Evidence-based research suggest the existence of globalization as a primary reason for the introduction of new challenges within the practice of nursing. The usage of technology among patients, including the widespread availability of the internet and app for mobile devices designed to monitor health information, presents a wedge between patient and physician by allowing an alternative technology to sometimes take the place of the traditional doctor’s visit. In many cases, a person can engage in communication with a healthcare professional or agencies with a simple click of a button. Since the accessibility of health information has become a global phenomenon, there are more opportunities for people to connect with appropriate health care solutions in different locations. The reality does not only affect professionals within the health care industry, but can been seen as impacting nearly all client-driven forms of operation. Even though communication has become more streamlined, healthcare professionals must ensure compliance with the Health Insurance Portability and Accountability Act and adhere to proper protocols for any communication or direct contact with clients. Despite the current landscape of nursing, some professionals may find the process of communicating with patients of a different culture or legally protected category like age and gender to be difficult. However, despite these prospective challenges, some professional do not receive adequate training on how to handle interaction with clients who differ from them in a variety of categories. The nursing profession commands the efficiency of such interactions; professionals may come into contact with all of people whether they are the diverse people native to their country, travelers, or immigrants. Nursing professionals are people who will come into contact with all sorts of people whether they be the diverse people native to their country, travelers, or immigrants. In order to ensure patients receive the highest quality of care, it is important for nursing professionals to develop a holistic view on the importance of culture and the impact it has on the field. The proceeding research will explain the impact culture holds on the practice of nursing, the identification of emerging challenges and recommended solutions. Evidence-based research suggests culture, as a social scientific construct, plays a profoundly significant role in shaping the way nurse practitioners and other professionals who help patients solve health issues.
What Is Culture and Why Is It Important?
While the concept of culture does not refer to the medical terminology referring to the nature of a particular element or instance of disease, the terminology primarily functions as a way of explaining social phenomena. Today’s academic literature and even some media reports use the term as a way of explaining human behavior. In the field of nursing, culture describes the shared patterns of interaction and behaviors, cognitive constructs, and affective understanding that is created through the process of socialization (Kroeber & Kluckholn, 1952; Harris, 2001). Shared patterns of interaction and behavior can include customs such as rituals, and could play a significant factor in deciding how to handle a potential patient. Cognitive constructs can be commonly held beliefs or ideas that are relative to the culture. The process of socialization refers to the method through which people become social beings. The socialization process includes how people learn their social identitites and turn them into roles (Kroeber & Kluckholn, 1952). Culture encompasses many aspects of a patient’s reality: collective knowledge, beliefs, attitudes, experiences, meanings, hierarchies, religion, roles, spatial relations, notions of times, and concepts of the universe that have been developed by a specific group of people. Culture may also play a role in assigning how the patient perceives themselves in relation to hierarchy, privilege, and oppression. These things are developed and maintained through generational exchange through different forms of communication. Essentially, people learn how to be themselves through the transmission of their culture.
Nurse practitioners exhibiting the appropriate level of culturally sensitive toward clients understand the complexity of the concept of many different vantage points. Successful health care professionals understand the importance of acknowledging culture, but also the social identity differences between the cultures. Exhibiting sensitivity toward gender, religion, ethnicity, social economic status, educational opportunities, and generational level remain important factors for healthcare professionals to consider.. These identities have all been shaped by the culture that surround people and are important for consideration. For example, a Muslim man in France may have a completely different cultural context than a Jewish woman in Spain. These differences make these people who they are and affect the way that they see and act upon the world. Therefore, a person’s culture may impact the line of communication between the patient and healthcare professionals within hospital and home-based settings.
While health care professionals do not use discriminatory practices in order to decide on the type of health care solutions to provide, culture can be used to differentiate people from one group to another. This is because culture is a collective set of knowledge that is demonstrated both explicitly and implicitly through patterns. There is an abundance of cultures throughout the world, each one with its own system of knowledge and its own way of life. Each culture has their own behavior, values, beliefs, and symbols which the subconsciously accept. These things are taught since young explicitly through direct education and implicitly through observation. Culture often times can feel as if it is natural because of the way that it is ingrained in people’s upbringing. However, all aspects of culture are learned which is why it is okay that each culture is different. Each culture has come to be based off of the circumstances and situations that a group of people have encountered. Sometimes a patient may need to make a special request for before receiving services due to cultural rules based on age, religion and other factors.
