Culture as Attributes of Learner That Influences Nursing Education

Influence of  Culture on Nursing Education

Whats Are Cultural Characteristics,Assessment Models for the Delivery of Culturally Sensitive Care,Assumption of Model,Cultural Adaptations,Client Nurse Negotiation Model,Cultural Assessment and Nursing Profession.

Whats Are Cultural Characteristics

    The racial makeup of the United States continues to undergo change. At the beginning of the 21st century, the composition of this nation's population was approximately 71.3% white and 28.7% minority. By 2012, minority representation in the country grew to 37%. It is anticipated that the minority population will continue to steadily increase in the coming decades. 

    By 2043, it is projected that there will be no majority group in the United States and that by 2060, minority groups will constitute 57% (241.3 million people) of the US population (US Census Bureau, 2012b). pacing increasingly more culturally diverse, nurses need to have sound knowledge of the cultural values and beliefs of specific subcultural ethnic groups as well as incorporating transcultural nursing into practice by recognizing and appreciating differences in individual healthcare customs and preferences (Maier Lorentz, 2008; Price & Cortis, 2000; Purnell, 2013).

    Lack of cultural sensitivity by nurses and other healthcare professionals has the potential to waste millions of dollars through misuse of healthcare services and misdiagnosis of health problems with tragic and dangerous consequences. Furthermore, cultural sensitivity may serve to reduce the racial and ethnic bias perceived by culturally diverse patients in healthcare settings and minimize the alienation of large numbers of people (Benjamins & Whitman, 2014; Nguyen & Mills, 2014).

    Underrepresented ethnic groups are beginning to demand culturally relevant health care that respects their cultural rights and incorporates their specific beliefs and practices into the care they receive. This expectation is in direct conflict with the uni cultural, Western, biomedical paradigm taught in many nursing and other healthcare provider programs across the country (Purnell, 2013).

Assessment Models for the Delivery of Culturally Sensitive Care

    Given increases in immigration and the birth rates of minority populations in the United States as well as the significant increased geographic mobility of people around the globe, the US system of health care and this country's educational institutions must respond by shifting from a dominant, monocultural, ethnocentric focus to a more multicultural, transcultural focus (Narayan, 2003). 

    To enhance the delivery of culturally relevant health care and to prepare culturally sensitive professionals, numbers of major textbooks are available (Andrews & Boyle, 2015; Giger, 2016; Leininger, 2002; Purnell, 2013) and for almost 3 decades the Journal of Transcultural Nursing has been publishing theoretical and research findings for application to practice by staff nurses, nurse educators, and nurse researchers. 

    These texts and journal articles are constant sources of useful information for nurses that assist in raising their awareness of the distinct customs, beliefs, values, and perspectives of many nationalities and races worldwide that constitute the primary ethnic subgroups.

    Leininger (1994), a noted proponent of transcultural nursing, posed a question that remains relevant today: How can nurses competently respond to and effectively care for people from diverse cultures who act, speak, and behave in ways different than their own ? Studies indicate that nurses are often unaware of the complex factors influencing patients' responses to health care.

    The Purnell model for cultural competence represents a popular organizing framework for understanding the complex phenomena of culture and ethnicity (Purnell, 2013). This framework “provides a comprehensive, systematic, and concise” approach that can assist health professionals to provide “holistic, culturally competent” (p. 15) care when teaching patients in a variety of practice settings.

Purnell (2013) has proposed that many factors influence an individual's identification with an ethnic group. These factors may be distinguished as primary and secondary characteristics of culture. Primary characteristics of culture include nationality, race, color, gender, age, and religious affiliation. Secondary characteristics of culture include many of a person's attributes that are addressed in this text, such as SES, physical characteristics, educational status, occupational status, and place of residence (urban versus rural). These two major characteristics affect one's belief system and view of the world.

The Purnell model, depicted in a circle for includes the layers of the following concepts:

1. Global society (outermost sphere)

2. Community (second sphere)

3. Family (third sphere)

4. Individual (innermost sphere)

The interior of the circle is cut into 12 equally sized, pie-shaped wedges that represent cultural domains that should be assessed when planning to deliver patient education in any setting:

1. Communication (eg, dominant language and nonverbal expressions and cues)

2. Family roles and organization (eg, head of household, gender roles, developmental tasks, social status, alternative lifestyles, roles of older adults)

3. Workforce issues (eg, language barriers, autonomy, acculturation)

4. Biocultural ecology (eg, heredity, biological variations, genetics)

5. High risk behaviors (eg, smoking, alcoholism, physical activity, safety practices)

6. Nutrition (eg, common foods, rituals, deficiencies, limitations)

7. Pregnancy (eg, fertility, practices, views toward childbearing, beliefs about pregnancy, birthing practices)

8. Death rituals (eg, views of death, bereavement, burial practices)

9. Spirituality (eg, religious beliefs and practices, meaning of life, use of prayer)

10. Healthcare practices (eg, traditions, responsibility for health, pain control, sick role, medication use)

11. Healthcare practitioners (eg, folk practitioners, gender issues, perceptions of providers)

12. Overview/heritage (eg, origins, economic status, education, occupation)

Assumption of Model

    Purnell has also identified 19 assumptions upon which the model is based, of which the following are most relevant to this chapter:

One culture is not better than another they are just different. The primary and secondary characteristics of culture determine the degree to which one varies from the dominant culture.

