Keywords

Cultural competency; Transcultural nursing; Health disparity; Care outcome

Introduction

Cultural competency remains one of the hot topics in health care today. In the United States, many people face greater obstacles to good health based on particular cultural bias. “A patient presenting with one or more of the following factors: racial or ethnic background, religion, age, sexual orientation, socioeconomic status, gender identity or other characteristics historically linked to discrimination or exclusion is more likely to become victims of health disparity”. Terms such as ‘cultural competence’ and ‘transcultural care’ have easily taken their place in the lexicon of health care. Madeleine Leininger, the founder of the specialty known as transcultural nursing, writes that culture usually comprises learned and transferred knowledge about lifestyle practices, rules of behaviour, values, and beliefs that control designated bodies in their thinking and actions in patterned ways. It would be fair to say culture develops over time as a result of exposure to social, religious and environmental influence. Each person, including healthcare workers, is culturally unique with a learned set of values and beliefs that need fostering.

Culturally Congruent Care

In the health care delivery system, as in day to day living, healthcare providers interact with people of similar as well as diverse cultural backgrounds. People may have a different set of criteria and various preferences regarding their health and health care needs, depending on their cultures. The meaning of illness and treatment are rooted deeply in particular cultural beliefs and values. Therefore, health care professionals must possess the requisite knowledge and skill to provide care to patients from different cultures. Health care should be culturally congruent. To attain this, the medical community may need to reconsider the moral significance of individual standard values, in particular, the status of patient autonomy and patient care outcome.

Leininger and Mcfarland define transcultural nursing as a comparative study of cultures to understand their similarities and the differences among them [1]. The objective of transcultural nursing is to deliver culturally congruent care or care that fits a person's lifestyle, values, and system of meaning. Behaviors and their meanings are generated by individuals themselves rather than from predetermined criteria. Acknowledging, respecting, and adapting to the cultural needs of patients, families, and communities are critical components of healthcare. Effective nursing care integrates the beliefs and cultural values of people, families, and communities with the views of a multidisciplinary team of health care providers. When you provide culturally congruent care, you bridge cultural gaps to provide essential and supportive care for all patients. Consider the following cases.

Cultural Encounters-Case Scenario

A pregnant Indonesian woman in labor waits to be examined by one of the physicians. When a male resident arrives, she and her husband demand a female doctor and send the resident away. Fortunately, there was a female resident available. She was able to perform the examination but became frustrated when the woman deferred all decisions to her husband. A woman in labor is regarded as unstable from the latent phase through the delivery of the placenta. Delaying care may pose a threat to her and her fetus’s health or safety. A complete evaluation of the woman and the fetus by a health care provider with skills and training appropriate to evaluate the woman in labour is warranted. Evaluation usually involves some subjective questions regarding the mother and the fetus. In this case of the Indonesian woman, deferring all decisions to her husband could severely jeopardize the health of the fetus and that of the mother since the man cannot know what the subjective symptoms related to her pregnancy. The female resident providing care to the Indonesian woman should have done a quick culture assessment. Also being culturally aware of what to expect in this situation would alert the provider that while the husband is present the wife would defer all questions to her husband. The resident should have asked the husband to allow his wife to answer the questions. The husband would most definitely comply in this case since care provided for his wife was by a female. Explaining the risk of not having the woman answer the subjective questions about her health and the fetus would also bridge the gap between culture and knowledge deficit. This would be delivering safe patient care in a culturally congruent manner.

A 32-year-old lesbian diagnosed with advanced stage cervical cancer. The patient was seen by her gynecologist annually but never had a Papanicolaou (Pap) tests done because she was self-identified as a lesbian. According to the gynecologist, invasive speculum exam is not usually necessary for a lesbian patient. Although cervical cytology testing remains an important part of preventive health care for lesbians, Female-To-Male (FTM) transgender individual and non-transgender females, Pap tests can be challenging for these patients due to a disconnect between biological sex and gender identity. Cancers of natal reproductive organs, including the cervix, can still occur and have been documented. The American College of Obstetricians and Gynecologists (ACOG) suggests that lesbians including transgender men with a cervix follow the same screening procedure as non-transgender females [2]. Additionally, patients should be informed before undergoing a Pap test to discuss any cultural issues that may concern them as heightened anxiety about undergoing genital exam may be present. Providers needed to be culturally aware of their personal feeling and addressed them.

A 34-year-old Haitian immigrant hospitalized in the neurosurgical intensive care unit with a traumatic brain injury after a 30-foot fall from a scaffold. His immediate family members and extended family insist on staying with him around the clock. His prognosis is poor, and when his attending physician discusses discontinuing life support therapy with his family members, they acquiesce but request that all family members be allowed to remain present to witness his death. Policies in the intensive care unit do not permit more than two family members to be with a patient at any given time. The staff members complain that they have difficulty completing their tasks with other critically ill patients because of the distractions they face from the multiple family members visiting this man. In the Haitian culture, when death is imminent, the entire family will congregate, cry, pray, and use religious medallions or other spiritual artifacts. When an individual dies, the entire extended family is affected. The oldest family member makes all the arrangements and notifies the family. Completing an initial culture assessment would have lessened the burden on the nursing staff and allow them to interact with other patients without neglecting the cultural need of the Haitian patient and family. Gently remind them that there may be times when they are asked to step out of the room, such as during bedside shift report or procedures. Another option would have been to communicate with the oldest family member to schedule turns for the visitors, to limit the number at his bedside.

The above vignette illustrates how culture ineptitude; can hinder the delivery of patient care in the midst of a conflict. Cultural awareness should be a fundamental competence in health care because it reflects the provider's ability to provide individualized care regardless of the patient's social or cultural background. The skill of conducting a cultural assessment would allow the provider to deliver culturally competent and patient-centered care that integrated the patient's values, beliefs, and practices into the treatment plan.

Cultural Awareness

Curiosity regarding other ways of being in the world especially how individuals operate on a day to day basis is an important attitude for cultural competence. However, it is also important for providers to acknowledge the forces that influence their world view. Everyone holds biases about human behavior. Bias is a predisposition to see an individual or things in a particular light, either positive or negative. Recognizing their personal biases and attitudes about human behavior is the first step in providing patient-centered care. Providers need to gain an awareness of the perceptions, traditions, practices, and value of culturally diverse individuals, families, communities, and populations for whom they serve, as well as a knowledge of the inextricable variables that affect the achievement of health and well-being. Healthcare providers should spend time cogitating on what they have learned, formally and informally, throughout their life about health and illness (physical and mental). Healthcare professionals should also reflect on the health care system, gender roles, sexual orientation, race, ability, age, family, and many other issues as a part of their commitment to becoming a culturally competent provider [3]. It is beneficial to think about cultural competence as a lifelong process of learning about others and also about yourself.

Culture Assessment

The purpose of a culture assessment is to acquire reliable data from the patient that enables you to create mutually acceptable and culturally relevant plan of care for each health problem of a patient [4]. Providers need skills to perform a systematic cultural assessment of individuals, groups, and communities as to their cultural beliefs, values, and practices. Numerous models and evaluation tools exist to facilitate culture assessment, including Leininger's Sunrise model [5], Giger and Davidhizar's Transcultural Assessment model [6], and the Purnell model for Cultural Competence [7]. Regardless of which one you select, a predesigned cultural assessment model will allow you to focus on the data that is most applicable to your patient's problems. It will also help you better appreciate the intricate factors that influence your patient's cultural worldview. Encourage your patients to detail the beliefs, values, and practices that are significant to their care.

An overwhelming body of research has documented health disparities affecting lesbian, gay, bisexual, and transgender community. In Healthy People 2020, the United States government officially committed for the first time to eliminating health disparities affecting the LGBT population. The Institute of Medicine report emphasized health disparities experienced by LGBT people and stressed the need to regularly collect data on gender identity and sexual orientation in healthcare settings as one approach to deter LGBT invisibility in health care and eliminate disparities. There are few providers adept in the unique medical requirements of transgender individuals, creating a barrier for access to quality care. For instance, most transgender women have a prostate and should be candidates for the same prostate screening that is recommended for all individuals [8]. Transgender men, even those who have had chest reconstruction surgery, may have residual breast tissue that necessitates cancer screening with mammography or sonography.

Many transgender men have a cervix and screening for cervical cancer would be warranted. These screenings must be done with sensitivity to the discomfort they may evoke in transgender patients. Most people in the LGBT community report culturally inadequate care or avoid visiting medical facilities for fear of receiving substandard care [8]. The fact that many providers do not know how to discuss sexual orientation or gender identity with their patients perpetuates invisibility of LGBT patients in clinical settings and contributes to the widespread lack of LGBT-inclusive cultural competency and clinical training for providers [9-11].

Conclusion

As the population continues to grow, cultural diversity and awareness will be a remarkable part of health care. As a provider, you will care for many diverse patients and work with diverse staff. Consequently, providers will need to learn about cultural diversity and become culturally competent [12,13]. Healthcare systems and providers add to the problem of health disparities as a result of inadequate resources, poor patient-provider communication and lack of culturally competent care. Culturally competent health care providers and organizations can contribute to the elimination of health disparities. Becoming culturally competent is an ongoing process for health care providers. A person's culture and life experiences shape his or her world view about health, illness, and health care. Disparities in accessing preventive health, quality health care, and health education contribute to poor population health [14].

Healthcare workers are expected to deliver culturally competent care to patients. Providers must work efficiently with the increasing number of patients, nurses, and health care team members whose ancestry reflects the multicultural complexion of contemporary society [15]. Key findings suggest that the ability to provide culturally competent care may be related to the nurse’s knowledge and experience of psychological empowerment through a sense of meaning and competence in work. It would also be noteworthy for future research to examine the effect of healthcare providers' acculturation in a different country on the correlation between cultural competence and cognitive empowerment. Additional, further knowledge will be achieved by conducting an intervention research study that incorporates a continuing education session on cultural competence, with a pretest-posttest design to evaluate the effect on cultural competence.

References

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