Cultural Uniqueness, Sensitivity, and Competence

assimilation (ă-SĬM-ă-LĀ-shŭn)

complementary and alternative medicine (CAM) (KŎM-plĕ-MĔN-tĕ-rē, ăl-TŬR-nă-tĭv)

cultural bias (BĪ-ăs)

cultural competence (KŎM-pĭ-tĕns)

cultural diversity (dĭ-VŬR-sĭ-tē)

cultural sensitivity (SĔN-sĭ-TĬV-ĭ-tē)

culture (ĕn-KŬL-chŭr-Ā-shŭn)

ethnic groups (ĔTH-nĭk)

ethnocentrism (ĔTH-nō-SĔN-TRĬZ-ĕm)

melting pot (NŎN-jŭj-MĔN-tăl)

prejudice (PRĔJ-ŭ-dĭs)

stereotype (STĔR-ē-ō-TĪP)

wellness and illness

You have chosen a career that will give you an opportunity to meet people who are different from you.

You will discover that people think, feel, believe, act, and see the world differently from you and your family and friends. Log on to www.minoritynurse.com/about/index.html to check out featured articles about issues facing nurses.

Review the standards of the National Association for Practical Nurse Education and Service, Inc. (NAPNES) at www.napnes.org, and the National Association of Licensed Practical Nurses (NALPN) at www.nalpn.org. You will note that both organizations have embraced statements that describe the need of the licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide health care to all clients regardless of race, creed, cultural background, disease, or lifestyle. This is an ethical expectation.

Review your state’s Nurse Practice Act (NPA). You will find that failing or refusing to render nursing services to a client because of the client’s race, color, sex, age, beliefs, national origin, disability, or sexual orientation is listed as unprofessional conduct. The ethical expectation now becomes a legal mandate. Nurses could risk legal suits because of their ignorance of the culture of the client and resulting poor nursing judgment.

Not only do LPNs/LVNs need to provide care for all persons, but they also need to provide culturally competent care. Cultural competence is the continuous attempt of LPNs/LVNs to gain the knowledge and skills that will allow them to effectively provide care for clients of different cultures. Cultural competence is not gained by reading a chapter in a textbook or by looking up a culture in a reference book. It is developing an awareness of different cultures (cultural sensitivity) and continually learning about people who are different from you. Giger (2017) describes cultural competence as “a dynamic, fluid, continuous process whereby an individual, system, or health care agency finds meaning and useful care delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care” (p. 7).

When differences are identified in a health care situation, the LPN/LVN needs to suggest adaptations to the plan of care so the plan recognizes these differences. In doing so, the client will be encouraged to follow suggestions, avoid treatment failures, and return to health as quickly as possible. Practical/vocational nurses will then be able to say that they have truly met the client’s needs. The U.S. Department of Health and Human Services, Office of Minority Health (2019) provides a free E-learning program, Culturally Competent Nursing Care: A Cornerstone of Caring, grounded in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. These standards aim to advance health equity. Improve quality and help eliminate disparities (U.S. Department of Health and Human Services, 2019). Visit https://ccnm.thinkculturalhealth.hhs.gov/ to access this training.

Culture is a way of life. It is the total of the ever-changing knowledge, ideas, thoughts, beliefs, values, communication, actions, attitudes, traditions, customs, and objects that a group of people possess and the ways they have of doing things. Culture also includes standards of behavior and sets of rules to live by. Customs are the generally accepted ways of doing things that are common to people who share the same culture.

An important point about culture is that it is learned behavior. The culture of a group is passed on from generation to generation. From the moment you were born, you began to learn about the culture of the group into which you were born. The process of learning your culture (the way your group does things) is called enculturation. A result of enculturation is a worldview that is generally shared by persons with the same cultural background. The worldview, or similar ways of seeing and understanding the world, becomes the reality of the group. This reality fills every aspect of life. It is a cultural bias (a mental leaning) that is never proved or questioned by the individual. The worth of everything, either within or outside the group, depends on whether or not it fits the worldview of the cultural group. One’s worldview can lead to ethnocentrism, prejudice, and discrimination, unless modified by knowledge and experience.

Socialization is the process by which a person of one culture learns how to function in a larger culture. Right now you are being socialized into the career of practical/vocational nursing. You are learning how to think and act like an LPN/LVN.

People who belong to the same cultural group may develop the attitude, through their worldview, that their way of doing things is superior, right, or better than that of groups with different cultures (ethnocentrism). The group uses its culture as the norm against which to measure and evaluate the customs and ways of others. The group can be uncomfortable with people who display customs and behaviors that differ from their cultural group. Ethnocentrism is common to all cultural groups. When intolerance of another cultural group occurs, prejudice results. When rights and privileges are withheld from those of another cultural group, this is called discrimination.