Culture has a powerful influence on one's interpretation of and responses to health care. Every individual has the right to be respected for his or her uniqueness and cultural heritage.

Prejudices and biases can be minimized with cultural understanding

Caregivers who intervene in a culturally competent manner improve the care of patients and their health outcomes.

Cultural Adaptations 

    Cultural differences often require adaptations to standard professional practices. Other models for conducting a nursing assessment have also been proposed (Shen, 2015). Giger and Davidhizar's (2004) transcultural assessment model was first developed in 1988 to teach nursing students how to provide appropriate care to culturally diverse patients. This model includes six cultural phenomena (Giger, 2016; Giger & Davidhizar, 2004) that serve as a framework to design and deliver culturally sensitive care:

(1) communication

(2) personal space

(3) social organization

(4) time

(5) environmental control

(6) biological variations

Client Nurse Negotiation Model

    Another model, the nurse client negotiations model, was developed in the mid 1980s for purposes of cultural assessment and planning for care of culturally diverse people. Although it is more than 30 years old, this model remains relevant. It recognizes differences that exist between what the nurse and patient think about health, illness, and treatments and attempts to bridge the gap between the scientific perspectives of the nurse and the cultural beliefs (known as popular perspectives) of the patient (Anderson, 1990) . 

    The nurse client negotiations model serves as a framework to attend to the culture of the nurse as well as the culture of the patient. In addition to the professional culture, each nurse has his or her own personal beliefs and values, which can operate without the nurse being fully aware of them. These beliefs and values may influence nurses' interactions with patients and families.

    Explanations of the same phenomena may yield different interpretations based on the cultural perspective of the layperson or the professional. For example, putting lightweight covers on a patient may be interpreted by family members as placing their loved one at risk for getting a chill, whereas the nurse may use this technique to reduce a fever. 

    As another example, a Jehovah's Witness family considers a blood transfusion for their child to be contamination of the child's body, whereas the nurse and other health care team members believe the transfusion is a life saving treatment (Anderson, 1987). The important aspect of the nurse-client negotiations model is that it can open lines of communication between the nurse and the patient/family. It helps each party understand how the other interprets or values a problem or practice such that they respect one another's goals.

    Negotiation implies a mutual exchange of information between the nurse and the patient. The nurse should begin this negotiation by learning from the patients about their understanding of their situation, their interpretations of illness and symptoms, the symbolic meanings they attach to an event, and their notions about treatment. 

    The goal is to actively involve patients in the learning process to help them acquire healthy coping skills and styles of living. Together, nurse and patient then need to work out how the popular and scientific perspectives can be combined to achieve goals related to the individual patient's needs and interests (Anderson, 1990).

General areas to assess when first meeting the patient include the following:

1. The patient's perceptions of health and illness

2. His or her use of traditional remedies and folk practitioners

3. The patient's perceptions of nurses, hospitals, and the care delivery system

4. His or her beliefs about the role of family and family relationships

5. His or her perceptions of and need for emotional support (Anderson, 1987; Jezewski, 1993)

According to Anderson (1990) and Narayan (2003), the following questions can be used as a means for understanding the patient's perspectives or viewpoints. The answers then serve as the basis for negotiation:

What do you think caused your problem? Why do you think the problem started when it did?

Which major problems does your illness cause you? How has being sick affected you?

How severe do you think your illness is? Do you see it as having a short or long-term course?

Which kinds of treatments do you think you should receive?

What are the most important results you hope to obtain from your treatments? 

What do you fear most about your illness?

Cultural Assessment and Nursing Profession 

    Nurses who are competent in cultural assessment and negotiation likely will be the most successful at designing and implementing culturally effective patient education. They will also be able to assist their colleagues in working with patients who may be considered uncooperative or noncompliant. 

    Using active listening skills to understand patients' perspectives and using the universal skills of establishing rapport with them can help nurses to identify potential areas of cultural conflict and select teaching interventions that minimize such conflict (Campinha-Bacote, 2011). Labeling of patient behaviors, which may stem from cultural beliefs and practices, can negatively influence nurse-patient interactions (Anderson, 1987. 1990; Gutierrez & Rogoff, 2003).

    Nurses must remember one very important caveat when conducting cultural assessments: They must be especially careful to avoid stereotyping patients based on their ethnic heritage. Just because someone belongs to a certain subculture does not necessarily mean that the person adheres to all the beliefs, values, customs, and practices of that ethnic group. 

    Nurses should never assume a patient's learning needs or preferences for treatment will be like those of others who share the same ethnicity. Knowledge of different cultures should serve only as background cues for gathering additional information about individual variations through assessment.