Illness, culture, and caring: Impact on patients, families, and nurses



Illness, culture, and caring: Impact on patients, families, and nurses



Learning outcomes


After studying this chapter, students will be able to:


• Differentiate between acute and chronic illness.


• Describe the stages of illness.


• Explain behavioral responses to illness.


• Distinguish between internal and external influences on illness behaviors.


• Discuss the influence of culture on illness behaviors.


• Describe the characteristics of the culturally competent nurse.


• Explain the concept of spiritual nursing care.


• Identify spiritual nursing interventions.


• Explain the physical, emotional, and cognitive effects of stress.


• Describe the effect of anxiety on patient learning.


• Discuss how family functioning is altered during illness.


• Explain the necessity of and strategies for self-care by nurses.


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To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve. elsevier.com/Black/professional.


Joyful partners stand at the altar or before a judge on their wedding day, vowing to “have and to hold . . . in sickness and in health . . .” On a day of robust health and exuberant energy, couples rarely envision the specter of illness as they celebrate their marriage. It is a day of hope and expectation. Sickness, and all it means, has little place at the wedding. Yet as the anniversaries of this beautiful day come and go, the meaning of sickness becomes clearer. A part of life, illness affects not just the sick person, but the people providing care—the spouse, the partner, their children. Illness changes lives (Figure 10-1). In Chapter 12, you will read about systems theory in more depth, but for purposes of this chapter, it is enough to understand that a change in one part of a system results in changes in other parts. A family is system; a change in one member affects the other members.


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FIG 10-1 In times of illness, roles in families change. A daughter is caring for and comforting her elderly mother. (Photo used with permission from iStockphoto.)

Chapter opening photo from Photos.com.


Managing illness and the complex changes and responses to illness are important to nursing. A unique characteristic of nursing is the emphasis on viewing patients holistically. Nurses recognize that human beings are complex beings with physical, mental, emotional, spiritual, social, and cultural dimensions. Each of these dimensions may be challenged by illness. A caring nurse considers each of these dimensions in the presence of some degree of illness. In this chapter, the stages of illness, illness behaviors, and cultural factors that influence them are explored, as is the impact of illness and culture on patients, families, and nurses. Developing strategies to maintain your own health and learning to develop balance in your life – care of self – is also explored.




Illness


Illness is a highly personal experience. Culture plays a powerful role in health beliefs and behaviors; it also determines how individuals and families react to illness. Nurses can be more effective in delivering care when they understand some of the factors that affect how people cope with illness.



Acute illness


Acute illness is characterized by severe symptoms that are relatively short-lived. Symptoms tend to appear suddenly, progress steadily, and subside quickly. Depending on the illness, the patient may or may not require medical attention. The common cold is an example of an acute illness that does not usually require a health care provider’s attention. Others, such as acute appendicitis, can become life-threatening without timely surgical intervention. Unless complications arise, people with acute illness usually return to their previous level of wellness. Some acute illnesses, such as acute myocardial infarction, may lead to chronic conditions, such as congestive heart failure. Another example is a new infection with human immunodeficiency virus (HIV). The initial signs and symptoms of HIV infection occur 2 to 4 weeks after exposure to the virus as a flulike syndrome with fever, malaise, rash, myalgia, and other discomforts. Usually lasting fewer than 10 days, patients believe that the resolution of their acute illness means that they are well, when in fact they are seropositive for HIV. They are chronically ill.


Individuals with sudden, catastrophic injuries, such as a spinal cord injury or major stroke, experience dramatic and extensive change in an instant. They face physical limitations, significant modifications in daily living, and changes in social roles for which they had no preparation. They face daily challenges that may seem unbearable. They use a variety of coping mechanisms, strategies that differ from person to person.



Chronic illness


A chronic illness usually develops gradually, requires ongoing medical attention, and may continue for the duration of the individual’s life. Hypertension, diabetes, and Parkinson’s disease are examples of chronic illnesses; they can be treated but not cured.


Chronic illnesses have a significant social and economic impact, being one of the fastest-growing health problems in the United States. In 2005, almost one of every two adults had at least one chronic illness (Centers for Disease Control and Prevention, 2010). Factors such as sedentary lifestyles, obesity, and the aging of the population are expected to contribute to a continued increase in the number of chronically ill Americans for the foreseeable future.


Chronic illnesses are caused by permanent changes that leave residual disability. They vary in severity and outcomes, but a state of “normal” health is elusive, although many chronic conditions can be managed successfully. Some chronic illnesses are progressively debilitating and result in premature death, whereas others are associated with a normal life span, even though functioning is impaired. Some chronic illnesses go through periods of remission, when symptoms subside, and exacerbation, when symptoms reappear or worsen.


Chronic illnesses are pervasive and life altering. They lead to altered individual functioning and disruption of family life. Long-term medical management of chronic illness can create financial hardship as well. Patients with chronic illness need to make lifestyle changes, often many changes simultaneously. They must begin doing things they are not accustomed to doing and stop doing things they normally do. Patients with diabetes, for example, must begin monitoring their blood glucose levels and change their eating habits. Box 10-1 presents the similarities and differences between acute and chronic illnesses.



BOX 10-1   TYPES OF ILLNESS




The diagnosis of an acute or chronic illness can be a major life crisis. The emotional reactions of the patient and family sometimes present a greater challenge than dealing with the physical aspects of the disease. Despite the prevalence of emotional responses to illness, most medical and nursing attention is focused on physical aspects of the disease process rather than emotions. Box 10-2 describes how one patient experiences a chronic illness, systemic lupus erythematosus, and describes its effect on her feelings, family responsibilities, and relationships. As you read her thoughts and feelings, take special note of her reaction to her nurses’ focus on her physical condition at a time when her emotional responses were her greatest concern.



BOX 10-2   COMMENTS OF A PATIENT WITH A CHRONIC DISEASE: SYSTEMIC LUPUS ERYTHEMATOSUS


If there is one thing I want to say to nurses who work with patients with chronic disease, it is “Be patient and understand our problems and feelings.” When I go to the doctor’s office or to the hospital, I usually leave feeling guilty because I have been impatient with everyone I saw. Guilt and anger are the two feelings I seem to have had since I was diagnosed with this disease. I alternate between being angry that I got lupus and feeling that I should be grateful for the fact that I have something I can at least live with when others are not so fortunate.


I guess the thing that bothers me most is that the nurses keep telling me what changes I need to make to take better care of myself. They never seem to understand that I am doing the best I can do. I can’t possibly get the amount of rest they seem to think I need, and I can’t avoid as much stress as they seem to think I should avoid. Both my husband and I work hard at our jobs, and I hate asking him and my sons to take over my responsibilities at home when I am sick, so I wind up compromising. I ask them to help some and I do more than I should. When I get the lecture from the nurses on how I should take better care of myself, I usually just nod and say that I will, even when I know that I probably won’t be able to.


Chronically ill people can become acutely ill with something not even related to their chronic illness, which will still need management even while the acute condition is being treated. Acutely ill people can become chronically ill as a result of the acute condition. For instance, an otherwise healthy baby born prematurely at 28 weeks of gestation may have setbacks in his hospital course that lead to lifelong disabilities and health challenges.



Adjustment to illness


Adjustment to illness is a process. Although the responses are different for each person, people who are ill typically progress through somewhat predictable states. Experts from medicine, sociology, psychology, and nursing have described the states that people experience in adjustment to illness as stages—disbelief and denial, irritability and anger, attempting to gain control, depression and despair, and acceptance and participation. Remember that there are many influences on the way a person responds to an illness and that these states are fluid, meaning that the patient will go back and forth between responses.



Disbelief and denial


People have difficulty believing that signs and symptoms are caused by illness. They may believe that the symptoms will go away. Fear of illness often leads to the mistaken belief that the symptoms will subside without treatment and can delay seeking a diagnosis.


Denial is a defense mechanism that people sometimes use to avoid the anxiety associated with illness. People who pride themselves on their vigorous health may downplay the significance of symptoms. If this occurs, they may avoid treatment or attempt inappropriate self-treatment. Extended denial can have serious results, because some illnesses, left untreated, may become too advanced for effective treatment. A nurse described her own prolonged denial of the significance of a lump in her breast:






Depression and grief


Depression is perhaps the most common mood disorder that occurs with illness. The ability to work is altered, daily activities must be modified, and the sense of well-being and freedom from pain may be lost. Illness results in many types of loss, and depression can occur. The difficulty is figuring out the difference between grief—the normal and expected response to any loss, including one’s health—and depression, a treatable mental health condition. Immediately after diagnosis, patients may grieve the loss of their previous state of good health. As time goes on and functional limitations add up, persons with chronic illnesses may undergo cycles of depression as remissions and exacerbations occur. Remember that it is beyond the scope of practice for a nurse to diagnose a condition such as depression, which is a psychiatric diagnosis that needs treatment. A careful assessment, however, of the patient’s mood states may give the observant nurse an indication that the patient is depressed and can help get them the care that they need.



Acceptance and participation


At this point, the patient has acknowledged the reality of illness and may be ready to participate in decisions about treatment. Active involvement and the hope attached to pursuing treatment usually lead to increased feelings of mastery of the illness. Patients with long-term chronic illnesses become experts in their own care and management of their condition. From the nurse with breast cancer:



Remember that these states are described as a means of describing how patients work through their illness. Patients do not move through these states in a linear way, nor should they be used by the student or nurse to characterize a patient’s particular response at any one time. Doing this ignores the complex changes that an illness brings to almost every element of a patient’s life. One’s response to illness is highly idiosyncratic, and it should be treated as such. Acute illness may be experienced in a very different way from chronic illness (Box 10-3).



BOX 10-3   STATES OF ACUTE ILLNESS




Modified from Ellis J, & Nowlis E: Nursing: A Human Needs Approach, ed 5, Philadelphia, 1994, JB Lippincott.



The sick role


Although illness is highly subjective and is experienced differently by each individual, a number of factors influence how a particular person will respond. One important factor is the cultural expectation about how people should behave when ill. Children learn the part they are expected to play as an ill person through modeling—that is, by observing how their parents or significant adults in their lives respond to major and minor illnesses. These responses can vary from stoic, uncomplaining independence to very passive dependence, with many variations in between. Stoicism in the face of illness should not be confused with strength of character—it may simply mean that the sick person is not comfortable sharing his or her symptoms and does not want to appear to be complaining.


Each culture generally requires that certain criteria be met before people can qualify as “sick.” Talcott Parsons (1964), a renowned sociologist, identified five attributes and expectations of the sick role that guided the view of illness in white American society for decades. According to Parsons, the sick white American:



In other words, Parsons’ definition of the sick role includes behavior that is dependent, passive, and submissive. For decades, Parsons’ sick role expectations were taught in medical and nursing schools and guided the way health care providers viewed patients’ reactions to pain and illness. This view is no longer adequate, because different cultures have differing sick role expectations. Moreover, patients have become increasingly likely to challenge providers and to seek information regarding their care from persons or sources that are not health care providers.


Migration has changed the world and requires that nurses are educated to attain a level of cultural competence. Cultural competence is having “the attitudes, knowledge and skills necessary for providing quality care to diverse populations” (American Association of Colleges of Nursing, 2008). Culturally competent nurses are prepared to provide patient-centered care with a focus on the patient’s specific needs that are shaped by culture. Being culturally competent means that nurses are more likely to be attuned to the massive problem of health disparities. Cultural competence does not mean, however, that nurses learn every facet in detail of each culture’s practices. In fact, mastering the subtleties of every culture is impossible.


It is crucial to understand that there is no normative illness response based on culture. “Normative” means that there is one standard by which all others are judged and valued. For instance, the current expectation of white Americans is that people should accept responsibility for their own care rather than completely submit to health care providers. This expectation is based on the assumption that ill people should want to get well and should behave in a way that leads to wellness. This, however, does not mean that all other cultural responses to illness are judged in relationship to the responses of white Americans.


This expectation that ill people should want to get well and return to their normal activities as quickly as possible means that patients should cooperate in the treatment process and, to a great extent, become submissive and compliant, placing themselves in the hands of the caretakers. People who refuse to take medications as ordered or who refuse to perform prescribed activities, such as adhering to an exercise program or therapeutic diet, are viewed negatively. Their friends and family members may become irritated at their lack of participation in getting well again. Their providers call them “noncompliant.” Often what is missing is an understanding of the patient’s perception of the illness. Illnesses and their treatments have great meaning to patients. One patient with HIV describes the meaning of taking antiretroviral medications:



Working with patients with chronic illnesses can be particularly challenging for nurses. The inability to cure disease sometimes leads health care providers to feel hopeless and powerless as they look at their very sick patients and to feel overwhelmed and inadequate at times. Self-aware nurses recognize these feelings and seek to address them outside of the clinical setting where it is safe to “vent” and work through these feelings.



Illness behaviors


Responses to illness vary widely and are, of course, idiosyncratic. Each person in whom diabetes, for example, is newly diagnosed behaves differently from other people with the same condition. Both internal and external variables affect how an individual acts when ill (Box 10-4). An individual’s personality has a great deal of influence on the response to illness. Past experiences with illness and cultural background also influence illness behaviors.



BOX 10-4   INTERNAL AND EXTERNAL INFLUENCES ON ILLNESS BEHAVIOR





Internal influences on illness behaviors

Personality structure is an internal variable that determines, to a large extent, how one manages illness. Personality characteristics the nurse should consider when assessing the ill person are dependence/independence, coping ability, hardiness, learned resourcefulness, resilience, and spirituality.



Dependence and independence.

Patients’ needs for dependence are unrelated to the severity of their illnesses. Some patients adopt a passive attitude and rely completely on others to take care of them. Others deny they are ill or have problems with being dependent and try to continue living as independently as they did before becoming sick.


People who perceive themselves as helpless may be more willing to submit to health care personnel and do what they are told. Those who are used to being in charge and see themselves as independent may resent the enforced dependency of hospitalization and illness. These two different attitudes are illustrated in Case Study 10-1.



CASE STUDY 10-1   Dependence vs. Independence


Example 1: Dependence


Mrs. Pierce has been in the hospital for several days after major abdominal surgery. Even after she progressed to the point at which she could feed herself, turn over in bed, and go to the bathroom unaided, she continued to call for assistance with these activities of daily living. She now calls the nurse every few minutes, making some small request that she is capable of performing for herself. She is communicating to the nurse that she needs a great deal of assistance and is demonstrating overly dependent behavior.



Both overly dependent and overly independent behavior can be frustrating to nurses, who sometimes become angry with patients who request help with activities they are capable of doing themselves. The patient who is too dependent requires encouragement to assume more responsibility. The patient who needs to be “in charge” may have problems turning control over to caregivers and is often too independent. This patient needs assistance in recognizing limitations and using available resources to meet his or her needs. For instance, Mr. Johnson in Case Study 10-1 risks a fall and injury by not recognizing that his recent surgery will require him to be temporarily more dependent than he is comfortable with.


Because nurses most often focus on promoting patient independence, they may react negatively to patients who are exhibiting dependent behavior. Keep in mind that these behaviors may be the patient’s way of signaling an increased need for security or support. Sometimes independence may not be the desired outcome. For patients with chronic illnesses who must rely on others for assistance in meeting their needs, too much independence may actually be dysfunctional, as well as dangerous.



Coping ability.

An individual copes with disease or illness in a variety of ways. Coping is a term that describes the strategies a person uses to assess and manage demands. With an acute illness, coping is generally short-term and leads to a return to the preillness state. With chronic disorders, coping behaviors must be used continuously.


Sick people use coping strategies to deal with the negative consequences of the disorder, such as pain or physical limitations. Each individual has a unique coping repertoire that is formed across previous illness episodes, modeling coping by others, and by significant factors in the context of his or her life over which he or she has little or no control, such as poverty, concurrent losses, tenuous employment, and unstable relationships, among others. Higher levels of life stresses are associated with patients’ perceptions of severe consequences of illness and less control over the illness (Karademas, Karamvakalis, Zarogiannos, 2009).



Resourcefulness.

Resourcefulness refers to the use of cognitive skills that minimize the negative effects of thoughts and feelings on one’s daily life and the way one adjusts to adversity (Bekhet and Zauszniewski, 2008). Throughout life, individuals acquire a number of skills that enable them to cope effectively with stressful situations. Resourceful people may have an attitude of self-mastery that can be particularly helpful in reducing the feelings of despair and helplessness that can accompany the numerous stressors of chronic illness. Note that “resource” does not refer to material belongings, but involves the ability to make the most out of what one has.


Resourcefulness can be taught as a form of coping. Stress inoculation and skills in self-regulation, problem solving, conflict resolution, and emotion management are examples of the types of educational interventions the nurse may implement.



Resilience.

Scholars studying human behavior have often noted that some children did well in spite of difficult circumstances that defeated others. They attributed the differing reactions as a function of the phenomenon of resilience. Resilience is an aspect of coping that can be defined as “a pattern of successful adaptation despite challenging or threatening circumstances” (Humphreys, 2001). Resilient responses are thought to be a result of three factors:



Resilience can be thought of as both a process and an outcome. It can develop over a person’s lifetime and can be taught, modeled, and learned.


The study of resilience has broadened to include adolescents and adults who face difficult, traumatic, or adverse circumstances. It has also been applied to adults with critical illness, battered women, survivors of sexual abuse, and others. You can expect to see much more about resilience as this phenomenon continues to be studied and better understood. A useful website (www.apa.org/helpcenter) sponsored by the American Psychological Association, includes links to a lengthy brochure “The Road to Resilience.” This document may be useful to you personally as you work to improve your own set of coping skills as you enter the profession of nursing. You may have occasion to use the content in caring for a patient who is struggling with a serious illness.



Spirituality.

Spirituality is commonly defined in terms of belief in a higher power, interconnectedness among living beings, and an awareness of life’s purpose and meaning. The way one’s spirituality manifests itself varies widely from person to person. Religion differs from spirituality in that religion refers to a codified way of organizing rituals and beliefs to create meaning. Spirituality is a larger concept of which religion is one of its many expressions. Spirituality is less differentiated than religion and can include concepts and beliefs from many religions and philosophies. Spiritual growth occurs over the life span and is an internal process; as such it cannot be directly observed. Spiritual growth consists of increasing awareness of meaning, connectedness, purpose, and values in life.


The role of spiritual beliefs in health and illness has only recently been formally investigated. A growing number of scholars and health professionals think that spiritual beliefs have psychological, medical, and financial benefits that can be proved scientifically. Questions about the effects of intercessory prayer (prayer by others on behalf of a sick person) have been debated. A scientifically rigorous, privately funded study of more than 1800 patients who had heart surgery was conducted over nearly a decade. To the disappointment of many, it found that intercessory prayer had no effect on recovery (Carey, 2006). In fact, 59% of participants who knew that someone was praying for them had postoperative complications, as opposed to 51% who were uncertain about whether they were being prayed for. The debate will undoubtedly continue.


One of the leading proponents of the spirituality and healing movement in American medicine is Dr. Herbert Benson. He originated the “relaxation-response” therapy to reduce stress in patients with hypertension, chronic pain, and other stress-related illnesses. Many people use prayer as part of the relaxation response (Benson and Klipper, 2000). Massachusetts General Hospital, a large medical center associated with the Harvard School of Medicine, is the home of the Benson-Henry Institute for Mind Body Medicine. Their website (www.massgeneral.org/bhi) describes the institute as “a world leader in the study, advancement, and clinical practice of mind/body medicine.” Mind/body medicine incorporates the relaxation response, positive coping strategies, physical activity, good nutrition, and social support (www.massgeneral.org/bhi/faq).


Another indication of the importance of meeting patients’ spiritual needs in health care settings is the increase in chaplain presence in some inpatient and outpatient settings. Chaplains are ordained clergy who have training and experience in pastoral care in health care settings and who have special skills in helping patients and their families with spiritual matters. Chaplains are typically on call around the clock, and in large medical centers, they have a presence in the hospital at all hours.


The Joint Commission, the International Council of Nurses, the American Association of Colleges of Nursing, and the National Council of State Boards of Nursing all acknowledge that spiritual nursing care is a responsibility that goes beyond calling the chaplain. Yet many nurses are reluctant to render spiritual nursing care. This reluctance may grow from feelings of inadequacy, lack of knowledge, embarrassment, their own spiritual uncertainty, lack of preparation, lack of privacy, lack of time, or failure to see it as a nursing role (McEwen, 2005).


Nurses are encouraged to view spirituality as one aspect of the whole human person and to assess patients for spiritual distress. They should recognize the individuality and value of each patient’s spiritual beliefs and encourage their use in coping with illness. Spiritual distress is a NANDA International (NANDA-I) (2009) diagnosis meaning “impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself” (p. 301). Patients who question the meaning of suffering and the meaning of life, who express anger at God or an other deity, or who view illness as punishment from their deity are experiencing spiritual distress. Spiritual distress can be painful and can hinder a patient’s progress. According to Eldridge (2007), nurses can help free a patient’s energy for healing by providing spiritual care.


Nurses with strong religious faith or deeply entrenched religious rituals have to pay attention to how they may use these beliefs with regard to spiritual care of their patients. As with every other domain of care, nonjudgment is key. You may have very significant disagreements with your patient’s religious beliefs, but it is his or her belief, not yours, and it is not your role to change your patient”s view. Proselytizing by nurses can be very upsetting for patients and can increase their spiritual distress. Your role is to help your patient access whatever higher power he or she believes in. This can be done as simply as providing the patient privacy, quiet, an open window shade, music, or your caring presence. If a patient asks you to read to him or her from his or her religious text, you can do this without risking your own faith if yours is different from your patient”s.


Sometimes patients ask nurses to pray with them or for them. If you are not comfortable with this, you can simply say, “Would you like for me to sit with you while you pray?” You can simply sit in silence, and, if the patient agrees, hold his or her hand while he or she prays (Figure 10-2). If you are not someone for whom prayer is part of your spiritual practice, you can simply tell patients who asks you to pray for them that you will have good thoughts for them. If patients trust you enough to engage you in their spiritual practices, they have paid you a great compliment. In addition, it is always appropriate to ask your patients if they would like for you to call a chaplain, rabbi, priest, or other clergy for them if they have deep spiritual needs that you cannot meet.


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FIG 10-2 In this illustration of a hospital scene during the Siege of Paris in 1870, two nuns pray for a dying man. Religion and nursing have been partners for centuries. (Photo used with permission from iStockphoto.)

Nurses are participating in the use of spirituality in healing. St. Francis Hospital’s Congregational Nurse Program in Evanston, Illinois, for example, is reaching more than 15,000 local families in an interfaith health project. After training as congregational nurses, nurses spend approximately 20 hours weekly at churches and other places of worship providing classes, counseling, and referrals. They dovetail their efforts with the spiritual beliefs and customs of each congregation. As you learned in Chapter 1, the faith community nurse concept is being implemented in numerous communities around the United States. By respecting and treating the whole person, these practitioners are affirming that a key dimension of health and healing is the spiritual dimension.



External influences on illness behaviors

External factors that bear on illness behaviors include past experiences and cultural group membership. Both directly influence how an individual perceives and responds to illness. The values that guide feelings about illness and steer a person toward particular methods of treatment are acquired primarily in the family of origin and in the culture.



Past experiences.

Some adults may accept being ill fairly easily and will accept care easily. It is unclear why some people more than others simply are able to acquiesce to illness, at least temporarily, and take on the sick role. Some adults, however, who as children received signals from their parents or adult caretakers that “it is weak to be ill” or “one must keep going even when not feeling well” may have difficulty accepting illness and the restrictions that accompany it. Other adults who experienced traumatic hospitalizations as children or who were threatened with injections for misbehaving may see hospitals and nurses as threatening. They are understandably affected by their early negative experiences. Nurses should determine the patient’s past experiences with illness and the health care system during a careful admission assessment. These findings can be used to individualize care.



Culture.

Culture has been discussed several times throughout this book and chapter, because it is difficult to discuss almost any topic related to health care without mentioning culture. Culture is a pattern of learned behavior and values that are reinforced through social interactions, shared by members of a particular group, and transmitted from one generation to the next. Culture exerts considerable influence over most of an individual’s life experiences. Meanings attached to health, illness, and perceptions of treatment are affected to a large degree by a person’s culture. Culture determines when one seeks help and the type of practitioner consulted. It also prescribes customs of responding to the sick. Culture defines whether illness is seen as a punishment for misdeeds or as the result of inadequate personal health practices. It influences whether one goes to an acupuncturist, an herbalist, a folk healer, or a traditional health care provider such as physicians and nurse practitioners.


Beginning in the early 1970s, schools of nursing began including cultural concepts in their curricula. Increasing numbers of universities and colleges offered graduate programs in transcultural nursing. The Transcultural Nursing Society was incorporated in 1981, and in 1988 it began certifying nurses in transcultural nursing. Through oral and written examinations and evaluation of educational background and working experiences, a qualified nurse can become a certified transcultural nurse (CTN). More information about this interesting certification can be found at www.tcns.org/Certification.html.


The Transcultural Nursing Society began publishing the Journal of Transcultural Nursing in 1989. By 1993, a resolution was adopted by the American Nurses Association’s House of Delegates to identify and determine strategies to promote diverse and multicultural nursing in the workforce.


In the decades since transcultural nursing was first emphasized in educational programs, the cultural makeup of the U.S. population has undergone rapid change. Census demographers, who study population trends, predict that today’s ethnic and racial minorities will outnumber non-Hispanic whites by 2042. Even sooner, by 2023, they will constitute a majority of the nation’s children younger than 18 years of age (Roberts, 2008). These cultural shifts mean that changes in the nursing workforce are needed to deal more effectively with commonalities and differences in patients. Significant disparities exist between the health status of whites and nonwhites in the United States. For example, the death rate for heart disease is more than 40% higher in African Americans than in the white population. Similarly discouraging disparities exist in death rates for cancer and HIV/acquired immunodeficiency syndrome (AIDS), among other diseases. Although these disparities may partly result from education, poverty, and lifestyle factors, there is a growing recognition among health professionals that racism may play a role. As a result, professional associations such as the American Nurses Association, The Joint Commission, and the federal government have all endorsed standards for culturally appropriate health care services.


In 2008, The Joint Commission announced its intention to revise and develop accreditation standards for hospitals to incorporate diversity, cultural, language, and health literacy issues into patient care processes. Some states have already passed legislation requiring health care professions to include cultural competence training in their educational and continuing education programs. The profession of nursing is largely white, whereas the nation is racially more diverse than ever before, which underscores the need for culturally competent nurses. Clearly, transcultural nursing is an important field of study, practice, and research and an essential one in today’s increasingly diverse society. The Joint Commission and The California Endowment published their recommendations in a document titled One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations (www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf).



The culturally competent nurse.


Cultural competence, defined earlier, guides the nurse in understanding behaviors and planning appropriate approaches to patient needs. Conversely, culture will also guide the patient’s response to health care providers and their interventions. The U.S. Office of Minority Health defines culturally competent health care as “services that are respectful of and responsive to the health beliefs and practices and cultural and linguistic needs of diverse patient populations” (U.S. Department of Health and Human Services, 2001, p. 131). Understanding a patient’s cultural background can facilitate communication and support establishing an effective nurse-patient relationship. Conversely, lack of understanding can create barriers that impede nursing care.


The shared values and beliefs in a culture enable its members to predict each other’s actions. They also affect how members react to each other’s behavior. When nurses work with patients from cultures different from their own and about which little is known, they lack these familiar guidelines for predicting behavior. This can cause anxiety, frustration, and feelings of distrust in both patient and nurse. Some of the issues that can arise when nurses care for patients from other cultures include stereotyping, communication difficulties, misperceptions about personal space, differing values and role expectations, ethnopharmacologic considerations, and ethnocentrism.

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Mar 21, 2017 | Posted by in NURSING | Comments Off on Illness, culture, and caring: Impact on patients, families, and nurses

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