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Decent Work Employment and Transcultural Nursing (NCM 120) When nurses communicate with others from cultural and TOPIC 1 OVERVIEW OF TRANSCULTURAL NURSING linguistic backgrounds differentfrom their own, the probability of...

Decent Work Employment and Transcultural Nursing (NCM 120) When nurses communicate with others from cultural and TOPIC 1 OVERVIEW OF TRANSCULTURAL NURSING linguistic backgrounds differentfrom their own, the probability of miscommunication increases significantly. A. Definition, Nature and History of Transcultural Nursing In promoting effective cross-cultural communication with clients Transcultural nursing a humanistic and scientific area of nursing from diverse backgrounds, nurses should avoid technical jargon, study and practice that focuses on how patterns of behavior in slang, colloquial expressions, abbreviations, and excessive use of health, illness, and caring are influenced by the values and beliefs of medical terminology specific cultural groups. I t applies this knowledge in the planning and provision of culturally appropriate care. Important Aspects of Communication 1. Language TRANSCULTURAL NURSING (NATURE) 2. Interpreters Leininger used the term transcultural nursing (TCN) to 3. Greetings describe the blending of nursing and anthropology into an area of 4. Silence specialization within the discipline of nursing. 5. Eye Contact and Facial Expressions Using the concepts of culture and care, Leininger 6. Gestures established TCN as a theory and evidence-based formal area of 7. Posture study and practice within nursing that focuses on people’s culturally 8. Chronemics based beliefs, attitudes, values, behaviors, and practices related to 9. Modesty health, illness, healing, and human caring (Leininger, 1991, 1995; 10. Technology assisted Communication Leininger & McFarland, 2002, 2006) 11.Literature, Arts, Music, and Dance Short History of TCN D. Key Concepts and Principles in TCN ▪ The foundations of transcultural nursing were laid in the 1. HUMAN CARE AS ESSENCE IN NURSING mid-1950s. Peplau first mentioned in 1950 that the Human Caring is part of the human condition and a way of Being cultures were an important variable affecting mental Human. Caring is found throughout time. Moreover, the notion of health. ‘caring’ in nursing has been a given throughout its history. ▪ In 1962, King stated that psychopathological behaviors differ from culture to culture. 2. CULTURE AND NURSING ▪ In 1969, the International Council of Nursing (ICN) began Culture using cultural content in nursing. is defined as the totality of socially transmitted behavioral patterns, ▪ The Transcultural Nursing Society (TCNS) was established arts, beliefs, values, customs, lifeways, and all other products of in 1974 to train nurses in this area. human work and thought characteristics of a population of people ▪ Madeleine Leininger(July 13, 1925 – August 10, 2012) was that guide their worldview and decision making an internationally known educator, author, theorist, administrator, researcher, consultant, public speaker, and IMPORTANT TERMS RELATED TO CULTURE the developer of the concept of transcultural nursing that Attitude is a state of mind or feeling about some aspect of a culture. has a great impact on how to deal with patients of Attitudes are learned; for example, some people think that one different culture and cultural background. culture is better than another. B. Importance of Transcultural Nursing A Belief is something that is accepted as true, especially as a tenet 1. A marked increase in the migration of people within and between or a body of tenets accepted by people in an ethnocultural group. countries worldwide. 2. A rise in multicultural identities, with people expecting their Ideology consists of the thoughts and beliefs that reflect the social cultural beliefs, values, and ways of life to be understood and needs and aspirations of an individual or an ethnocultural group. respected by nurses and other health care providers. 3. An increase in health care providers’ and patients’ use of Cultural knowledge is all we know that characterize a particular technologies that connect people globally and simultaneously may culture. It can include descriptions such as those known as cultural become the source of conflict with the cultural values, beliefs, and dimensions and can also include other information that may explain practices of some of the people receiving care. why people conduct themselves in a particular way. 4. Global cultural conflicts, clashes, and violence that impact health care as more cultures interact with one another. Cultural awareness has to do with an appreciation of the external 5. An increase in the number of people traveling and working in signs of diversity, such as the arts, music, dress, foods, and physical different parts of the world. characteristics. 6. An increase in legal actions resulting from cultural conflict, negligence, ignorance, and the imposition of health care practices. Cultural sensitivity has to do with personal attitudes and not saying 7. A rise in awareness of gender issues, with growing demands on things that might be offensive to someone from a cultural or ethnic health care systems to meet the gender- and age-specific needs of background different from that of the health-care provider’s cultural men, women, and children. or ethnic background. 8. An increased demand for community- and culturally based health care services in diverse environmental contexts (Leininger, 1995) Generalization—reducing numerous characteristics of an individual or group of people to a general form that renders them C. Communication as Major Factor in TCN Practice indistinguishable—made about the behaviors of any individual or Effective communication begins with an assessment of the large group of people is almost certain to be an oversimplification. client’s ability to read, write,speak, and comprehend messages. Effective communication in contemporary society sometimes In sociology, anthropology, and cultural studies, a subculture is requires literacy in the use of computers, smartphones, and defined as a group of people with a culture that differentiates them numerous technology-assisted medical or health devices. from the larger culture of which they are a part. Effective communication includes the ability to convey sincere interest in others, patience, and willingness to intervene or begin Countercultures, on the other hand, are cultures with values and again when misunderstandings occur. mores that run counter to those of established society and whose To provide safe, quality, affordable, accessible, efficacious, norms and values may be incompatible with prevailing cultural culturally congruent, and culturally competent nursing and health norms. care, members of the interprofessional health care team must communicate effectively. Cultural humility, another term found in cultural literature, focuses Communication occurs verbally, nonverbally, in writing, and in on the process of intercultural exchange, paying explicit attention to combination with technology. clarifying the professional’s values and beliefs through self-reflection Communication should be appropriate for the client’s age, and incorporating the cultural characteristics of the health-care gender, health status, health literacy, and related factors. professional and the patient into a mutually beneficial and balanced c. Acculturation is closely related to enculturation but has some relationship (Trevalon and MurrayGarcia 1998) differences. Acculturation refers to the process by which an individual or group from Culture A learns how to take on many (but Cultural safety is a popular term in Australia, New Zealand, and not all) values, behaviors, norms, and lifeways of Culture B. Canada, although it is used elsewhere. Cultural safety expresses the d. Socialization differs slightly from the above concepts. It refers to diversity that exists within cultural groups and includes the social the social process whereby an individual or group from a particular determinants of health, religion, and gender, in addition to ethnicity culture learns how to function within the larger society (or country), (Guidelines for Cultural Safety 2005). that is to know how to interact appropriately with others and how to survive, work, and live in relative harmony within a society. Cultural leverage is a process whereby the principles of cultural e. Assimilation refers to the way an individual or group from one competence are deliberately invoked to develop interventions. culture very selectively and usually intentionally selects certain features of another culture without necessarily taking on many or all Acculturation occurs when a person gives up the traits of his or her attributes of lifeways that would declare one to be acculturated. culture of origin as a result of contact with another culture. Assimilation is the gradual adoption and incorporation of TOPIC 2 Foundation for Culturally Competent Care characteristics of the prevailing culture (Portes, 2007). Enculturation is a natural conscious and unconscious conditioning Cultures and Tribes of Nursing, Hospitals, and the Medical Culture process of learning accepted cultural norms, values, and roles in (M. Leininger) (CHECK PPT PAGE 3) society and achieving competence in one’s culture through socialization. Cultures and Tribes of Nursing, Hospitals, and the Medical Culture Cultural competence in nursing implies the ability of health care (M. Leininger) workers to give the best medical care to patients while Definition of Culture and Subculture of Nursing demonstrating cultural awareness for their beliefs, race, and values. Culture of nursing refers to the learned and transmitted lifeways, It entails having knowledge of patients’ cultural diversity and values, symbols, patterns, and normative practices of members of treating them with this in mind. the nursing profession of a particular society. 