ways to access a bus, subway, or train might inhibit one's ability to find work, shop for groceries, and access preventive healthcare services. Likewise, consider a neighborhood where elementary schools lack adequately prepared teachers and sufficient textbooks and do not have a school nurse. Children in this neighborhood may have a foundational education that is inferior compared with children living in a neighborhood where schools are exceptional and have superior teachers and state-of-the-art classroom resources. Physical geography also influences what the individual breathes (e.g., clean air versus polluted air), the quality of the drinking water, and what diseases people living in that area may be exposed to (e.g., asthma). Geography and health are very closely linked, and when considered together, they allow the nurse to consider patient risk factors and health needs from a broader perspective. The nurse's role is to identify the degree to which geography negatively affects health and develop opportunities and provide resources that the patient may access to minimize the risk for disease. Bias and Discrimination Every individual has the potential for forming an opinion that is unfair or prejudicial in some way. This perception is termed bias. An individual, as well as groups of individuals, may hold multiple biases. There are two aspects to bias that are important to understand because both are associated with inferior, insensitive, and inappropriate healthcare. Implicit or unconscious bias is related to associations outside conscious awareness that foster a negative evaluation of a person on the basis of irrelevant characteristics such as race, gender, age, and so forth. Implicit bias may emanate from negative and positive stereotypes and affect one's judgment and is automatically activated and often unintentional. Implicit bias is subconscious and may be visible through subtle behaviors, such as being more relaxed when addressing one patient while being distant or aloof with another. Implicit bias explains the potential differences between explicit beliefs and actions to treat everyone equally and the influence of hidden negative implicit associations on beliefs and actions. Conscious bias, or explicit bias, is blatant, purposeful, targeted, and intentional. For example, conscious bias results when an individual has deliberate thoughts and feelings about an individual, such as an obese male, as well as groups of obese individuals. The intent of conscious bias is to demonstrate whether or not the negative aspects or evaluations of the individual or group are true. Bias can lead to stereotyping, which is grouping all individuals in a group together and forming a broad generalization (e.g., "all homeless individuals are illiterate"). Provider cultural insensitivity inhibits therapeutic communication with patients. Bias and Healthcare Professionals Healthcare professionals have personal belief systems, values, and attitudes. These personal attitudes, values, and beliefs can impede a provider's ability to understand and accept patients with different backgrounds or belief systems or patients who may not do things or act in a way that the professional "expects." This lack of understanding and acceptance can affect patient care and, ultimately, patient outcomes. In 2002, the Institute of Medicine (now named the National Academy of Medicine) reported that differences in patient care may be related to the behaviors of healthcare professionals, specifically bias or prejudice directed toward certain groups; greater clinical uncertainty when interacting with patients who are part of a minority group; and beliefs, or stereotypes, held by the provider regarding the behavior or health of patients who are part of minority groups. The report, Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare, explains that there are differences in the way patients respond to treatment and interventions as well as variations in their treatment-seeking behaviors when patients encounter biased or prejudiced care. Despite this and other reports, unequal treatment and health inequity are still evident in the current healthcare environment. Providers must adjust practices to address patient behaviors, attitudes, and care responses, and they must not allow bias to enter into patient care practices. It has also been found that clinical judgment and decision making may be influenced by providers who stereotype patients based on personal misperceptions. Stereotyping leads to differential care contributing to healthcare disparities. Research exploring the impact of the implicit racial and ethnic biases of healthcare professionals and the impact on health outcomes revealed low or moderate levels of implicit bias in healthcare professionals toward people in racial minority groups. Providers reported expressing more frustration with minority patients and even recalled losing their temper more often as compared with nonminority patients. Minority patients reported much more provider macroaggression experiences, and repeated exposure results in patients reporting less life satisfaction. LGBTQIA patients report that when interacting with providers, their trust was damaged because of poor communication, misgendering (incorrectly assigning a gender to a patient), and disrespect by the provider. In patients with psychiatric disorders, stigmatizing attitudes are lower for psychiatrists yet higher for medical students and other providers. Bias may lead to stigmatization or discrediting and devaluing an individual. Acting on the belief that an individual or a population is of no value leads to unequal treatment and discrimination. The provider--patient relationship can also create a power dynamic in which the provider has the bulk of the power. This can alter interactions between healthcare providers and patients if providers consider the patients to be "less than" themselves or "beneath" them. A power imbalance fueled by the negative impact of bias and stereotyping can result in actions that are aggressive toward the patient and can lead to unfair treatment by the provider. When an individual is afraid and demonstrates hatred or distrust this is called xenophobia. Xenophobia is often expressed by fear, intolerance, dislike, and prejudice against individuals from other countries and for those who may be different. Biases, conscious or unconscious, are not limited to characteristics such as ethnicity and race; biases may exist toward any social group. Bias, discrimination, stereotyping, stigmatizing, and hatred alter judgment, influence behavior, and create isolation and disassociation between nurses and patients and/or family members. Therapeutic communication is compromised, thereby impeding the nurse's ability to develop person-centered care. The distortions in healthcare provider judgment and decision making are key contributors to patient safety events as well as health inequality and disparities. Connection Check 3.2 Select the response that acknowledges that social factors place patients at risk for health disparities. A.  Anyone can be poor and have limited income; that does not affect access to healthcare. B.  Having faith and being religious help patients deal with health adversity. C.  Many patients speak a language other than English, but translation services help them a lot. D.  Unemployment is a barrier that negatively affects housing, food, and healthcare access. Connection Check 3.3 Which thought by the nurse suggests that the nurse is considering whether unconscious bias is influencing their judgment? A.  "All obese patients just make bad nutritional decisions." B.  "I wonder if my feelings about abortion made me say that." C.  "Is cultural awareness as important as cultural competency?" D.  "Why do they all act that way?" CASE STUDY: EPISODE 2 Mrs. Liu is admitted to the hospital for rectal bleeding. During the nursing assessment, the nurse learns about Mrs. Liu's recent move to live with her daughter and son-in-law and their visit to the Chinese medicine store. The nurse does not understand why Mrs. Liu went to the Chinese medicine store. Further discussions reveal that Mrs. Liu consulted the local deity (or spiritual leader) when her bleeding first began to ask for guidance. Mrs. Liu brings in her prescriptions, Coumadin and digoxin, and a vial, without a label, containing blue pills. The nurse becomes concerned when she learns that the bleeding started 5 days before admission and that Mrs. Liu did not contact her primary care physician. Mrs. Liu's daughter explains that her mother values traditional Chinese medicine over conventional healthcare in the United States. Despite that, the nurse recommends some tests to determine the cause of the bleeding. After testing, the nurse determines that Mrs. Liu's rectal bleeding was a consequence of an elevated international normalized ratio (INR). The Coumadin dose is decreased, and Mrs. Liu's rectal bleeding resolves. However, the nurse now notices that Mrs. Liu appears withdrawn, avoiding eye contact whenever the nurse enters the room. The nurse considers that Mrs. Liu might feel socially isolated, unable to fully participate in her care management, perhaps because of a language barrier or unfamiliarity with the conventional healthcare in the United States. Mrs. Liu's daughter explains that Mrs. Liu feels fearful... ELIMINATING DISPARITIES AND CREATING HEALTH EQUITY Social Determinants of Health The social determinants of health (SDOH) consist of a variety of circumstances and conditions "in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks" (Office of Disease Prevention and Health Promotion, 2022). The SDOH include specific factors, such as socioeconomic status; level of education; neighborhood and physical environment where one resides; employment, unemployment, or underemployment; presence of social support networks; and ability to access healthcare. Healthcare providers must consider the relevant SDOH for each patient and address those SDOH relevant to improving health and reducing disparities in health and healthcare. The SDOH model (Fig. 3.1) serves as a visual representation framework for the Healthy People 2030 population health indicators. These indicators show high-priority issues that affect the health and well-being of all individuals but especially those who are vulnerable, marginalized, and burdened by social factors. Examples of leading health indicators are suicide, obesity, and substance abuse. Additionally, genetics plays an important role in one's ability to maintain health, and given that genetic makeup cannot be altered, nursing efforts must focus on modifiable elements contributing to the individual determinants of health (e.g., homelessness or low literacy). The SDOH model has five key elements: Economic stability Education Social and community context Health and healthcare Neighborhood and built environment Box 3.4 shows the social factors that are included in each of the five SDOH elements. The care provided to the patient must acknowledge the influence of each SDOH element on the current health situation as well as the role