Each culture has its own set of features that define it against other cultures. This also means that in different cultures, there are different things that are considered to be culturally permissible, while other things are not. For examples, in some cultures it is believed that elders are especially important because of their past experiences in life. It is believed that elders must be shown a different form of respect than everyone else, so people behave differently towards them than they do their peers. One such case of this is in Korean society where elders are addressed with honorifics in order to distinguish them from other people. However, this belief is not one typically held in America. Though, in some aspects elders are respected, there is no special form of language used to distinguish them from other people. In Korean society, this distinction may be one that feels natural to the people who grew up there. However, in an American perspective, it seems different and unnatural. This, however, is not an issue of what is natural, this is an instance of culture. Though culture may seem like a natural thing, it is not. Culture is a set of learned social behaviors and do not dictate what is scientifically or biologically human, but rather shows that malleability of human nature. Being able to distinguish between what is and what is not culture is important because this knowledge will help people to better understand differences without demeaning the people who have them.
Relevant Cultural Theories
An exercise in evidence-based research requires an examination of applied cultural theories. The most widely accepted concerts are the following: cultural determinism, cultural relativism, and cultural ethnocentrism. Cultural determinism theory states that the behaviors that people learn through culture are what determine human nature. In basic terms, people are what they learn. This definition positions human nature to be one that is malleable and consistently changing based on new things that are taught. However, it is also suggesting that humans are stagnated based on what they learn, meaning that humans cannot control what they learn and are at the mercy of culture for knowledge. This theory is relevant because understanding that human nature can change helps people to better understand that there way of life is not the only way of life and that new ways of life can be learned. Though these new ways of life can be learned, it is important to go about doing the teaching in a way that is respectful and cognizant of other people’s cultures. This is particularly important to remember in nursing where there is a great deal of contact with people from other cultures. Cultural determinism is just one of the theories that is relevant to the way that nursing is practiced. Patient client relationships occur efficiently in the absence of disruptions based on cultural communication.
Another cultural theory that is relevant to the way that nursing is practiced in society today is cultural relativism. The term refers to the notion that there is no culture that is superior or inferior to another, but rather that all cultures are different. This thought derives from the fact that there is no scientific standard to decide the value of a culture. In recognizing this, the theory notes that before a person makes a judgment or takes action against another culture, that they should first gain information about the nature of the cultural differences between the societies. In having a better understanding of where someone is coming from and why they are the way they are, parties from different cultural contexts are more likely to understand each other. Cultural relativism states that the worth of different cultures fall are relative because there is no real standard to base it off of. Cultural relativism is another theory that is relevant to nurses.
The final theory that will be included because of its relevance to nursing practitioners is that of cultural ethnocentrism. The term involves the belief that a person’s own culture is superior to other cultures. This often manifests itself in judgments of other cultures as lesser by judging them to have a distorted version of one’s own culture. This occurs as a result of ignoring environment factors. By not recognizing the differences between cultures or by belittling them, people are unable to adequately work with people who are different from them. Cultural ethnocentrism is often seen throughout humanity, but particularly in the nursing profession. This is an issue not only in practice, but in ethics. If everyone is meant to receive equal and fair treatment, then an ethnocentric view can be detrimental to that. If people are treated as lesser because of coming from a different culture, then there will be all sorts of negative effects that come with it. These effects will be discussed in the remainder of this paper. In order to give everyone access to quality healthcare, ethnocentrism must be addressed. An issue in the nursing profession is that people hold ethnocentric values that are not addressed educationally or in practice. These ethnocentric values have a negative effect on the overall health of people from different, generally minority cultures. Therefore, a flexibility among healthcare professionals to exhibit an awareness of cultural ethnocentrism represents an effective strategy for developing strong patient-client relationships.
Issues with Culture in Nursing
Culture is what informs beliefs in a particular culture. This includes beliefs about healthcare. Culture informs a group’s perceptions on health promotion and illness prevention. Culture is also used to determine the cause, the methods used to detect and treat the illness; who is considered ill and who is considered healthy; how people who are ill are cared for; who one goes to when they are ill; as well the expectations, social roles, and relationships that guide the dynamic between patients and their health care provider. This means that culture guides a person in all levels of their decisions about health care including whether or not they need it and how they behave once they have engaged with health care providers. Culture has a huge influence over the health of a society. In order to provide quality healthcare for all patients, culture must be considered. There are several methods that can be used. In order to fully understand what culture is and how it affects people, there are many things that must be considered.
Reconciliation of Cultural Differences
Differing cultures is a reality that is not going to change anytime soon. People are going to come into contact with people who are completely different from them more and more often. Unfortunately, there aren’t many avenues for people to intentionally address the feelings that arise with these situations. It also may be unclear on how one is supposed to work with people who are different from them as some things that feel natural to a practitioner may seem alien to a patient. In order to circumvent these issues, it is important that people build their cultural competence. Cultural competence is a skill that can be used to work with people from all backgrounds efficiently and respectfully. It is a challenging skill to curate because it involves intense critical reflection and questioning of one’s self.. It also requires a lot of effort as it is a skill without an end goal and one that must be continuously cultivated. However, once these steps are implemented, nursing practitioners will be on their way to working with people all over the world and will also have a better understanding of their own cultural environments. Following are a set of stages that can be used in order to build cultural competence.
Cultural Self Awareness
Cultural self-awareness is what happens when health care professional deliberately goes through the cognitive process of evaluating and understanding their own cultural values, beliefs and practices. It is important for health care professionals to realize that the way that they view the world involves their culture as well. The meeting between two people of differing cultures should not be viewed as normal vs others in an ethnocentric manner but rather as the coming together of two different perspectives on life. This is then followed by the process through which professionals learn to become sensitive and appreciate the cultural characteristics of their patients. It may not be possible for people to fully remove their own cultural lens on life. However, being able to recognize that each person has their own cultural lens will help people to be more insightful when attempting to understand other people’s behavior and a person’s own cultural biases. Examining one’s own prejudices, biases, and attitudes towards diverse group that have developed through culture or through one’s own interactions help people to have a better understanding of their own cultural self and lessens instances of cultural ethnocentricity. Cultural self-awareness is an important step for health care professionals to take if they want to attempt to ameliorate the negative effects that can occur with transcultural communication.
Cultural Knowledge
Cultural knowledge is the process that occurs when one seeks out and obtains a knowledge of various world views of differing cultures. The goal of obtaining cultural knowledge is to gain a better understanding of patient’s worldview. This knowledge obtainment can happen in various manners. Various fields are dedicated to the understanding of culture and its applications. Learning about culture through fields such as sociology, psychology, and anthropology is a recommended method of learning more about a person’s culture. This knowledge can be achieved through interaction with people from different cultures. This interaction is a more personal connection to the knowledge. This knowledge should be related to health, but also to the social hierarchies within a community that could affect the differing perspectives and privileges surrounding health within a community. Cultural knowledge means that a professional has some sort of understanding of the group that they are working with. They are not working based off of assumptions and have a general knowledge that acknowledges some factors that may be different when approaching health.
Cultural Skills
There are many skills that can be developed by health care professionals that relate to culture. One of these skills is the ability to conduct a cultural assessment. All patients deserve to have a culturally assessment, not just those that appear to be ethnically different. This is particularly important because of the differences that are inherent within culture. Having a cultural assessment will ensure that the healthcare provider does not assume that there are no cultural differences between themselves and the patient. Two people could phenotypically look similar and have two completely different cultures. Two people could look completely different and have a similar cultural context. There shouldn’t be assumptions on what a person’s cultural context is just because of their phenotypical traits. Developing cultural skills is an important part of becoming a culturally competent healthcare professional.
Cultural Encounters
Though it was noted in cultural knowledge, cultural encounters are a very important part of the process of becoming a healthcare professional who can work with people of all backgrounds. Cultural encounters are what happen when a person directly interacts with a person from a cultural background that is different from theirs. Though the knowledge obtained from books is important in its own right, there is great variation between people within any given society. Through interacting directly with people from different cultures will help burses to verify, validate, negate, and refine the knowledge that they have learned from books. This is a way to gain experiential knowledge about a certain group. This knowledge will serve as a way to develop a framework in developing culturally sensitive and relevant interventions. Using one’s cultural awareness and with practice through cultural encounters, nursing professionals will be able to send and receive nonverbal and verbal messages of communication effectively and appropriately outside of their own cultural context. Cultural encounters are an important step in becoming a culturally inclusive health care professional.
Valuing Difference
Diversity is not just something that happens between healthcare practitioner and patient, but rather it is happening all throughout the world out in the open and behind closed doors. Diversity needs to stop being seen as an issue, but rather to be recognized as a positive attribute of people and of organizations. The goal of this is to emphasize the positive aspects of diversity and grow them rather than methods that focus simply on eradicating or diminishing the negative aspects. Cortis incorporates a model of managing diversity developed by Walker in her description of how to manage diversity. The approach states that:
“1. People work best when they feel valued.
2. They feel most valued when they believe that their individual and group differences have been taken into account,
3. The ability to learn from people regarded as different is the key to becoming fully empowered, and
4. When people feel valued and empowered, they are able to build relationships in which they work together synergistically and on an interdisciplinary basis.”
This means that it is not only recognition of differences and the ability to work with differences that encourage culturally inclusive practices, but also the acceptance of and valuing of the existence of those differences. It further shows that people are empowered and are able to be more effectively build relationships when their differences are valued. This is important for the heath fields in terms of patient-healthcare interactions, but also in terms of workplace relationships.
The concepts addressed in the managing diversity are important aspect of becoming culturally inclusive. The principals included address issues on an organizational level, rather than just on a personal level. It requires that professionals are accountable to their patients and to their coworkers and creates an environment where people can further pursue the knowledge and skills needed to become even more inclusive. Cortis notes that environments that only tolerate difference, rather than valuing it convey the message that there is something wrong with or negative about the differences that a person has. This viewpoint is unacceptable and comes with consequences that often rears its ugly head in the form of oppression and often times, racism.
Addressing Racism
Racism is a form of oppression that occurs in many cultures throughout the world. There are different levels of racism. One form of racism is known as institutional racism. Institutional racism is the name for the structural aspect of racism within society that is defined by the social patterns of inequality among racial lines. It is what happens when an institution is unable to give fair professional services to a person because of their phenotypical qualities, culture, or ethnicity and can be detected in the discriminatory attitudes, beliefs, and processes that generally disadvantage people of color. These behaviors can be explicit or implicit and generally run through the veins of a given institution. Yet, often times they are not recognized as open racism.
There is a concept that is pervasive in America called “color blindness.” Color blindness is where people believe that they don’t make judgments based off of the color of a person’s skin. This thought in nursing often leads to thoughts that the way a person should be treated has nothing to do with a person’s race, ethnicity, or color with the assumption being that the interpersonal relations are not influenced by the group membership. The underlying concept to color blindness is that race and racism have become taboo subjects and that people should not notice each other’s racial group. The concept of colorblindness has a lot of consequences that are particular to the nursing field. The main one being that it silences the voices of people who are experiencing racism. Colorblindness denies the differing experiences that people are having while minimizing the people who are experiencing those obstacles. As addressed earlier, rather than ignoring differences, people should address them and learn to value the fact that they exist. In doing so, they should also address the racism that exists within society.
There are several steps that can be taken as an individual and as an organization to ensure that health care organizations are more culturally inclusive. These stages include becoming more culturally self-aware, gaining cultural knowledge, cultivating cultural skills, experiencing cultural contact, learning to value differences, and understanding the implications of racism on the field. Going through these stages intentionally will enable healthcare professionals to more efficiently work with people of differing cultures.
Applications
There is a lot of theory behind the ideas of cultural competence and why it relates to the nursing field. However, these theories are useless if they do not work in real life. It is the practicality aspect that matters in nursing. The following section will include examples of cultural competence’s uses within the field of nursing.
Conflict Management
In the workplace, there are many opportunities for conflict to arise, including cultural conflict. Conflict among nurses can have consequences that affect more than just the people directly involved. Workplace conflict between nurses can impact teamwork, retention, and the quality of patient care. Conflict is what happens when there is discord between two or more party’s ideas, beliefs, or goals. These are all things that come from culture. Since, the workplace is filled with people who are different in various ways, conflict will happen. Conflict is not inherently negative, but can become so if it is handled inappropriately or ignored. Having an understanding of culture and being able to use cultural skills can help to mitigate conflict within the workplace. Understanding culture is akin to understanding people. Being able to understand what influences people’s action will help a health care professional to be able to better understand what underlies a conflict. The emotional intelligence that one must have to work with people of different cultures than them is the same type of emotional intelligence needed to ameliorate workplace conflict practical application of cultural competence in nursing is in workplace conflict management.
New Zealand Maori
The Maori are the people of aboriginal descent in New Zealand. They came to New Zealand via canoe about a thousand years ago. Maori traditional culture has a legend that tells the great migration story of the Maori. It is said that the Maori came from a city called Hawaiki and came to settle in Aotearao (New Zealand) and this story is passed intergenerationally through story and song. Maori live all over New Zealand, however they are mostly in the northern part of the island. At one time the Maori were the sole inhabitants of New Zealand. However, that changed in 1769 when white Europeans arrived. With them, the Europeans brought firearms and infectious disease, both of which were deadly to the Maori people. Despite this, the Maori and the European settlers lived together peacefully. This was until New Zealand became a British Colony when the Treaty of Waitangi was signed in 1840. At this point, a lot of settlers from Britain immigrated to New Zealand leading to the disregarding of the treaty by enough people (Schub & Smith, 2014). From this point on, the people of Maori were at a disadvantage, having their language restricted and the resources taken. This is the history of the Maori people and how New Zealand came to be what it is today.
There are several prominent health conditions and risk of health conditions of the Maori people. For example, the Maori people have higher rates of infant mortality than any other group of New Zealanders. One of the most surprising facts is that although the Maori only make up fifteen percent of the population of New Zealand, seventy percent of the instances of sudden infant death syndrome (SIDS) occur among infants of Maori descent. The risk of and occurrences of health conditions doesn’t just happen in terms of infants, it also relates to other life altering illnesses. The mortality rates of the Maori people for cancer are higher than those of the rest of New Zealanders. Maori people are nineteen percent more likely to be diagnosed with cancer than other groups and seventy-eight percent more likely to die of cancer than people who are not Maori. The Maori people are twice as likely to be cigarette smothers, 50 percent more likely to be overweight to the point of obese and 3 times as likely to be both a smoker and obese. They are also twice as likely to commit suicide or to be involved in a motor vehicle accident than other New Zealanders. The average life expectancy of the Maori people is less than that of other New Zealanders. They are also more likely to exhibit social and behavioral problems including drug abuse, alcoholism, and domestic violence. Adding to this Maori comprise fifty-one percent of the prison population in New Zealand. There are several problems that are experienced by the Maori in comparison to their non-Maori counterparts. It is the belief that rather than genetic factors being the proprietor of these issues, that there are lifestyle factors at play including low employment rates, low socioeconomic resources, poor educational levels, and racial discrimination. The Maori were experiencing all sorts of disparities in terms of health due to issues that lay outside of the health. They way that these issues were dealt with demonstrates the importance of cultural competence of nursing practitioners.
Irihapeti Ramsden is a Maori nurse who was working within the Maori community. She recognized that there were several cultural barriers that stopped Maori people from being able to achieve holistic health. In response to this issue she created an educational framework for nursing practitioners called “cultural safety.” This framework has been a part of the New Zealand nursing curriculum since 1992. This framework was created based off of the belief that nurses empowered themselves and their patients when they used culturally appropriate programs and behaviors to deliver healthcare. Maori identity is based on kinship relationships and reflects more of a collectivist mindset than that of the rest of New Zealanders. Though some of this collectivist mindset has been diminished through enculturation and assimilation, it is still a cultural value that they hold that is being destroyed by the presence and overvaluing of Western education. The cultural safety framework used this knowledge as well as others in order to make it as known as it is today.
The cultural safety framework is unique to nursing practitioners in New Zealand. This education tool is used to teach nursing students to how to recognize and understand the dynamic behind cultural, person, and professional power and the ways in which these shape relationships in nursing and health care. It takes the shift away from the fact that diversity exists and digs deeper by emphasizing the fact that there needs to be safety when working with diversity. The process of becoming culturally competent was hard for some people as it felt emotionally threatening for them to have to evaluate their own identity. However, once the experience was had they were better able to understand themselves and appreciate the positive aspects of culture. Since its implementation, the overall health of all New Zealanders has improved
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Conclusion
Globalization continues to make its mark on humanity, representing the single greatest challenge to the field of health. The necessity for health care professionals to demonstrate effective communication with people from other cultures remains a top priority for hospitals and care institutions. The nursing profession is one in which there is great importance in recognizing the impact that culture has on people. Culture plays a significant role in health care as it determines who believes they are sick, what people do when they are sick, and how they are once they seek help. In order for nurses to give quality health care to everyone who comes to them, they must be able to exhibit cultural competence. This paper outlines several steps that people could take in order to achieve that competence including gaining a cultural self-awareness, obtaining cultural knowledge, cultivating cultural skills, engaging in cultural interaction, valuing diversity and addressing racism. Supporting evidence outlines two examples of how using these steps positively influenced both working conditions and health care given to patients. Cultural competence significantly aides nurse practitioners ability to community with clients, thereby increasing the prospect of helping the patient receive the proper healthcare solution.
