Diversity in Health and Illness



Diversity in Health and Illness


Cathy L. Campbell, PhD, APN-BC and Ishan C. Williams, PhD



OBJECTIVES


At the completion of this chapter, the reader will be able to:


• Describe nursing care strategies that may be used to provide care to a diverse patient population.


• Describe methods used to become culturally competent.


• Identify societal factors affecting the delivery of culturally responsive nursing care in the United States.


• Identify barriers to and resources for minority access to care in the United States.


• Describe the differences in the concepts of race, culture, and ethnicity.


• Discuss strategies to approach diverse populations in the provision of culturally relevant care.




PROFILE IN PRACTICE: NURSING STUDENTS WITHOUT BORDERS



Established in 1999, Nursing Students Without Borders (NSWB) is a student-run organization at the University of Virginia School of Nursing. The goal of the founding members was to organize the concept of global community service into a health care program that had a sustainable impact on underserved communities. While expanding the perspectives and experiences of nursing students, the mission of NSWB is to launch health education initiatives, outline a network to access health care resources within the community, and distribute material donations.


The UVA chapter of NSWB is currently focused on building a primary care clinic for the Red Cross in San Sebastián, El Salvador, which will serve the town and surrounding cantones, or rural communities. The region, home to 19,000 people, still suffers from the economic and developmental devastation incurred during a 12-year civil war that ended in 1992. A current clinic operates out of a two-room rented house and provides basic primary care services by a local physician during the day and emergency care at night by volunteers. As the sole free-of-cost, 24-hour clinic in the area, the Red Cross clinic offers an invaluable service to people who could not otherwise afford health care.


When NSWB began working with the community in 1999, members developed a 3-year education campaign in the San Sebastián schools that concentrated on first aid, hygiene, nutrition, and reproductive health. Other objectives for the co-op included independent research studies for the NSWB students, providing contemporary medical information and supplies to the town clinic and midwives, holding advanced first aid courses for the Red Cross volunteers, and training them to continue the educational drive. Over time, many of these objectives were met or became sustainable by the community. For example, Red Cross volunteers are now able to train younger members using a system based on the one developed by former NSWB educators.


As these previous objectives were met, a new need was identified when it became clear the Red Cross could no longer effectively provide care in their current structure. Although the current clinic does not lack skilled providers, the work is greatly constrained by an unsterile environment and limited resources. NSWB collaborated with the Red Cross and local community leaders to make plans to build a new larger facility that would permit the Red Cross to provide a broader spectrum of care to a greater number of people.


As this project has unfolded over the past several years, a reciprocal learning partnership developed as NSWB team members interacted with the San Sebastián leadership—each encountering and learning from the differences in approach that team members from both cultures brought to the project of creating sustainable and affordable access to improved health care.


Initially, in an attempt to build a clinic facility designed to meet the specific needs of the population, NSWB brought an American architect to San Sebastián to meet with the physician and Red Cross volunteers in their environment. Together, they discussed common goals for the new building and developed architectural plans that were practical for the staff and feasible to build. The local environment, which has a fairly temperate climate, played a large role in the design, and the new clinic will have outdoor access from each room, providing natural ventilation and eliminating the cost of an expensive central air system. By working collaboratively and using local architecture as an example, the clinic was designed on an affordable budget without compromising the integrity of the space.


Another important aspect was the inclusion of a library and conference room. In a desire to continue and promote further learning, NSWB and the Red Cross members decided that a space dedicated to further training promoted the values of members from both groups and would serve as a reminder of the mission for the clinic. Including the input of both NSWB and Red Cross members allowed for a design that would improve upon current conditions and allow the Red Cross to meet its potential while being appropriate for the specific community.


The location of the clinic was an important decision that required cultural sensitivity. A piece of land was purchased in a central location in town, easily accessible to those utilizing and providing the services. As was typical in El Salvadoran culture, the deed was placed in the name of a neutral third party, who was also a trusted official in the community. Because the Roman Catholic Church is regarded so highly in El Salvador, the priest of the local church was chosen to serve this purpose, despite there being no connection between the Red Cross and the Catholic Church. By choosing to include the Church, NSWB gained credibility within the community and acquired a deeper understanding of the importance of religion in the local culture.


In the fall of 2008, when NSWB broke ground on the clinic, the Church once again played an important role in the community ceremony and celebration. When working with Red Cross members to plan the details of the ground-breaking, it was requested that a benediction of the clinic site by a priest begin the ceremony, which also included speeches by a number of community leaders, most notably San Sebastián’s mayor, before the El Salvadorian tradition of pouring the first bit of cement for the foundation took place, marking the official beginning of construction.


The close communication between NSWB team members and the Red Cross leadership resulted in inclusion of the priest and local government officials, who do not regularly participate in clinic business. This was a key element in building a foundation of support for this ambitious project among the rest of the local community. If the importance of bringing in these trusted key officials had been overlooked, the project would have lost critical support among community members and some residents might have been reluctant to accept the new building as part of their community.


Construction blueprints and ceremonial details are just two examples of the many aspects of this project through which NSWB has learned the importance of working collaboratively to create a sustainable project that is culturally relevant and supported by the local community. Time and again, relationships and friendships built on trust have been proven to be the most effective—and the only way to work in San Sebastián. Nursing students are placed outside their comfort level and societal norms as they adapt to a system in which community consent dictates the success of a project.


NSWB trips to El Salvador are designed to include exposure to political, historical, religious, and economic issues, all of which have significant impact on the delivery of care to the impoverished town of San Sebastián. By creating a lasting partnership built on a foundation of cultural competence and reciprocal learning, NSWB and the Red Cross continue to work to provide health care to the community, while teaching nursing students how to work in a global society.




PROFILE IN PRACTICE: HEALTH CARE NEEDS IN RURAL APPALACHIA



I have had the privilege of coordinating the nursing volunteers for the Remote Area Medical (RAM) Clinic in Wise, Virginia, over the last 10 years through Community Outreach and Service at the University of Virginia Health System. Having worked as an emergency department (ED) nurse for many years, I understand that the ED has become the safety net for many of our patients. In fact, many vulnerable and underserved populations rely on the ED as their primary source of health care. Often, by the time patients are seen in the ED, they are in very poor health because they did not seek health care earlier for a minor complaint, which has now worsened. Poor socioeconomic status is the primary predictor of poor health status. Continually seeing the plight of these patients was a motivator behind my decision to begin volunteering with the RAM clinic.


The majority of the patients served at RAM live in the rural Appalachian mountainous region. The population of this area is higher than the national average in several categories: persons greater than 65, persons younger than 18, and persons living below the poverty line. These factors make the people we serve through RAM a particularly vulnerable population. Culturally, this very rural population has a strong sense of independence based on their geographic isolation, economic hardships, and the lack of health care sources of usual health care, especially in specialty practices. Many residents lack health insurance or coverage for preventative health screenings, including dental or eye care. Travel to areas where these individuals could receive free or reduced-fee specialty care can be difficult or impossible because of logistical and economic hardships. Initially, the RAM clinic focused on vision screenings and dental care. From an aesthetic perspective, if a person has poor dentition, it diminishes employment opportunities, thus meaning the person is less likely to have health insurance. Even if this person has health insurance, it is unlikely to cover dental care, and since everyday survival is given higher priority than dental care, a vicious cycle of poor health is perpetuated. From a medical perspective, patients with poor dentition are less likely to eat fruits and vegetables and more likely to eat soft, nonnutritious foods, thus aggravating conditions such as diabetes and obesity. In turn, these medical conditions become the primary focus, and dentition again takes a back seat, continuing the cycle.


To address this problem, in the second year of RAM, a medical clinic was added. The population living in this region has a higher incidence of heart disease, pulmonary disease, diabetes, and hypertension. Because of the high incidence of diabetes, endocrinologists recommended that we perform routine fingerstick glucose screenings on all patients who present to the clinic. For many patients, a visit to the RAM clinic will serve as their yearly physician check-up, and they will see no other provider unless they become acutely ill.


A mobile “health wagon” managed by a nurse practitioner provides primary care based on ability to pay ($3 per visit) for one area in southwest Virginia. The health wagon is the yearly financial sponsor of the RAM clinic. Every summer, more than 5000 patients are cared for in 2.5 days at the county fairgrounds. All test results are reviewed, and all abnormal tests and lab data are followed by attempts to help patients identify a primary care provider or to refer patients to specialists as needed. The University of Virginia has partnered with the health care providers in southwest Virginia to strategize development of a plan to improve access to health care for patients in this region.


Rural communities are often reluctant to receive services from people outside of their communities. Thus the health wagon meets with stakeholders on a monthly basis in preparation for the summer clinic. Telemedicine sites now dot the map of southwest Virginia and provide access to specialty care providers. Providers working with patients at these clinics must understand the patient’s culture, including the social context and significance in the patient’s life, since these factors affect the patient’s ability to comply with physician’s instructions or patient education. For example, consider a rural patient who has diabetes and is overweight. Simply telling this person to increase physical activity by walking a mile a day may not be helpful if the person lives on the side of a mountain and walking down the road increases the risk of being hit by a car. On the other hand, encouraging such patients to walk a certain number of minutes inside their home or around the outside of their house, weather permitting, is a more realistic instruction and demonstrates an understanding of the patient’s environment. Another realistic option would be walking the perimeter of a store parking lot when the patient goes to buy groceries or other goods. Because of geographic isolation, the lack of access to health care, and limited financial resources, these rural patients and their family members often need to perform tasks and learn skills that may in other settings and situations be provided by a professional and/or covered by insurance. Thus family members must be incorporated into the patient’s plan of care. For example, identifying the person who prepares the meals in the home will facilitate nutrition education. The team takes advantage of such episodic encounters to provide as much teaching as possible to help these patients facilitate self-care and to build on the cultural value of self-reliance. The patients we work with at the RAM clinic are gracious and have taught us much about their culture and their challenges in managing their health care.



INTRODUCTION


America is more of “mixed salad” than a “melting pot” and is composed of diverse groups of individuals. Yet the nursing profession in the United States does not reflect the diversity of the population it serves. This is a significant challenge for the nursing profession and for the 88% of nurses that are non-Hispanic whites. The nursing profession needs to address recruitment of a diverse workforce and the preparation of professional nurses who competent to deliver culturally responsive care. Professional nurses must develop the knowledge, skills, and values to provide culturally responsive care. Professional nursing is also uniquely positioned to address health care disparities within the health care delivery system. This chapter explores the relationship between diversity and health and offers frameworks for exploring culture and care. Specific nursing-related barriers, strategies, and resources are identified for developing cultural competency in health care delivery.



imageDiversity and Health


We live in a pluralistic society, and it is becoming more evident that cultural differences, if not acknowledged, will increasingly serve to isolate and alienate us from one another. It is not enough to simply educate people about cultural differences; one must also confront these competing standards of truth. Given that health care professionals learn from their culture the “art” of being healthy or ill, it is imperative for health professionals to treat each patient with respect to his or her own cultural background. Culture can be defined in multiple ways. In general, most definitions encompass socially inherited and shared beliefs, practices, habits, customs, language, and rituals. Culture shapes how people view their world and how they function within that world. Culture can transcend generations. The one unifying theme in defining culture is that it is learned. Much of what we believe, think, and act is attributable to culture. Hence one’s culture can profoundly determine what is perceived as health versus illness. There are also numerous definitions for diversity. Many people define diversity simply as racial or ethnic differences. This chapter considers diversity more broadly to encompass differences that may be rooted not only in culture, but also in age, health status, gender, sexual orientation, racial or ethnic identity, geographical location, or other aspects of sociocultural description and socioeconomic position (Kennedy, Fisher, Fontaine, & Martin-Holland, 2008). Given the importance of culture in how we define ourselves and our environment, each person must be treated with respect and his or her cultural sensitivity must be valued.


How nurses incorporate the patient’s cultural diversity in their general plans of care can mean the difference between success and failure (Seidel, Ball, Dains, & Benedict, 2006). Kleinman and Benson (2006) notes that cultural issues are crucial to all clinical care and management of illness, because culture shapes health-related beliefs, values, and behaviors. Thus providing culturally responsive care requires that the nurse, when confronted with culturally diverse patients, is attuned to the cultural cues presented while balancing sensitivity, knowledge, and skills to accommodate social, cultural, biological, psychosocial, and spiritual needs of the client respectfully. When clinicians are focused only on the disease without a context, there is a distortion of reality.


The importance of being sensitive to cultural diversity cannot be overemphasized. The ability to build on the strengths of diverse communities and to understand and respect other cultures results in interventions that can lead to healthy practices and behaviors. Health and illness can be perceived in a variety of ways, and acknowledging the significance of culture in people’s problems as well as their solutions is essential. Moreover, numerous expectations exist of what is considered appropriate treatment and care. Cultural values and social norms are major influences and can greatly affect the interaction and outcomes for both nurses and patients (Box 14-1).



BOX 14-1   Case Study: Visiting


When Ellen began her clinical rotation on a large American Indian (Lakota) reservation, her thinking revolved around what she could teach the community workers there. She spent days traveling many miles with various community health representatives (CHRs). These were American Indian men and women who had approximately 1 month’s training (sometimes in addition to other training and student experiences). They then assumed roles as providers, visiting homes of other tribe members, doing routine and basic care, and acting as liaisons between the American Indian population and the biomedical system. Slowly, Ellen realized how Lakota culture shaped the CHRs’ and other residents’ perceptions of health, illness, and their expectations for treatment and care. As the weeks went on and Ellen learned to be open to new ways of knowing and doing things, her interpretations changed, as her following journal entries indicate:



Week 1: “The CHRs don’t really do anything. They just go and drink coffee and sit down and visit.”


Week 2: “I think they just visit because they don’t know what else to do. They even talk about themselves there and the problems their own kids are having. And they are all quiet a lot. Sometimes they hardly talk about the patient’s problem.”


Week 3: “You know, something happens when the CHRs visit, but I don’t know what it is. I don’t see how their visiting works, but I see that people appreciate it.”


Week 4: “The patients do what the CHRs want them to do. Something goes on, but I don’t get it; they never actually tell the patients what to do.”


Week 5: “I still don’t see how the visiting works when the CHRs don’t do much instruction. They do other things—wash the quadriplegic man’s long hair, dress decubitus ulcers, weigh babies—but mostly they visit. Somehow it works.”


Week 6: “I’ve got it. Visiting is what the CHRs do. That is what is important and how they intervene. It is because of the visiting that the patients respond, not because of what the CHRs do when they visit.”


As the United States continues to increase in diversity, nurses will be providing care for patients from many backgrounds different from their own. It would not be feasible or realistic for nurses to try to memorize cultural traits from every diverse cultural group (Engebretson, Mahoney, & Carlson, 2008). Instead, nurses must have an appreciation of the cultural differences among his or her clients, respect each client’s culture, and behave in a way that demonstrates this respect.


Many theoretical frameworks exist to provide nurses with a contextual basis for understanding and providing culturally and linguistically appropriate care. Leininger’s (1991) theoretical framework for transcultural nursing emphasizes the commonalities and differences among world views that reflect various aspects of society to diverse health systems (Figure 14-1). This depiction of the many interrelated dimensions of culture and care is useful for exploring important meanings and patterns of care. The theoretical framework is focused on comparative culture care examined through a holistic and multidimensional lens (Leininger, 2002). The purpose of the theory is to provide culturally congruent, safe, and meaningful care to clients from different or similar cultures. Furthermore, the theory posits that world view, cultural, and social structures and others influence care outcomes related to culturally congruent care; generic emic (folk) practices (an attempt to understand the viewpoint of the people themselves) and professional ethic nursing practices (according to the principles, methods, and interests of the observer) influence outcomes; and the three modes for transcultural care actions and decisions are culture preservation and/or maintenance, cultural care accommodation and/or negotiation, and cultural care repatterning and/or restructuring to provide culturally congruent care (Leininger, 2002). When nurses work with patients who have cultural orientations that are different in minor or major ways from their own, those considerations are particularly significant. Further discussion of Leininger’s framework occurs in Chapter 5.


image
FIGURE 14-1 A modification of Leininger’s model of transcultural nursing. (Modified from Leininger, M. M. [1991]. Culture care diversity and universality: A theory of nursing. New York: National League for Nursing; with permission of the National League for Nursing, New York, NY.)

Another model for examining cultural competence in nursing care is the Campinha-Bacote Model of Cultural Competence (Campinha-Bacote, 2002). In this model, nurses continuously work toward cultural competence by addressing five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. The final—and perhaps the most important—concept in the model is cultural desire: “Cultural desire is the spiritual and pivotal construct that provides the energy source and foundation for the health care provider’s journey toward cultural competence” (Campinha-Bacote, 2002). Thus cultural competence can be illustrated as a volcano, depicting how cultural desire stimulates the process of cultural competence.


The Campinha-Bacote Model of Cultural Competence is an interactional dynamic model of cultural competence, requiring that all five identified constructs be achieved. The process of cultural awareness occurs when the nurse is able to examine his or her own values, biases, and stereotypes. Cultural awareness also requires the nurse to examine the potential cultural biases (racism) that may exist within the health care setting. The process of cultural knowledge occurs when nurses educate themselves about the world views of other cultures and ethnic groups. This cultural knowledge may include learning how disease processes and management may vary depending on the cultural group. Cultural skill occurs when the nurse can conduct a relevant cultural assessment. Hence cultural skill is achieved when cultural data are used to develop and implement a culturally relevant treatment plan. Cultural encounters encourage the nurse to engage directly with patients from different ethnic and cultural backgrounds to modify existing beliefs about a cultural group and prevent potential stereotyping. Finally, cultural desire addresses the motivation of the health care provider to acquire new knowledge about different cultures. This last construct is based solely on the nurse’s intrinsic need to acquire new cultural knowledge and cannot be driven by external regulations or requirements.


Similar to the Campinha-Bacote model, the U.S. Health Resources Services Administration attempted to identify the critical domains of cultural competence for health care providers and organizations (USDHHS, 2006). These nine domains are value and attitudes, cultural sensitivity, communication, policies and procedures, training and development, facility characteristics, intervention and treatment models, family and community participation, and monitoring and evaluation. By addressing all nine domains, both health care providers and organizations can achieve cultural competence.



VALUES THAT SHAPE HEALTH CARE AND NURSING


The discipline of nursing reflects the values and norms of a society; in the United States these values and norms are predominantly Eurocentric, middle class, Christian, and androcentric in view. In general, the American culture tends to value personal freedom and independence (Shaw & Degazon, 2008), as well as individual achievement over the common good (Seidel et al., 2006). For example, the concept of a single autonomous decision maker that is the hallmark of a Eurocentric world view does not accurately capture the involvement of family members and other significant people in health care decision making (Campbell, 2007). The notion that everyone be treated exactly the same is idealized and unrealistic. Traditionally, health care providers are presumed to know more about their patients’ needs than patients themselves do. This concept, known as paternalism, is discussed further in Chapter 12. Although there is a growing movement to listen to patients’ goals and beliefs and incorporate such goals and beliefs as resources in their care, this continues to be a challenge when patients’ beliefs differ greatly from those of the providers of health care.

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Oct 26, 2016 | Posted by in NURSING | Comments Off on Diversity in Health and Illness

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