of each determinant in the patient's pathway to improved health. Failing to consider the SDOH when providing care is a barrier to providing person-centered care. FIGURE 3.1 The Social Determinants of Health (SDOH) model. Box 3.4 Social Determinants of Health (SDOH) Economic Stability Employment Food insecurity Housing instability Poverty Education Early childhood education and development Enrollment in higher education High school graduation Language and literacy Social and Community Context Civic participation Discrimination Incarceration Social cohesion Health and Healthcare Access to healthcare Access to primary care Health literacy Neighborhood and Built Environment Access to foods that support healthy eating patterns Crime and violence Environmental conditions Quality of housing Based on Office of Disease Prevention and Health Promotion. (2022, February 6). Social determinants of health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health Healthy People Initiative The United States has a national initiative centered on creating health equity by focusing on health promotion, disease prevention, and quality of life. According to the Office of Disease Prevention and Health Promotion, the Healthy People initiative focuses on 10-year national objectives meant to improve the health of all Americans by utilizing science-based initiatives. In each of the 10-year goals, the focus is on addressing health for all and reducing inequities and health disparities for some social groups over another. In Healthy People 2000, the goal was to reduce health disparities for Americans. In Healthy People 2010, the goal was to eliminate health disparities. In Healthy People 2020, the goal is more specific and directed to achieve health equity, eliminate disparities, and improve the health of all groups. Healthy People 2020 also covered more vulnerable groups, including the LGBTQIA populations, as well as those with special needs and considerations. Healthy People 2030 objectives, published in 2020, include goals specifically focused on eliminating health disparities by addressing the SDOH and improving the health and well-being of all people, across the life span. When nurses develop culturally sensitive and respectful care, conscious decisions are made to minimize barriers to care, including all determinants of health conditions and factors. Although each patient presents unique needs, nurses may use the Healthy People framework and the leading health indicators to develop patient, family, and community interventions that contribute to the improved health of the nation. Considering the needs of the patient and family empowers the nurse to intervene using evidence-based strategies that are holistic in nature. African American patients reporting higher levels of stress from lifetime discrimination were found to have a greater risk of hypertension. Improving Health Literacy Nurses communicate with patients on a daily basis such as when discussing a discharge plan or conducting a patient education session. The goal is to assist the patient in knowledge acquisition that will lead toward health-promoting behaviors (e.g., taking a medication as ordered or drawing up the correct amount of medication in a syringe). Literacy is the ability to read and write; health literacy is the ability to read, understand, and use health information. A person can have a high literacy level but a low health literacy level. There are several evidence-based interventions that may be incorporated into a healthcare provider's practice to improve health literacy, thereby minimizing the potential barrier of the patient's ability to understand the plan of care. These interventions include the following: Breaking down information or instructions into small concrete steps to improve understanding Incorporating technology and Web sites with realistic pictures and clear captions to improve comprehension Integrating teach-back and plain language into instructions to improve knowledge retention Using simple language and photograph- and pictogram-based care plans to improve patients' disease management abilities Confirming comprehension by using teach-back or show-me techniques Developing print materials to be at or below the sixth-grade reading level Creating a shame-free environment where all questions are welcomed and fear is minimized As noted in Health People 2030, health literacy means the patient has the skills to use and appraise information to make informed decisions rather than simply understand information. Language and Literacy It is important to assess patients for individual language needs and for healthcare providers to adjust their communication style to meet these needs. Patients with limited ability to speak, write, or read English (individuals with limited English proficiency \[LEP\]) face additional barriers. Additional safeguards must be in place within healthcare organizations to prevent or minimize potential discrimination. Specifically, Title VI of the Civil Rights Act of 1964 states that "no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." Applicable to all facets of life in the United States, this law is also relevant to supportive services in healthcare, such as medical translators and language resources. Per the Civil Rights Act, printed materials in languages other than English must be available for patients based on the patient population being served. Patients deemed LEP must be provided with services that support their ability to access healthcare and services, communicate with healthcare providers, and receive information in a manner that facilities their understanding. These practices reflect the incorporation of cultural awareness principles in the provision of individualized care. In fact, The Joint Commission (2020) accreditation standards acknowledge the need to respect and support patients and families from diverse backgrounds. From an organizational perspective, organizations can demonstrate this in a variety of ways such as having healthcare interpreters or developing patient education materials in multiple languages and dialects. Cultural sensitivity leads to preventing inequalities in healthcare and maintains patient safety during the provision of care. Culturally and Linguistically Appropriate Services (CLAS) The Office of Minority Health (OMH) formed the Center for Linguistic and Cultural Competency in Health Care (CLCCHC) to address the unmet needs of patients seeking healthcare and to decrease barriers to healthcare literacy. The CLCCHC developed Culturally and Linguistically Appropriate Services (CLAS) as national standards for healthcare facilities to use when developing services, policies, and educational materials to mitigate health inequities and disparities related to individuals with LEP. The CLAS focus is respect and responsiveness, which translates into respecting the wholeness of each individual and responding to each individual's needs, preferences, and desires in order to provide services that reflect an individual's culture and language preferences. The goal of these services is to support healthcare professionals in facilitating positive health outcomes for diverse populations. The 15 CLAS standards are listed in Box 3.5. Connection Check 3.4 What is the most accurate description of the social determinants of health? A.  Biological, socioeconomic, psychosocial, behavioral, or social factors influencing an individual's health B.  Factors that contribute to health inequity, discrimination, and healthcare professional bias C.  National standards that are used to develop culturally competent and linguistically appropriate patient care D.  Services used within healthcare facilities to identify which patients require culturally competent care CULTURAL ASSESSMENT MODELS Models of cultural competence serve as a framework to meet the increasing heterogeneity of patient populations. These theories and models exist to assist nurses in developing culturally and linguistically appropriate healthcare that is free of behaviors, attitudes, and judgments influenced by fear, discrimination, and bias. Culturally congruent care, the outcome, requires nurses to embrace lifelong learning and cultural humility. Each model offers healthcare professionals a means to understand personal uncertainties and knowledge gaps related to patients with different experiences, needs, belief systems, cultures, and lifestyles. All of the theories and models highlight the importance of developing an authentic connection based on acceptance, understanding, and respect for human life. Box 3.5 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Healthcare Standards Principal Standard: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Governance, Leadership, and Workforce Standards: Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance Standard: Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all healthcare and services. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, Continuous Improvement, and Accountability: Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization's planning and operations. Conduct ongoing assessments of the organization's CLAS and related activities, and integrate CLAS and related measures into measurement and continuous quality improvement activities. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. Based on Office of Minority Health. Office of Minority Health. (n.d.). What is CLAS? https://thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf Transcultural Nursing Transcultural nursing acknowledges that nurses meet and care for patients who are different from themselves, and these differences may present a challenge. Learning about patients' cultural backgrounds, experiences, and desires requires nurses to enter into meaningful conversations about how patients' cultures affect their lives, thereby decreasing discrimination and bias. The recognition by the nurse of how culture influences an individual's values, beliefs, and worldviews reflects cultural awareness. This also underscores the importance of nurses acknowledging that these differences exist and respecting these differences. Transcultural Nursing Model Nursing theorist Madeline Leininger based the Transcultural Nursing (TCN) cultural assessment model on a humanistic approach that broadly supports individuals, organizations, communities, and societies and linking caring within the context of culture. In her work, Leininger blended concepts from both nursing and anthropology to explain caring as the central link between the human being (the patient) and the nurse (provider of care). The concept of caring is considered as assisting, supporting, or enabling the patient's behaviors while also helping the patient improve health and performance. A nurse who practices humanistic care seeks to understand and know the person, the human being, in order to improve health and ameliorate suffering. Culture Care Diversity and Universality Theory Leininger's Culture Care Diversity and Universality Theory explains that nurses must first know the patients they are caring for---individual patterns, beliefs, practices, and personal expressions. The nurse is then informed and able to provide care that is congruent with the belief systems of the patients. The term transcultural nursing refers to the nurse's desire to cross the divide and meet the patient where they are, as an individual in a global and diverse patient population. Culturally competent care only occurs when culture care values are known and serve as the foundation for meaningful and just care, shifting from less aware to more aware. Moreover, Leininger explains that nurses must be educated and immersed in learning about the nuances of a patient's cultural beliefs and values so that the care provided does not harm or prevent the patient from attaining the highest degree of possible health. The Culture Care Diversity and Universality Theory focuses on examining and addressing the differences and similarities of global cultural care. Sunrise Model Leininger depicts the Culture Care Diversity and Universality Theory using the Sunrise Model (Fig. 3.2), which shows the factors and conditions that influence care. The concept of a sunrise is one that is most fitting to represent the process of cultural awakening; the rising sun begins first with a dim light but soon becomes bright. In a similar way, the professional nurse may begin with little cultural knowledge but strives to become aware and to expand knowledge and practice to better develop culturally focused interventions for the most vulnerable patients. In the model, the outermost "ring" represents cultural care and the worldview, the way in which the nurse views the world. This worldview informs the nurse's knowledge about patients, families, and/or communities within the healthcare system. Nurses use their education to learn more about the next ring, which includes cultural and social dimensions that influence each patient: technological, religious/philosophical, kinship/social, cultural values and lifeways, sexual identity, political and legal, economic, and education. By addressing the language and environmental barriers, nurses create pathways that respect patients' experiences, patterns, and practices, leading each to a state of holistic health. Finally, the nurses integrate patients' folk or traditional health beliefs with the professional healthcare systems to devise care that is respectful, just, inclusive, and person-centered. ASSESSING CULTURAL COMPETENCE Characteristics of Cultural Diversity Cultural specifics affect individual health beliefs and behaviors. Knowledge of the cultural specifics of the groups in a community helps explain why patients from different cultures have different expectations of healthcare. The six cultural specifics that influence health are communication, space, time orientation, social organization, environmental control, and biological variations. Communication Communication is an exchange of information, ideas, and feelings, including verbal and nonverbal language (i.e., spoken language, gestures, eye contact, and even silences). Language differences present one of the most difficult obstacles to providing individualized, person-centered care. Even when the nurse and the patient speak the same language, culture influences how feelings and thoughts are expressed and which verbal and nonverbal expressions are appropriate to use. Assessment and Strategies Ask the following questions: By what name do you prefer to be called? What is your preferred language, spoken and written? What is your preferred pronoun? Do you want a family member with you at this time? Incorporate the following actions: Be an active listener, and become comfortable with silence. Avoid appearing rushed. Be formal with greetings until told to do otherwise. Take greeting cues from the patient. Speak slowly and clearly. Do not speak loudly or with exaggerated mouthing. Explain why you are asking specific questions. Give reasons for treatments, interventions, and/or instructions. Repeat questions as needed. Provide written instructions in the patient's preferred language. Obtain a professional interpreter if needed. FIGURE 3.2 Leininger's Culture Care Diversity and Universality Theory---the Sunrise Enabler Model. Nurses should refrain from relying on untrained individuals to interpret, especially family members. Although it may seem logical that a patient's best advocate is a family member, it is risky to rely on family members to interpret medical or health information for the following reasons: Family members may not be proficient in medical terminology. They may not possess the skills needed to interpret. They may unintentionally or intentionally omit or alter important information. Using family members to interpret may raise privacy issues protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If children are used as translators, they may not be emotionally mature enough to handle the information being conveyed. Space Space refers to a person's personal space, or the boundaries that determine how close one person can be to another person. A person's comfort level is related to space. When you invade another's personal space, a common reaction is for the person to move away from you. A similar concept is territoriality, which is related to the geographical space a person views as owned or claimed, such as an area or room. When an individual's personal space is protected, there are feelings of safety, security, control, and reduced anxiety. Within all cultural groups, personal space varies depending on the relationship between the people speaking: intimates versus acquaintances, people of the same versus opposite sex, and people of a different position within the social hierarchy. Assessment and Strategies Ask the following questions: Are you comfortable? Am I sitting or standing too close to you? Do you have any concerns you would like to discuss? Would you like a family member with you? Incorporate the following actions: Ensure patients are comfortable before interviewing them. Maintain appropriate physical distances while also observing for cues. Be aware of cultural differences. Be aware of physical objects that may be a barrier to comfort. Make sure that the patient's physical environment is arranged to ensure safety, security, confidentiality, and familiarity. Time Orientation Time orientation varies among people of different cultures, and the perception of time has two dimensions. The first dimension is related to clock time versus social time. For example, some cultures have a flexible orientation to time and events, and appointments take place when the person arrives. For others, time is less flexible, and appointments and social events are expected to start at the agreed-on time. For many, social events may be flexible, whereas medical appointments and business engagements start on time. The second dimension of time relates to whether the culture is predominantly concerned with the past, present, or future. Past-oriented individuals maintain traditions that were meaningful in the past and may worship ancestors. Present-oriented people accept the day as it comes, with little regard for the past; the future is unpredictable. Future-oriented people anticipate a bigger and better future and place a high value on change. Some people balance all three views---they respect the past, enjoy living in the present, and plan for the future. Differences in time orientation are important considerations when planning nursing interventions. It is important to understand patients' time orientation to best prepare them for the timing of appointments, tests, and treatments. In addition, an assessment of the patient's usual routines is necessary in order to incorporate these as much as possible into the daily care. Assessment and Strategies Ask the following questions to understand patients' time orientation: How important is it for you to be on time for an appointment? What daily routines are important to you to follow? How stressful is it for you to wait for a meeting or an appointment? How do you manage time-dependent activities? What time do you usually eat your meals? Take your bath or shower? Incorporate the following actions: Suggest using a cell phone to send an appointment reminder. Assess for orientation and reorient to time as needed. Assess if time is viewed as being more fluid as compared with fixed. Prepare patients before a procedure or test. Give time options when appropriate (e.g., "Would you like to take a walk now or in an hour?"). Social Organization Social organization includes the family unit (e.g., nuclear, single parent, extended, or LGBTQIA family) and the wider organizations (e.g., community, military, religious, ethnic, or online) with which the individual or family identifies. Families may be traditional, consisting of a man, a woman, and one or more of their biological or adopted children, or alternative, referring to those cohabitating, or same-sex families, or those practicing polygamy. Family organization includes the perceived head of the household, gender roles, and roles of the senior and extended family members. The household may be patriarchal (dominated by men), matriarchal (dominated by women), or egalitarian (shared equally among several members to include those external to the family; spiritual leader). An awareness of the family dominance pattern is important for determining which family member to speak to when healthcare decisions are made. Confidentiality issues can complicate this issue. Be sure to follow the institution's policies when communicating with family members. The patient's permission may be needed before planning care with family members. In some cultures, specific roles are outlined for men and women. Men may be expected to protect and provide for the family, manage finances, and deal with the outside world. Women may be expected to maintain the home environment, including childcare and household tasks. Not all societies share or even desire an egalitarian family structure. Avoidance of stereotyping is critical to ensure that the nurse's personal value system does not influence their judgment. Roles for older adults and extended family vary among culturally diverse groups, as well as in blended families (two or more adult partners and their children, together with their children from previous relationships living together). In some cultures, adults are seen as being wise, are deferred to for making decisions, and are held in high esteem. Children are expected to provide for older family members when they are no longer able to care for themselves. In other cultures, older people may be loved by family members, but may be cared for outside the home when self-care or assistance with daily activities becomes a concern. The extended family is very important in some groups, and a single household may include several generations living together out of desire rather than out of necessity. The extended family may include both blood-related and non--blood-related persons who are given family status. In other families, each generation lives in a separate home or living space. Assessment and Strategies Ask the following questions: Who do consider as your family? How are decisions made in your household? How are money matters, cooking, and childcare managed? Who decides when it is time to visit a healthcare provider? Who lives in your household? Incorporate the following actions: Assess which family member speaks and which member remains silent. Observe the use of touch between family members. Let family members decide where they want to stand or sit for comfort. Include elder or other family members in the discussions. Environmental Control Environmental control consists of three major concepts: people's perception of the ability to control what happens to them and their health, beliefs about health and illness, and beliefs in alternative healthcare therapies such as folk medicine. For example, if individuals do not believe they have control of their health, they may not be receptive to nursing interventions that require self-confidence, such as self-administration of insulin. Regarding health beliefs, if individuals believe that illness is due to a spiritual cause and not bacteria or believe in folk healing practices, they may not understand the need to take antibiotics. Nurses need to consider their patients' cultural values and beliefs, especially when they differ from those of the conventional healthcare system in the United States. Distinctions are made between health and illness and what people do to promote or maintain health and to prevent and treat illnesses. Not all patients use a conventional healthcare provider in the United States. People may try some form of alternative therapy before seeking treatment or even during conventional healthcare in the United States (e.g., Ayurveda or the traditional American Indian remedies). People also use alternative therapies and religious systems, such as prayer, in combination with the scientific medical system. Assessment and Strategies Ask the following questions: How do you define health? Illness? What special beliefs do you hold concerning health and illness? What do you do to keep healthy? When you feel ill, what is the first thing you do to get better? How do you and your family express grief? Are there any cultural beliefs or practices that I need to know about to plan your care? Where do you seek healthcare services? Incorporate the following actions: Be aware of possible cultural beliefs and practices. Never stereotype based on what you know about different cultures; always ask for specific information. Perform a cultural assessment on all of your patients. Ask if patients have received treatments of any kind for their illness. Ask about religious beliefs and practices. Encourage helpful practices. Acknowledge choice to practice alternative forms of treatment or remedies. Biological Variations Biological variations include ways in which people are different genetically and physiologically, including body variations and medication metabolism. Biological variations create susceptibility to certain diseases and injuries and explain differences in response to treatment. Consequently, clinical trials (medication studies) now recommend incorporating biological variations. Biological variations also refer to differences in nutritional practices, including the personal meaning of food, food choices and rituals, prohibited foods, and how food and food substances are used for health promotion and wellness. Cultural beliefs influence what people eat or avoid. In addition to being important for survival, food offers security and acceptance, plays a significant role in socialization, and can serve as an expression of love. Culturally congruent dietary counseling, such as adapting preparation practices and including particular food choices, can reduce health risks and add to a sense of well-being. Whenever possible, determine a patient's current dietary practices as food choice is influenced by sociocultural traditions (e.g., Kosher or vegan diets). Counseling about food group requirements or dietary restrictions must respect an individual's cultural background. For many, a balance of different types of foods is important for maintaining health, preventing illness, and respecting religious beliefs and national heritage. For example, some Hindu castes follow a strictly vegetarian diet and organize food consumption around their traditional beliefs. Assessment and Strategies Ask the following questions: What food practices are important to your social identity? What is your ideal weight? How are home-cooked meals prepared? How important are social eating events? For example, Hari Raya Puasa (a religious festival celebration at the end of the fasting month Ramadan) or Chinese New Year (a nonreligious cultural celebration) Do you have any medication or food allergies? What genetic conditions do one or more family members have, if any? Are there certain foods you do not eat? Why? What is a typical morning, midday, and evening meal for you? Incorporate the following actions: Teach about biological variations that may pertain to the patient. Determine and respect usual eating patterns whenever possible. Teach the basics of a balance nutritional intake, taking into account patient preferences. Refer to a dietitian if appropriate. Connection Check 3.5 Which action by the nurse reflects the use of a cultural competency model to assess knowledge, beliefs, and attitudes? A.  Acknowledging that education level plays a role in the ability to buy a home B.  Believing that patients bring on their own illness by making poor choices C.  Considering how similar spiritual beliefs are to those of another nurse D.  Thinking about how one American Indian tribe member looks like another Making Connections CASE STUDY: WRAP-UP The nurse requests an interprofessional team meeting to discuss and develop a discharge plan addressing Mrs. Liu's care needs. A medical interpreter is assigned to Mrs. Liu and will follow her as both an inpatient and outpatient. This consistency is important to establish trust and to give the interpreter the opportunity to assess Mrs. Liu's health literacy needs. Social workers will work with Mrs. Liu to identify a Taiwanese community center, helping her to build a social group of friends and peers. The nurse working in the Coumadin Clinic will contact Mrs. Liu, with the assistance of the interpreter, to perform medication reconciliation and symptom management and will also determine if Mrs. Liu has visited the Chinese medicine practitioner. If Mrs. Liu has visited the Chinese medicine practitioner, the nurses plan to gently probe her to determine if she began any new complementary therapies. All communications, assessments, and interventions will be documented in the electronic medical record, allowing the primary care physician and cardiologist to access critical patient information during Mrs. Liu's medical visits. Case Study Questions 1\. Mrs. Liu is challenged by a low level of health literacy; what interventions might the nurse suggest to the interprofessional care team? A. Ask if she wants to continue to see the Chinese medicine practitioner. B. Locate a family member who can translate all healthcare documents for her. C. Secure relevant patient teaching materials written in her native language. D. Talk only to her daughter and son-in-law to expedite all communications. 2\. The nurse verbalizes annoyance and fear when learning about the visit to the Chinese medicine practitioner. This attitude best reflects which characteristic? A. Bigotry B. Discrimination C. Hatred D. Xenophobia 3\. What resources might the nurse secure to improve the nurse's knowledge of the cultural beliefs and values of Taiwanese patients? A. Calling the nurse manager to discuss the situation B. Consulting with the care coordination manager to discuss CLAS standards C. Discussing the patients with other staff nurses during hourly rounds D. Managing all communications quickly through the patient's daughter 4\. How might feelings of social isolation influence Mrs. Liu's ability to adapt to her new living environment? A. Attributing loneliness to food items she has never eaten B. Developing new hobbies and interests to fill up her day C. Fearing engagement with conventional healthcare providers in the United States D. Making long-term plans with her daughter and son-in-law 5\. Which strategy reflects a nurse's ability to apply communication to culturally specific influences in an encounter with Mrs. Liu? A. Actively listening following a question placed to Mrs. Liu B. Increasing the tone of voice after Mrs. Liu appears confused C. Nodding to Mrs. Liu when she is speaking D. Quickly calling in the interpreter, then walking out of the room CHAPTER SUMMARY Nurses care for patients who are diverse, different, and complex, and this is the reality of the world. It is of utmost importance that nurses are aware that differences exist while remaining open to assessing all factors contributing to each patient's ability to strive for the highest level of health. All this must be done without displaying judgment, displeasure, stereotyping, or bias. Becoming a culturally competent healthcare provider, possessing cultural humility, sensitivity, and awareness, means demonstrating care, compassion, and tolerance to all human beings regardless of their lifestyle choices. This process requires the nurse to acknowledge differences and similarities among patients, groups, and populations. Moreover, guided by the ANA's Nursing: Scope and Standards of Practice, the nurse will advocate for all patients and populations; embrace diversity, equity, and inclusion; and respect patient and family preferences. Guided by focused assessments, the nurse will develop care and services that acknowledge the social determinants of health affecting the patient. Understanding key terminology and concepts helps to minimize barriers that prevent the nurse from providing care that is free of bias, judgment, stereotypes, hatred, and bigotry in order to work with other members of the healthcare team to facilitate the provision of individualized and person-centered care. Taking time to learn which social determinants of health may place a patient at greater risk of poor health is important as social factors contribute to poor health outcomes and health inequity. Customizing the patient's care plan and employing culturally sensitive communication techniques minimize provider bias and the potential for discriminatory practices. There are several cultural competence models to assist nurses in assessing their knowledge, skills, and abilities so that they may appropriately guide their actions, ensuring culturally competent and appropriate healthcare. Nurses may apply the Culture Care Diversity and Universality Theory and Sunrise Enabler Model of Leininger to help them assess their knowledge, skills, and attitudes toward becoming culturally competent professionals and to enhance care delivery for diverse populations. Additionally, consideration of the six cultural specifics that influence health ensures the nurse's actions are focused on minimizing health disparities and maximizing care based on the unique needs of each patient.