3. CULTURAL DIVERSITY, UNIVERSALITY, RACISM, AND RELATED In contrast, a subculture of nursing refers to a subgroup of nurses CONCEPTS who show distinctive values and lifeways that differ from the Cultural Diversity is the existence of a variety of cultural groups dominant or mainstream culture of nursing. within a society. An ideal culture refers to attributes that are the most desired and VARIANT CHARACTERISTICS OF CULTURE: preferred or the wished for values and norms of a group, whereas Nationality manifest culture refers to what actually exists and is identifiable in Race the day-to-day world such as patterns, values, lifestyle patterns, and Color expressions. Age Religious affiliation CULTURALLY COMPETENT HEALTH CARE Educational status Cultural competence in health care is having the knowledge, Socioeconomic status abilities, and skills to deliver care more congruent with the patient’s Occupation cultural beliefs and practices. Increasing one’s consciousness of Military experience cultural diversity improves the possibilities for health-care practitioners to provide culturally competent care. Political beliefs Urban versus rural residence Cultures and Tribes of Nursing, Hospitals, and the Medical Culture Enclave identity (M. Leininger) Marital status Historical Images of Nursing from the Kalischs’ Research Parental status Sexual orientation ✓ The first image identified by the Kalischs is the Angel of Sex and Gender Nursing, in which the nurse is portrayed as “noble, moral, Physical characteristics religious, virginal, ritualistic, and self- sacrificing.” This image Immigration status (sojourner, immigrant, or undocumented prevailed from 1914 to 1919 and concluded with World War I status when nurses were viewed as heroic and noble. Length of time away from the country of origin ✓ The Kalischs’ second image, called Girl Friday, prevailed as an image from 1920 to 1929. The nurse was portrayed as CULTURAL UNIVERSALITY “subservient, cooperative, methodological, dedicated, modest, Defined as being anything common that exists in every human and loyal.” culture on the planet yet varies from different culture to culture, Thisimageshowedthenurseasahandmaidenandrevealedsomedecl such as values and modes of behavior. Examples of elements that ineinnursingeducationalstandards resulting from the may be considered cultural universals are gender roles, the incest proliferation of hospitals with nursing students being exploited taboo, religious and healing ritual, mythology, marriage, to staff hospitals under poor working conditions and receiving no language, art, dance, music, cooking, games, jokes, sports, birth and salary. death because they involve some sort of ritual ceremonies ✓ The third media image was called The Heroine, which covered accompanying them, etc. 1930 to 1945. This image portrayed the nurse as “brave, rational, dedicated, decisive, humanistic, and autonomous. RACISM ✓ The fourth image portrayed the nurse as a maternal, Prejudice, discrimination, or antagonism directed against a person sympathetic, passive, and domestic person, called the Mother or people on the basis of their membership in a particular racial or Image, from 1945 to 1965. In this period it was believed that ethnic group, typically one that is a minority or marginalized. married women nurses should be in the home and function as dutiful and conscientious lay mothers rather than as professional 4. FIVE BASIC INTERACTIONAL PHENOMENA working people. a. Culture encounter or contact refers to a situation in which a ✓ The fifth image was the most negative, in which the nurse was person from one culture meets or briefly interacts with a person from viewed as a Sex Object, who was “a sensual romantic, another culture. hedonistic, frivolous, irresponsible, promiscuous individual.” b. Enculturation is a very important phenomenon to understand in ✓ The Kalischs’ sixth image was The Careerist (after 1965 to mid transcultural nursing. It refers to the process by which one learns to 1980s), which they described as “an intelligent, logical, take on or live by a particular culture with its specific values, beliefs, progressive, sophisticated, empathic, and assertive woman who and practices. is committed to attaining higher and higher standards of health care.” RATIONALE FOR CULTURALLY COMPETENT HEALTH CARE Diversity in the workplace carries a host of benefits for healthcare Vulnerable populations employers, their staff, and their patients. Those benefits include: Immigration and migration Stronger Individual Motivation. Nurses respond to global health care needs Better Problem Solving Nurses also respond to natural and human-made disasters Better Results around the world and provide care for refugees Final note on the benefits of healthcare diversity Interprofessional collaborative practice What are the Risks of Lacking Healthcare Diversity? In all of these situations, nurses are expected to demonstrate Communication Breakdown effective cross-cultural communication and deliver culturally Limited Perspectives congruent and culturally competent nursing care to people from Lack of Role Models diverse countries and cultures. Lack of Future Diversity Bias DEFINITIONS AND CATEGORIES OF CULTURAL COMPETENCE Individual Cultural Competence C. CULTURAL INFLUENCES AFFECTING NURSING CARE Refers to the care provided for an individual client by one or more Culture affects health in many ways, such as: nurses, physicians, social workers, and/or other health care, Acceptance of a diagnosis, education, or social services professionals. Acceptance of preventive or health promotion measures Perception of the amount of control individuals have in Organizational Cultural Competence preventing and controlling disease. Focuses on the collective competencies of the members of an Perceptions of death, dying organization and their effectiveness in meeting the diverse needs of Use of direct versus indirect communication their clients, patients, staff, and community. Willingness to discuss symptoms with a health care provider Influence of family dynamics INDIVIDUAL CULTURAL COMPETENCE Perceptions of youth and aging. Accessibility of the health system BASIC PRINCIPLES OF CULTURAL ASSESSMENTS 1. All cultures must be viewed in the context in which they have developed. 2. The meaning and purpose of the behavior must be interpreted within the context of the specific culture. 3. There is such a phenomenon as intracultural variation. Not every member of a cultural group displays all the behaviors that are associated with that group. ETHICAL CONSIDERATIONS IN TRANSCULTURAL NURSING Ethical Diversity B. CULTURAL DIVERSITY IN HEALTH CARE Ethical relativism holds that morality is relative to the norms of a Cultural diversity refers to the variations and differences among and particular culture; hence, there are no universal truths in ethics. It between cultural groups resulting from differences in lifeways, emphasizes the need to examine the context of the decision language, values, norms, and other cultural aspects. because sociocultural differences influence whether an act is Cultural universals refer to the commonalities among human beings moral. or humanity that reveal the similarities or dominant features of humans. Universality THEORY DESCRIPTION Biomedical ethics exemplifies a number of ethical Universality refers to the nature of a being or an object that is held principles: beneficence, nonmaleficence, as common or universally found in the world as part of humanity. autonomy, veracity, confidentiality, justice, and fidelity (Edge & Groves, 1994; Beauchamp & What is Diversity in Healthcare? Childress, 2001; Veatch, 1977). “Ethical principles Diversity in any workplace means having a workforce comprised of are basic moral truths that guide deliberation and multiple races, ages, genders, ethnicities, and orientations. In other action” in medicine and nursing and are grounded words, it refers to when the medical and administrative staff of a in ethical theories (Burkhardt & Nathaniel, 2008, healthcare facility represents a wide range of experiences and p. 53). background. In modern society, healthcare diversity can refer to a number of qualities, including but not limited to the following Biomedical Beneficence is to do good and requires nurses to characteristics: Ethics act in ways that benefit or are good for patients. Race Nurses are obligated to act beneficently—what is Ethnicity morally and legally demanded by nursing’s Gender professional role (Burkhardt & Nathaniel, 2008). Political beliefs Nonmaleficence is a principle that requires nurses Education to act in such a way that no deliberate harm, risk Physical abilities and disabilities of harm, and harm that relates to doing no harm Age in the wake of doing good. The first principle of Sexual orientation the Hippocratic oath of medicine is to do no harm Religion (Burkhardt & Nathaniel, 2008, pp. 60–62). Socioeconomic background Language Culture CULTURAL DIVERSITY IN HEALTH CARE Diversity in the workplace carries a host of benefits for healthcare employers, their staff, and their patients. Those benefits include: Higher Employee Morale Better Care for Diverse Populations Higher Employee Retention Better Recruitment  THEORY DESCRIPTION Autonomy means to facilitate the freedom for Transcultural Nursing and Health Care Principles self-governance or self-organization in patients 1. The principle of moral justice. with the assistance of family members or 2. The principle of cultural respect and human rights. significant others. Often there is a critique of the 3. The principle of benefits of the common good. principle of autonomy or self-governance in 4. The principle to serve and protect others from destructive acts. cultures, such as in Native American culture, 5. The principle of frequent ethical and moral assessments. where decisions are more communally based (Smith-Morris, 2007). Allowing choice, working TOPIC 2 2.2 Cultural Diversity in the Health Care Workforce with the patient, family, and community to A. DIVERSITY IN THE NURSING WORKFORCE cocreate what is needed for health and well-being Workplace diversity refers to differences between individuals in is a primary nursing role. Nurses are to be the work setting in any attribute that may evoke the perception advocates of the patient through knowledgeable that another person is different from oneself (Dijk & van Engan, caring, which means that within the principle of 2013; Guillaume, Dawson, Woods, Sacramento, & West, 2013). autonomy, there should be no coercion, paternalism, thoughtlessness, and deception. Advantages Veracity is an ethical principle that relates to It contributes to the organization’s collective decision making telling the truth. “Truthfulness is widely accepted It enhances the organization’s ability to evaluate the intended and as a universal human virtue....[t]ruth-telling unintended consequences of decisions engenders trust” (Burkhardt & Nathaniel, 2008, p. It enhances rational decision making and organizational efficiency 65). In terms of relational caring, trust is one of and effectiveness (Ewoh, 2013; Singh, Winkel, & Selvarajan, Biomedical the most important ways of being (Hilsenbeck, 2013). Ethics 2006; Ray, Turkel, & Marino, 2002). Value for patient care and health care Justice is “the ethical principle that relates to fair, Better patient outcomes equitable, and appropriate treatment in light of Increases quality of care what is due or owed to persons, recognizing that giving to some will deny receipt to others who B. QUALITY OF CARE THROUGH CULTURAL AND LINGUISTIC might otherwise have received these things” COMPETENCIES (Burkhardt & Nathaniel, 2008, p. 73). Justice issues Linguistic Competence:Providing readily available, culturally relate to the distribution of the greatest good to appropriate oral and written language services to limited English the greatest number. In health care and public proficiency (LEP) members through such means as health care in particular, the principle focuses on bilingual/bicultural staff, trained medical interpreters, and distribution of goods, money, and services qualified translators. (distributive justice). Cultural Competence:A set of congruent behaviors, attitudes, and Fidelity is an ethical principle that relates to policies that come together in a system or agency or among faithfulness and keeping promises. In nursing, the professionals that enables effective interactions in a cross-cultural principle of fidelity means loyalty to the patient framework. within the nurse-patient relationship (Burkhardt & Cultural and Linguistic Competence:The ability of health care Nathaniel, 2008). Nurses make promises to their providers and health care organizations to understand and patients by means of the social contract of a respond effectively to the cultural and linguistic needs brought by nursing license or certificate of competence and as the patient to the health care encounter. they care for the patients. Nurses must do everything in their power to be a patient advocate QUALITY OF CARE THROUGH CULTURAL AND LINGUISTIC Transcultural ethics is very complex and dynamic. COMPETENCIES The immediate purpose of transcultural ethics is to “hear the other” and “learn from the other” with mutual respect. This validates the idea that all people are cultural beings and have diverse values, beliefs, and attitudes. As cultural beings Transcultural relate, transcultural ethics offers a framework Ethics within which to interact. The conscience in which this ethics illuminates strives to mitigate disrespect or elements of misconduct and to propagate the good, purpose, truth, and beauty within the interactions of all people and in nursing, nurses and patients, families or community groups. The Importance of Transcultural Ethical, Moral, and Legal Care Knowledge ✓ Cultures have ethical guides that enable them to respond to many situations as a “given” or natural way with strangers and nonstrangers. STANDARDS OF PRACTICE FOR CULTURALLY COMPETENT NURSING ✓ Most ethical values are generally derived from one’s worldview, CARE religious beliefs, kinship norms, and reinforced cultural values in STANDARDS daily living. Professional nurses shall promote social justice for ✓ Cultural disparities and variabilities exist and need to be assessed all. The applied principles of social justice guide and understood from cultural and transcultural viewpoints. The decisions of nurses related to the patient, family, term “disparities” has recently come into vogue, but adds little to 1. Social Justice community, and other health-care professionals. common and universal differences in almost everything. Nurses will develop leadership skills to advocate for socially just policies. Contextual Spheres of Ethical Culture Care and Conflict Areas Nurses shall engage in critical reflection of their Most nurses deal with at least three major sets of ethical spheres of own values, beliefs, and cultural heritage in order rights. 2. Critical to have an awareness of how these qualities and 1. Personal (emic) cultural ethical values. Reflection issues can impact culturally congruent nursing 2. Professional (etic) cultural values. care. 3. Institutional or community. Nurses shall gain an understanding of the 4. societal or dominant cultural values. 3. Knowledge of perspectives, traditions, values, practices, and 5. Global human culture. Cultures family systems of culturally diverse individuals, families, communities, and populations for whom  they care, as well as knowledge of the complex variables that affect the achievement of health and well-being. 4. Culturally Nurses shall use cross-cultural knowledge and Competent culturally sensitive skills in implementing culturally Practice congruent nursing care. 5. Cultural Healthcare organizations should provide the Competence in structure and resources necessary to evaluate and Healthcare meet the cultural and language needs of their Systems and diverse patients. Organizations Nurses shall recognize the effect of healthcare policies, delivery systems, and resources on their patient populations, and shall empower and 6. Advocacy and advocate for their patients as indicated. Nurses Empowerment shall advocate for the inclusion of their patients’ cultural beliefs and practices in all dimensions of their health care when possible. Nurses shall actively engage in the effort to ensure a multicultural workforce in health-care settings. 7. Multicultural One measure to achieve a multicultural workforce Workforce is through strengthening of recruitment and retention effort in the hospital and academic setting. Nurses shall be educationally prepared to promote and provide culturally congruent health care. 8. Education and Knowledge and skills necessary for ensuring that Training in nursing care is culturally congruent shall be Culturally included in global health-care agendas that Competent Care mandate formal education and clinical training, as well as required ongoing, continuing education for all practicing nurses. Nurses shall use culturally competent verbal and 9. Cross-Cultural nonverbal communication skills to identify Communication patient’s values, beliefs, practices, perceptions, and unique health-care needs. Nurses shall have the ability to influence 10. Cross-Cultural individuals, groups, and systems to achieve Leadership positive outcomes of culturally competent care for diverse populations. Nurses shall have the knowledge and skills to work with public and private organizations, professional 11. Policy associations, and communities to establish policies Development and standards for comprehensive implementation and evaluation of culturally competent care. Nurses shall base their practice on interventions that have been systematically tested and shown to be the most effective for the culturally diverse 12. Evidence- populations that they serve. In areas where there Based Practice and is a lack of evidence of efficacy, nurse researchers Research shall investigate and test interventions that may be the most effective in reducing the disparities in health outcomes.