Each Culture And Person Is Unique

Remember that each individual is unique and a product of their experiences, cultural norms, and beliefs (Giger, 2013). Giger and Davidhizar’s Transcultural Model (1991) provides a framework for caring for clients in a variety of settings focused on their unique personal identity. Giger and Davidhizar (1990, 2002, 2017) describe six cultural phenomena that are critical to the assessment of clients in providing data necessary for decision making in providing culturally competent care. See Fig. 10.1 for details. These six phenomena include communication, space, social organization, time, environmental control, and biological variations. A brief discussion follows.

In the nineteenth century, waves of immigrants from all over the world came to the United States. The United States was eventually called a melting pot, meaning that these immigrants had given up their native cultures and adopted the culture of the American people.

The 2010 U.S. Census included the categories of Hispanic/Latino/Spanish origin (if so, indicate if Mexican, Mexican American, Chicano, Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on), white, black, African American or Negro, American Indian or Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, other Asian (Hmong, Laotian, Thai, Pakistani, Cambodian, and so on), Native Hawaiian, Guamanian or Chamorro, Samoan, other Pacific Islander, or other race. Effective July 2019, data.census.gov will be the primary way to access Census Bureau data including Census 2020. If current trends continue, the U.S. Census Bureau predicts that minorities will make up 57% of the U.S. population by 2060 (United States Census Bureau, 2012).

In 2017, the Census Bureau’s American Community Survey reported the following distribution: 61% of the U.S. population is white, 12% black, 18% Hispanic, 6% Asian, 1% American Indian/Alaska Native, and, 1% Native Hawaiian/other Pacific Islander and 3% two or more races (Keiser Family Foundation [KFF], 2019). The concept of the melting pot has been replaced by the concept of cultural diversity, which refers to the many differences in the elements of culture in groups of people in American and Canadian society.

Cultural diversity goes beyond racial and ethnic groups. As an LPN/LVN, you need to define this concept more broadly so culturally diverse groups can also mean single parents, people who live in poverty, homosexuals, bisexuals, the wealthy, the poor, the homeless, the elderly, and people with disabilities.

The concept of race as a means of categorizing people by biologic traits has come under attack by social scientists. These scientists suggest using ethnicity as a more accurate means of capturing the great diversity found in over 7.753 billion people in the world (World Bank, 2021). Members of ethnic groups are a special type of cultural group, composed of people who are members of the same race, religion, or nation, or who speak the same language. They derive part of their identity through membership of the ethnic group. Examples of ethnic groups in the United States include Italian Americans, African Americans, American Indians, Asian Americans, German Americans, Mexican Americans, Jewish Americans, Arab Americans, Greek Americans, Finnish Americans, and many more.

You have started the long road to becoming an LPN/LVN who gives culturally competent care. Up to this point, participating in this chapter has given you the opportunity to do the following:

Your next step to cultural competence is to develop a knowledge base for a few cultures that are different from yours.

Imagine this scenario: a 60-year-old client requires an urgent surgical procedure. The health care provider is frustrated as the consent form still is not signed and surgery is imminent. This client speaks limited English. You are struggling to determine why the consent is still not signed. Through discussion the husband explains the decision-making role of the elders important to their family’s cultural lifestyle and research, using the Dimensions of Culture website (www.dimensionsofculture.com), you conclude that people often need extra time to sign consent forms, as discussion with elders and the family (clan) needs to occur. Given this information, you assist the client in contacting their elders, the health care provider obtains consent, and surgery occurs as planned.

Each client of a different culture needs to have data gathered regarding activities of daily living (ADLs) and personal health beliefs and practices. Develop a fact sheet for collecting data for a client.

Use websites such as https://www.thinkculturalhealth.hhs.gov/ to access general information about caring for different cultural groups. This information is helpful when you are dealing with a client from a culture with which you are not familiar because they offer general information about, for example, wellness and illness beliefs and practices, nutritional preferences, and communication issues. These quick sources of generalities of various cultural groups are a starting point for learning which topics to include when collecting data (assessing) that must be clarified and validated with the individual client. Remember that general group behavior sometimes explains observed behavior but it is not predictive of individual behavior. Assumptions based on generalizations should not be made. When using this information, avoid stereotyping your client. Use Box 10.3 as a guide to help you avoid falling into the stereotype trap.

Suspect cultural differences when a client is not following the plan of care, refuses treatment, labeled by some erroneously as a “problem” client and so on. Question the client about their ADLs and wellness and illness beliefs.

Jackson (1993) offers suggestions for finding out about clients’ health beliefs, along with guidelines for developing plans of care that incorporate those beliefs through a process with the client. Jackson points out that discovering specific health beliefs is easier if the nurse is familiar with a specific culture, but this is not absolutely necessary. Jackson suggests ways of co-creating a treatment plan with culturally diverse clients. The LPN/LVN can collaborate with the professional nurse to incorporate these beliefs into the client’s plan of care: