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5 Ways to Improve Cultural Competence in Nursing Care - Minority Nurse
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Will you please let me know if there is anything about your background that would be helpful for me to know in working with you or your mother, father, sister, brother? Information from references 5 , 19 ,and Cultures that place a higher value on beneficence and nonmaleficence relative to autonomy have a long tradition of family-centered health care decisions.
In this collective decision process, relatives receive information about the patient's diagnosis and prognosis and make treatment choices, often without the patient's input. Compared with persons of black and European descent, Koreans and Mexican-Americans were more likely to consider family members, rather than the patient alone, as holding the decision-making power regarding life support.
However, acculturated Mexican-Americans continued to view decision making as a family-centered process. Among Asian cultures, family-based medical decisions are a function of filial piety—an orientation toward the extended family as opposed to individual patient self-interest. Many societies attribute a high degree of authority, respect, and deference to physicians. Eastern European medicine has had a long tradition of physician-centered, paternalistic decision making. In Russian medicine, the physician rather than the patient or patient's family often unilaterally determines a patient's level of life support.
Racial and ethnic minorities are disproportionately burdened by chronic illness
In Asian, Indian, and Pakistani cultures, family members and physicians may share decisional duties. Family care of the terminally ill in Asian and Indian cultures is a shared responsibility for cognitively intact and incapacitated relatives. Physicians in Pakistan may be adopted into the family unit and addressed as parent, aunt, uncle, or sibling. Survey data suggest that about 20 percent of the U.
The low rates of advance directive completion among non-whites may reflect distrust of the health care system, health care disparities, cultural perspectives on death and suffering, and family dynamics such as parent-child relationships Tables 3 5 , 19 , 25 and 4 34 , Ethnic minorities, which compose about one third of the U. Physicians can become knowledgeable about cultural norms in patients they commonly treat. They can describe the dimensions as they apply to specific ethnic groups see Table 1.
Physicians should ask patients directly about cultural issues that may affect communication patterns and treatment.
Up to 17 percent of the U. Physicians must find accessible, trained translators. Untrained translators should be briefly oriented to their role see Table 2. Some cultures view directly informing patients of a serious diagnosis as harmful. Physicians can ask patients if they would like to be directly informed of the results of medical investigations.
Physicians can let patients know that they will discuss the patient's condition with the patient at any time. These exchanges should be documented in the medical record see Table 3. Patients may prefer that their family members be the recipients of diagnostic and treatment information. If a patient prefers that family members receive information, find out which family member s. Treatment decisions may be made by an informally appointed family member, family-wide consensus, or physician-family collaboration.
Physicians should ask patients how they would like treatment decisions to be made. When compared with whites of Northern European background, patients who belong to other ethnic groups are less likely to complete formal advance directives. They can ask the patient or family if there is a preferred approach for making decisions on the patient's behalf. Patients from some cultures, particularly those with histories of health care discrimination, may not trust physicians who are of a different ethnic background. In this situation, it is good to ask patients directly if they are comfortable working with a physician of a different ethnic background.
When appropriate, physicians can acknowledge that members of a particular ethnicity have had histories of less than optimal care. Patients and family members can be encouraged to inform the physician immediately if they have quality-of-care concerns. Information from references 34 and Among blacks, nonacceptance of advance directives appears to be part of a much broader pattern of values regarding quality of life, as well as a historical legacy of segregation. DNR orders may be viewed as a way of limiting expensive health care or as cutting costs by ceasing care prematurely.
The Tuskegee syphilis study, 36 in which infected black men were followed for 40 years but were not informed of the availability of penicillin treatment, is well known in the black community. The reluctance of blacks to formally address end-of-life care also may stem from a history of health care discrimination. Although individual studies vary, the preponderance of evidence indicates that nonwhites, even after controlling for income, insurance status, and age, are less likely to receive a range of common medical interventions such as cardiac catheterization, immunizations, and analgesics for acute pain.
In addition to a historical legacy of unequal care, black patients also appear to view suffering somewhat differently than whites of European background. While whites may be concerned about dying patients undergoing needless suffering, black physicians and patients are more likely to think of suffering as spiritually meaningful, and life as always having some value.
Among Hispanics, the lack of acceptance of advance directives may stem from a view of collective family responsibility. Instead, a consensually oriented decision-making approach appears to be more acceptable in this population. Formalization of this process is seen as unnecessary and potentially harmful, because it may lead to increased and extended family conflict. Finally, among Asians, aggressive treatment for elderly family members is likely to be guided by filial piety.
Asian adults feel a responsibility to reverently care for aging parents. This sense of obligation makes it difficult for relatives to request other than extraordinary measures. Physicians can actively develop rapport with ethnically diverse patients simply by demonstrating an interest in their cultural heritage. The power imbalance of physician-patient interaction may make it particularly difficult for ethnic minority patients to directly request culturally sensitive care.
Patient preferences for nondisclosure of medical information and family-centered decision making may be disorienting initially to American-trained physicians. When treating patients from cultures with norms of nondisclosure, physicians might describe the dimensions of informed consent and offer to provide diagnostic and treatment information Table 4.
How Do Different Cultures Take Care of Seniors?
Physicians should also appreciate that, in certain cultures, while communication about serious illness and death may not be overt, information may be conveyed with subtlety. Facial expressions, voice tone, and other nonverbal cues may convey the seriousness of a patient's status without the necessity for explicit statements.
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The physician's partnership with his or her patients and their families provides unique insight into their values, spirituality, and relationship dynamics, and may be especially helpful at the end of life. By eliciting and following cultural preferences regarding disclosure, advance planning, and decisional processes that relate to seriously ill patients, family physicians can provide culturally sensitive end-of-life care.
Already a member or subscriber? Log in. In addition, he is clinical associate professor of community and family medicine at Saint Louis University School of Medicine. Searight received a doctorate in clinical psychology from Saint Louis University, and a master's degree in public health from Saint Louis University School of Public Health.
She received her doctorate in clinical psychology from Saint Louis University and completed an internship at the University of Vermont Medical Center. Address correspondence to H. Russell Searight, Ph. Louis, MO e-mail: russellsearight msn. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest.