CARING IN NURSING PRACTICE,
CULTURE AND ETHNICITY
NURSING’S THERAPEUTIC VALUE
Nursing is both an art and a science that leads to therapeutic outcomes in clients. The term therapeutic describes actions that are beneficial to the client.
Definition of Nursing
According to the American Nurses Association (ANA) (1995), nursing is defined as “the diagnosis and treatment of human responses to actual or potential health problems” (p. 9). This definition places nursing’s focus on the individual experiencing a health problem rather than on the problem (or disease) itself—that is, on caring for clients as they deal with health issues. Fitzpatrick (1983) perceives nursing “as facilitating the developmental process toward health, thereby helping clients to more fully develop their human potential” (p. 296). The idea of helping persons to grow and achieve their potential is pivotal iursing.
The Canadian Nurses Association (1986), similarly, describes nursing as a caring relationship that helps the client achieve and/or maintain an optimal level of health.
Nursing: A Blend of Art and Science
Nursing creates therapeutic change through the application of scientific principles. As the science of nursing has rapidly progressed over the past decade, nurse theorists have formulated various frameworks by which to organize nursing’s unique body of knowledge. While continuing to expand its theoretical base, nursing must remain firmly rooted in its essence—caring. In other words, nursing does not rely on science alone. The “art” of nursing refers to the caring, compassionate manner in which interventions are performed. “Nursing art is defined as helping patients create coherence in lives threatened by illness and change” (LeVasseur, 1999, p. 48). A prerequisite for the nursing art is the nurse’s committment to helping the client; this trait is also referred to as intentionality. As Isenalumhe (2000) states: Therapeutic use of self marks the art of nursing as different from the science of nursing. . . . The theories, concepts, and standard procedural techniques for clinical performance or practice in any profession constitute its scientific base. . . . The art of nursing can be learned, through shared, as well as hands-on, experience. (p. 25)
Purposes of Nursing
A therapeutic relationship is one that benefits the client’s health status. The therapeutic relationship is based on the belief that a person has a natural drive toward optimal health. Caring—being willing and able to nurture others—is an attribute of the effective nurse. Curing rids the client of the disease or disability; caring nurtures the person even if the disorder is incurable. When it is understood that complete, or perhaps even partial, recovery is not possible, nursing goals focus on facilitating comfort by alleviating pain and promoting as much client autonomy as possible. Nursing promotes healthy lifestyle behaviors, prevents the development of illness and/or injury, and restores individuals to their optimal level of functioning.
Another purpose of nursing is to improve client satisfaction with the delivery of health care services. Consumer satisfaction greatly influences where services are provided. “Nurse caring is an important predictor of patient satisfaction” (Dingman, Williams, Fosbinder, and Warnick, 1999, p. 30). Nurses who demonstrate caring behaviors enhance the quality of care provided; thus, clients are more satisfied with the care delivered in a caring, compassionate manner. The accompanying display lists some specific caring behaviors.
Caring behaviors demonstrated iursing practice
• Demonstration of concern
• Anticipation of client needs
• Providing preprocedural information
• Alleviation of anxiety and fear
• Effective communication
• Responding to client requests
(Data modified from Dingman, S. K., Williams, M., Fosbinder, D., & Warnick, M. [1999]. Implementing a caring model to improve patient satisfaction. Journal of Nursing Administration, 29(12), 30–37.)
Nursing: A Healing Modality
As stated by LeVasseur (1999), “Nurses endeavor to nurse patients through an illness to a satisfactory outcome, whether this is regaining health and function or coping with disability or the ultimate transition of a peaceful death” (p. 61).
Nursing is a humanistic discipline that provides care from a holistic framework. Seeing and responding to the client as a whole person instead of a disease, disorder, or case leads to complete care of the total person.
Healing is the process of recovery from illness, accident, or disability. This return to an optimum level of functioning may occur rapidly or gradually. Healing encompasses the physical, emotional, and spiritual domains of individuals. Nursing and caring are essential components in the healing process. See Chapter 15 for further discussion of nurses as healers.
CARING: AN INTEGRAL COMPONENT OF NURSING
Caring is a universal value that directs nursing practice. Leininger (1981) defines caring in the nurse-client relationship as “the direct (or indirect) nurturant and skillful activities, processes, and decisions related to assisting people to achieve or maintain health.” Even though clients cannot always be cured, caring is ongoing within the nurse-client relationship.
There are numerous concepts relative to caring iursing. Some major ideas related to caring have been postulated in Watson’s Theory of Human Caring,
Leininger’s Theory of Transcultural Caring, and Benner’s Novice to Expert model.
The following carative factors are directly related to the science of caring (Watson, 1999):
• Developing a humanistic-altruistic value system
• Nurturing faith-hope
• Cultivating sensitivities to one’s self and others
Leininger identifies several behaviors as caring and states that these behaviors occur in various cultures; see the accompanying display.
Caring—being willing and able to nurture others—is a hallmark of the effective nurse. Caring occurs when a nurse acts in a genuine, authentic manner with the client. The professional mask is removed, allowing the nurse to respond in a compassionate manner. Providing emotional support is central to the act of caring.
Caring is more than an intuitive process; it can be learned both intellectually and interpersonally. One learns caring by interacting with others who demonstrate caring. Wheurses exhibit caring behaviors, they are serving as role models—to students, colleagues, clients, and families. Caring is a process and an art that requires commitment and knowledge. Caring is a combination of behaviors and attitudes. The way in which nursing actions are implemented expresses caring. Specific behaviors that indicate caring are provision of information, relief of pain, spending time with clients and families, and promoting client autonomy. Treating each client in a dignified, courteous manner is the true expression of caring. Touch is an effective method for communicating a sense of caring (Figure 11-1).
Touch, no matter how well intended, may sometimes be misinterpreted by a client. Therefore, it is wise to avoid touching clients who are suspicious, hostile, or very confused.
Dingman et al. (1999) described the following as nursing behaviors that demonstrate caring:
• Introduce self to client.
• Call clients by their preferred names.
• Spend time with the client to review the plan of care.
Care in the High-Tech Environment
Caring is the soul of nursing. It is what clients want and need most from nurses. Although technological advances have resulted in many possibilities in health care, the major risk of reliance on technology is that clients can be perceived as objects. The focus of attention becomes the disease, instead of the individual experiencing the illness. The professional nurse treats each client with respect and dignity because “persons in a technologically driven health care system will feel the need to be comforted, listened to, and treated with the utmost dignity and respect” (Bernardo, 1998, p. 47).
Depersonalization is the process in which individuals are treated as objects instead of people. Some dehumanizing actions are checking on the equipment and not the person, failing to respond to the client, or communicating a lack of interest in what the client says.
Nursing care counteracts depersonalization by seeing that “technology can be used so that care is person focused rather than technologically focused” (Bernardo, 1998, p. 41
The reason people are admitted to acute care facilities is to receive nursing care. Most diagnostic testing, treatment procedures, and some surgical interventions can be performed in outpatient settings such as clinics or physicians’ offices. While receiving care, people want to be treated with compassion. The nontechnical element of care makes clients feel cared for as individuals; the use of high-touch activities communicates caring. As society continues to place a high value on technology, caring is often undervalued. Nursing makes a crucial contribution by valuing both care and technology.
Ideally, “in the best of nursing practice, science and technology are only the tools for caring” (Benner & Wrubel, 1989, p. 211). Nursing care counteracts depersonalization by emphasizing a client’s individuality. It is through caring that the nurse humanizes the client.
Simpson (1999) states, “no matter how advanced we get technologically, humans and human interaction are at the core of everything that humans do” (p. 33).
NURSE-CLIENT RELATIONSHIP
Caring is communicated interpersonally, thus the vehicle for communicating a caring intent is the nurse-client relationship.
The nurse-client relationship is the one-to-one interactive process between client and nurse that is directed at improving the client’s health status or assisting in problem solving. The primary goal of the relationship is the client’s achievement of therapeutic outcomes. The nurse-client relationship is a planned process that focuses on meeting the needs of the client. There are many differences between the therapeutic nurse-client relationship and a social relationship
The interactive process between client and nurse greatly influences the client’s progress in healing. Peplau (1952), the first nurse theorist to define nursing as an interpersonal process, viewed the nurse-client relationship as the basis of nursing. Interpersonal skills are the foundation for establishing the therapeutic relationship.
Only through interacting does the nurse have the ability to adequately assess the client’s needs, teach methods for best meeting those needs, empower the client to achieve goals, and evaluate the outcome of nursing interventions.
Phases of Therapeutic Relationship
The three phases of the nurse-client relationship are orientation, working, and termination. These phases overlap and influence each other. Each phase is characterized by specific client behaviors and nursing goals. Figure 11-3 illustrates the phases of the interactive relationship.
Orientation Phase
The orientation (or introductory) phase is the first stage of the therapeutic relationship, in which the nurse and client become acquainted with each other, establish trust, and determine the expectations of the other.
Usually, the only knowledge the client and nurse have of each other is preconceived ideas. The nurse gets to know the client as an individual by giving up biases and judgmental thoughts. This stage is especially important because it is the time in which the foundation for the relationship is established.
The most important nursing goal during the orientation phase is to assess the client—to determine the client’s needs, knowledge base, strengths and limitations, coping mechanisms, and support system. Often clients do not express their needs directly; behavior is the only clue to their needs. The nurse’s goal is to determine the real meaning of the behavior and to assess the client’s perception of the most crucial needs and problems.
To reduce a client’s anxiety and promote trust, the nurse provides some specific information. Information the client should receive during the orientation phase includes:
• Nurse’s name
• Nurse’s role
• Confidentiality and its parameters
• Reasons the nurse must ask questions
The usual response of the client in the orientation stage is anxiety, which can result from several factors:
• Fear of the unknown
• Pain or distress
• Unfamiliar environment
• Undergoing unfamiliar, often painful, procedures
• Loss of freedom
As a result of the client’s insecurity, anxiety escalates.
Because anxiety is communicated interpersonally, the nurse should project a calm, relaxed attitude during every interaction with the client to decrease anxiety.
Another behavior frequently exhibited by the client during the orientation stage is testing. The client attempts to determine the degree of the nurse’s trustworthiness. Through behavior, the client is asking:
• Is the nurse truly willing to help?
• Is the nurse competent to help?
• Is the nurse reliable and trustworthy?
The nurse answers such questions through consistent, reliable behavior which promotes the development of trust.
Working Phase
The working phase is the second stage of the therapeutic relationship in which problems are identified, goals are established, and problem-solving methods are selected. Actions are chosen after carefully considering both the consequences of actions and the client’s values. It is necessary to consider the client’s value system when determining problem-solving methods. Client participation increases when consideration of values is incorporated into care planning. See Chapter 16 for a complete discussion of the concepts of culture, one of which is a system of dominant values.
The client engages with the nurse in active problem solving to achieve mutually developed outcomes. The nurse seeks to maximize the client’s success in problem solving. Behaviors that indicate the client is in the working phase are:
• Asking questions about own problems
• Seeking clarification from the nurse
• Being attentive to instructions
• Asking for more information about his role in recovery
Nursing goals to be achieved during the working phase are to:
• Reevaluate goals and related activities as new information arises
• Support realistic problem-solving activities of the client
Termination Phase
The termination phase is the third and final stage of the of the therapeutic relationship. It focuses on the evaluation of goal achievement and effectiveness of treatment.
It is important that the client has been prepared for the final stage of the relationship by encouraging discussion of feelings. Some clients welcome this final phase, whereas other clients who have become overly dependent on their nurse will be more resistant to saying goodbye.
Planning for termination is actually initiated during the beginning of the relationship. A relationship that ends abruptly is likely to place the client at risk for difficulties such as increased:
• Anxiety levels
• Frustration
• Suspiciousness
• Unwillingness to engage in future relationships with health care providers
Evaluation is the primary goal for the client and nurse in the third stage of the nurse-client relationship.
Questions to be answered include:
• Were the goals meaningful?
• Were the goals realistic?
• Were the client and family actively involved?
The following nursing checklist can be used to evaluate skill in establishing a therapeutic nurse-client relationship.
THERAPEUTIC USE OF SELF
The interpersonal process between nurse and client is a therapeutic process because interventions are planned and implemented to benefit the client. The nurse’s most effective tool for bringing about positive change is the therapeutic use of self, a process in which nurses deliberately plan their actions and approach the relationship with a specific goal in mind before interacting with the client. The nurse’s most effective tool for demonstrating caring is not some technologically sophisticated machine with lights and alarms but rather one’s self. Figure 11-4 illustrates therapuetic use of self. Therapeutic use of self is “an opportunity for the nurse to be with persons at a human-to-human level” (Bernado, 1998, p. 48). The term presence refers to the process of “just being with” another. According to Bulechek and McCloskey (1985), presence is “a therapeutic tool of the nurse an intervention instrument by merely remaining physically present with the patient” (p. 31).
Therapeutic use of self involves verbal and nonverbal communication. Just as important as what one says is how one says it. In this deliberate, planned approach, the nurse communicates a sense of caring and willingness to help: the nurse is committed to helping clients find ways to help themselves. The nurse’s true expression of humanistic concern for a client is shown by taking the time to simply “be with” the client. Watson (1988) describes therapeutic use of self as the transpersonal aspect of nursing, that is, “an intersubjective human-to-human relationship in which the person of the nurse affects and is affected by the person of the other. Both are fully present in the moment and feel a union with the other” (p. 32).
CHARACTERISTICS OF THERAPEUTIC RELATIONSHIPS
“The route to therapeutic support for any client starts with establishing a positive relationship” (Isenalumhe, 2000, p. 25). To establish therapeutic relationships, the nurse must possess certain interpersonal skills (listed in the accompanying display), in order to encourage the client’s expression of feelings.
The term catharsis, which refers to the relief experienced from verbalizing one’s problems, is illustrated in Figure 11-5. This “getting things off one’s chest” is a universal experience that is therapeutic for individuals experiencing anxiety. Nurses use interpersonal skills to help clients meet their needs. A discussion of each characteristic follows.
Warmth
Warmth means exhibiting positive behaviors toward the client. Respect, genuine interest, caring—all are expressions of warmth. The nurse who demonstrates warmth is approachable and available rather than aloof. Warmth means projecting a friendly, interested attitude without overwhelming the client with a false sense of cheerfulness.
The nurse demonstrating warmth responds to the client as one human being to another. The therapeutic nurse is approachable and available yet maintains objective boundaries.
Hope
Hope means anticipating the future by helping clients look realistically at their potential. Hope is strengthened by relationships with others; social isolation reinforces a sense of despair. Many clients, especially those with great losses, experience distress, despair, and hopelessness. The reemergence of hope may be a gradual process. Hope is not to be confused with false reassurance. “Hope is the energy source that allows individuals to plan, act, and achieve” (Forbes, 1994, p. 6).
Rapport
Rapport is a bond or connection between two people that is based on mutual trust. Such a bond does not just happen spontaneously; it is planned by the nurse who purposefully implements behaviors that promote trust.
The nurse sets the tone of the relationship by creating an atmosphere in which the client feels free to express feelings. When seeking to establish trust, the nurse recognizes the client as a unique individual and reinforces that individuality. In other words, actions that humanize the client are therapeutic. To establish rapport, the nurse’s actions show that the client is considered important.
Actions are implemented to boost the level of the client’s self-esteem. Nonverbal interventions are of utmost importance in helping establish rapport.
Interacting with family and significant others is also helpful in establishing rapport with the client (Figure 11-6). Recognizing the importance of the family’s influence on the healing process allows the nurse to bond with those who will encourage and support the client.
Trust
Trust must be present for help to be given and received. A therapeutic relationship is firmly rooted in trust. How does the nurse promote a trusting relationship? Three major activities will facilitate the development of trust: consistency, respect, and honesty. Table 11-3 lists actions that facilitate the development of trust. Being consistently trustworthy is an expression of the nurse’s personal integrity and builds the foundation for nursing effectiveness.
Empathy
Empathy—understanding another person’s perception of the situation—is a key element in the therapeutic relationship.
The phrase “Walk a mile in my shoes” describes empathy well. The empathic nurse understands that the client’s perception of the situation is real to the client. By perceiving clients’ understanding of their oweeds, the nurse is better able to assist clients in determining what will work best. Empathy enables the nurse to assist the client to become a fully participating partner in treatment rather than a passive recipient of care.
Through empathy, the nurse validates the experiences of the client. The challenge for the nurse is to see the world from the client’s perspective with as much understanding as possible. Empathy is not the same as sympathy. Sympathy is rarely therapeutic; in fact, a barrier occurs when the nurse is caught in sympathy and becomes paralyzed by the expression of pity. For example, through empathic listening does the nurse encourage the client to find meaning in his experience and move on to problem solving.
Acceptance
Accepting the client as a person worthy of dignity and respect is basic to providing nursing care. Acceptance means accepting and working with clients, even those who sometimes exhibit undesirable behaviors. It is extremely important for the nurse to show acceptance of the client while setting limits on unhealthy or undesirable behavior. The accepting nurse conveys the message that the client does not have to put on a front. The client knows it is safe to be genuine because of the nurse’s acceptance.
Acceptance means caring for individuals whose value system may differ greatly from that of the nurse and not expressing shock or surprise at the client’s behavior.
Active Listening
Active listening (listening that focuses on the feelings of the individual who is speaking) is the basic skill for interpersonal effectiveness. Active listening is facilitated by attending behaviors, a set of nonverbal listening skills that conveys interest in what the other person is saying.
These behaviors allow the nurse to show caring, concern, and acceptance. Behaviors such as sitting down, maintaining eye contact, facing the client, and head nodding facilitate the development of trust. Active listening requires the nurse to turn down inner dialogue. Total attention must be focused on what the client is saying.
Also, it is important for the nurse to avoid looking rushed or distracted. The primary message that is communicated through active listening is the nurse’s concern and intent to assist in problem solving. Active listening is required in every nurse-client relationship.
The active listener is cognizant of all three elements of communication: the verbal, paraverbal, and nonverbal. The verbal message is what is said.
Paraverbal communication is the way in which a person speaks, including voice tone, pitch, and inflection, and the nonverbal message is body language. The active listener pays attention to all three aspects to hear the true intent of the communicator.
Active listening means that the nurse focuses on the feelings behind the words, not just the words themselves. It is important for the nurse to note any incongruities between the client’s verbal and nonverbal messages. For example, if the client says, “Oh, I’m just fine!” and is slumped over with head hanging down, there is an incongruity—the behavior and the words do not match.
The client’s expression of feelings demonstrates trust in the nurse. This expression of trust must be recognized and respected. By listening carefully to the client, the nurse is able to learn what the client perceives as the most crucial problem. Listening is the first step in personalizing care for each client. Listening can improve client outcomes.
Humor
Humor is another characteristic of therapeutic nurses. The use of humor as a therapeutic intervention is not a new concept for nurses. Nightingale (1860) recognized the influence of the mind on the body and acknowledged humor as an important nursing intervention.
As shown in Figure 11-7, humor can assist in establishing a relationship because it helps break the ice, decreases fear, and establishes trust. Humor is a medium for sharing; thus, it can be used to strengthen the therapeutic relationship.
Humor is defined to a great deal by one’s cultural background, so it is imperative that the nurse be sensitive to the client’s interpretation and use of humor. A humor assessment can be conducted by noting:
• What makes the client smile or laugh
• The use of jokes by clients
• Type of humor expressed by the client
Humor is a powerful tool for coping. Humor helps individuals to relieve stress and to express anger in a socially acceptable manner.
Nurses turn to humor to defuse the stress of the lifeand-death situations that they face on a daily basis.
Although humor can relieve tension and stabilize highstress situations, it must be used with caution. It can be dangerous and destructive if used carelessly.
Compassion
Compassion is truly caring about what happens to another person. Kindness and genuine concern are demonstrated through compassionate acts. Some behaviors that communicate the nurse’s compassion include:
• Acting on the belief that everyone is equally deserving of care.
• Treating individuals with dignity.
• Respecting a client’s privacy—simple acts such as keeping the client covered and knocking on the door before entering the room show compassion.
Other examples of compassion are a nurse caring for the homeless in a shelter or holding the hand of a person with acquired immunodeficiency syndrome (AIDS).
Self-Awareness
Self-awareness is necessary for the nurse to be therapeutic. Being aware of one’s feelings is the first step in developing therapeutic behavior. Knowledge of one’s assets is necessary in that effective nurses are able to identify their own skills and abilities. Conversely, only after identifying deficits in knowledge and skills can the nurse initiate necessary improvements. This process of analyzing one’s strengths and limitations is an ongoing basic part of learning. The therapeutic nurse knows that learning is a lifelong process that contributes to growth—personally and professionally. Self-awareness allows the nurse to remain objective, that is, separate enough to distinguish one’s own feelings and needs from those of the client.
Nonjudgmental Approach
Nonjudgmental behavior must be used if nursing interventions are to be therapeutic. Nonjudgmental means acting without biases, preconceptions, or stereotypes.
Nonjudgmental nurses do not evaluate the client’s moral values nor tell the client what to do; these nurses accept people as they are. Nonjudgmental nurses do not stereotype people, nor expect others to behave in certain ways because they belong to a certain group. Judgment influences perceptions because people tend to see what they expect to see.
According to Sayer (1992, p. 48): We see individuals as being representative of a social group. Here our own stereotypes and prejudices about the group come into play. Individuals may be seen as a representative of race, age group, socioeconomic level, gender, occupation, or disability. They will then be given the characteristics we believe people in that group have.
Judgmental behavior based on biases can interfere with the therapeutic value of nursing interventions. It is nontherapeutic for nurses to allow biased views that stem from personal values to influence their actions. The initial assessment of clients is often influenced by preconceived ideas.
Becoming nonjudgmental is an ongoing process. In a classic article, Blumenstock (1970, p. 37) stated: Becoming nonjudgmental is hard work and a life time process, for none of us is ever free of judgmental feelings arising from our own evolving values. Thus, each of us is always in a state of “becoming.”
There are several steps in becoming nonjudgmental:
• The first step is the most difficult—recognizing that one’s thought are biased and prejudicial.
• Second, to change, nurses must accept their own feelings.
• The third step is identifying the source of the negative feelings—not to blame but to gain an understanding of the origins.
To counter such negative feelings, learn about different cultures. Getting to know people with diverse cultural backgrounds expands the knowledge base and helps one become more tolerant and open-minded.
Flexibility
Flexibility is another trait necessary for nurses to create a therapeutic relationship. A flexible nurse is one who is ready for the unexpected—knowing that every day is filled with unplanned events and situations. The flexible nurse is able to adapt by “taking things in stride” and making necessary adjustments. Some of the unexpected events require immediate actions. The flexible nurse is able to establish priorities by determining which needs are urgent and which can be tended to later. Staying calm during a crisis is characteristic of the flexible nurse.
Risk-Taking
Risk-taking is a behavior that leads to innovative problem solving. To become effective risk-takers, nurses must give themselves permission to try something new, to step outside the ordinary, and to not be bound by tradition or fear. The result is creative solutions to problems.
Successful risk-takers give themselves credit for trying something new regardless of the outcome. Smart risktakers learn from those risk-taking ventures that are less than successful. They do not allow themselves to become complacent, content to stay at a comfortable plateau.
THERAPEUTIC VALUE OF THE NURSING PROCESS
The nursing process provides a framework for the delivery of compassionate care. It gives direction by organizing the nurse’s actions: assessing, diagnosing, planning, implementing, and evaluating.
The nursing process itself is therapeutic because it focuses on the client’s response to illness, disease, or disability rather than just on the problem. By focusing on the caring aspects, the nursing process helps nursing define its practice. Professional accountability is reinforced by the use of this process, which is client-centered.
When functioning within the parameters of the nursing process, the nurse assumes a variety of roles.
NURSING ROLES
A role is a set of expected behaviors associated with a person’s status or position. Role includes behaviors, rights, and responsibilities. Nurses function in a variety of roles every day (see the accompanying display). Often roles overlap, which may lead to a conflict in expectations or responsibilities. A discussion of some predominant nursing roles follows.
Caregiver
The caregiver is the role most commonly associated with nursing by the general public. In the role of caregiver, the nurse provides direct care when clients are unable to meet their oweeds. Specific activities characteristic of the caregiver role include feeding, bathing, and administering medications.
Counselor
When acting as a counselor, the nurse assists clients with problem identification and resolution. The counselor facilitates client action and does not tell clients what to do but assists clients to make their own decisions.
Counseling is done to help clients increase their coping skills. Clients are frequently counseled in stress management, how to deal with chronic conditions, grief and bereavement. Effective counseling is holistic, in that it addresses the individual’s emotional, psychological, spiritual, and cognitive dimensions.
Teacher
Teaching is an intrinsic part of nursing. The nurse views each interaction as an opportunity for education; both client and nurse can learn something from every
encounter with each other. Teaching by nurses can be formal, informal, intentional, or incidental.
Client Advocate
A client advocate is a person who speaks up for or acts on behalf of the client. Advocacy empowers clients to be partners in the therapeutic process rather than passive recipients of care. The relationship that encourages client empowerment is one of mutual participation by client and nurse. Clients and families are actively involved in establishing goals.
Frequently, clients and families do not communicate their concerns to physicians but will do so to the nurse with whom a bond has been established. Nurses function as client advocates by listening and communicating the expressed concerns to other health care providers and including those concerns into care planning.
Change Agent
Nurses who function in the role of change agent recognize that change is a complex process. The nurse change agent is proactive (takes the initiative to make things happen) rather than reactive (responding to things after they have happened). Change should not be done in a random manner. It should be planned carefully and implemented in a deliberate way to facilitate the client’s progress.
Team Member
A vital role of the nurse is that of team member. The nurse does not function in isolation but rather works with other members of the health care team. Collaboration requires the nurse to use effective interpersonal skills and promotes continuity of care.
Resource Person
The nurse functions as a resource person by providing skilled intervention and information. Identifying resources and making referrals as needed also fall under the auspices of this role. Nurses must consider the client strengths and access to resources, including physical, intellectual, economic, social, and environmental.
KEY CONCEPTS
• Caring is the fundamental value iursing.
• Today’s “high-tech” environment requires that nurses provide humanistic caring.
• The therapeutic nurse-client relationship is the one-to-one interactive process between client and nurse that is directed at improving the client’s health status or assisting in problem solving.
• Therapeutic relationships differ from social relationships in that they are deliberately planned, focus on client problems, and communicate acceptance of the client.
• Nursing is an interpersonal process between someone who needs help in meeting needs and someone who is competent to assist in meeting those needs.
• The three interwoven phases of the nurse-client relationship are orientation, working, and termination.
• Therapeutic use of self is a process in which nurses deliberately plan their actions and approach the relationship with a specific goal in mind before interacting with the client.
• Several interpersonal characteristics and skills can be developed to increase the therapeutic value of a nurse’s interventions. These include warmth, hope, rapport, trust, empathy, acceptance, active listening, humor, compassion, awareness, nonjudgmental attitude, flexibility, and risk-taking.
• The nursing process is the framework for providing compassionate care.
• Nurses function in a variety of roles when working with clients. The roles overlap and have specific responsibilities.
CULTURE AND ETHNICITY
CONCEPTS OF CULTURE
Each individual is culturally unique. Behavior, self-perception, and judgment of others all depend on one’s cultural perspective. This section discusses the concepts of culture, race, ethnicity, and stereotyping and provides an overview of the dominant cultural values in the
Culture
Culture refers to knowledge, beliefs, behaviors, ideas, attitudes, values, habits, customs, languages, symbols, rituals, ceremonies, and practices that are unique to a particular group of people. This structure of knowledge, behaviors, and values provides a group with a “blueprint” or a general design for living “that guide their worldview and decision-making” (Purnell & Paulanka, 1998, p. 4).
Culture is not static nor is it uniform among all members within cultural groups. Culture represents adaptive dynamic processes learned through life experiences.
People have culturally predetermined values and beliefs that may change as new information is gained. There is much diversity among cultural groups. Such differences result from individual perspectives and practices.
Consider for example how a family deals with a crisis. A crisis may cause some families to become closer, whereas the same situation may cause another family to withdraw and create distance among its members.
Cultural messages are transmitted in a variety of ways such as through schools and churches. The various media are also powerful transmitters and shapers of culture.
People learn about culture through traditions. When people state “That’s how we’ve always done it,” they are describing cultural traditions. Cultural beliefs, values, customs, and behaviors are transmitted from one generation to another. Grandparents, other elders, and parents teach children cultural expectations and norms through role modeling, demonstration, and discussion (Figure 16-1).
Characteristics of Culture
Differences exist among cultural groups and among individuals within a single culture. Despite these variances, all cultures exhibit the characteristics shown in the accompanying display.
Ethnicity and Race
Ethnicity is a cultural group’s perception of themselves (group identity). This self-perception influences how the group’s members are perceived by others. Ethnicity is a sense of belongingness and a common social heritage that is passed from one generation to the next. Members of an ethnic group demonstrate their shared sense of identity in common customs and traits.
Race refers to a grouping of people based on biological similarities. Members of a racial group have similar physical characteristics such as blood group, facial features, and color of skin, hair, and eyes. There is often overlap between racial and ethnic groups because the cultural and biological commonalities support one another (Giger & Davidhizar, 1999). The similarities of people in racial and ethnic groups reinforce a sense of commonality and cohesiveness.
Labeling and Stereotyping
Problems arise when differences across and within cultural groups are misunderstood. Misperception, confusion, and ignorance often accompany people’s expectations of others. There are numerous ways in which people are different and, thus, classified by others.
Members of some cultural groups have historically and globally experienced oppression in the forms of racism, sexism, and classism. The basic underlying premise of these biases is that one way is assumed to be better or “right” and every other way is inferior.
Ethnocentrism is the belief that one’s own culture is superior to all others. According to the American Nurses Association (1994): This belief is common to all cultural groups, all groups regard their own culture as not only the best but also the correct, moral, and only way of life. This belief is pervasive, often unconscious and is imposed on every aspect of day-to-day interaction and practices including health care. It is this attitude which creates problems betweeurses and clients of diverse cultural groups. (p. 3)
Ethnocentrism results in oppression. Oppression occurs when the rules, modes, and ideals of one group are imposed on another group. Oppression is based on cultural biases, which stem from values, beliefs, tradition, and cultural expectations. Racism, a form of oppression, is defined as discrimination directed toward individuals who are misperceived to be inferior due to biologic differences.
Stereotyping is an expectation that all people within the same racial, ethnic, or cultural group act alike and share the same beliefs and attitudes. Stereotyping results in labeling people according to cultural preconceptions; therefore, an individual’s unique identity is often ignored.
Dominant Values in the
Cultural differences refer to values, practices, and rituals that vary from those of the dominant culture. The dominant culture of the
• Achievement and success
• Individualism, independence, and self-reliance
• Activity, work, and ownership
• Efficiency, practicality, and reliance on technology
• Material comfort
• Competition and achievement
• Youth and beauty
Frequently, these dominant values (which may be blatant or subtle) conflict with the values of minority groups. A minority group can be composed of an ethnic, racial, or religious group that constitutes less than a numerical majority of the population. Because of their cultural or physical characteristics, such groups are labeled and treated differently from others in the society. Minority groups are usually considered to be less powerful than the dominant group (Giger & Davidhizar, 1999).
People assume the characteristics of the dominant culture through acculturation (process of learning norms, beliefs, and behavioral expectations of a group). Acculturation is encouraged through schools and the media. Assimilation is “cultural and structural blending into a dominant entity” (Kavanaugh et al., 1999, p. 10).
Cultural assimilation occurs when individuals from a minority group are absorbed by the dominant culture and take on the characteristics of the dominant culture.
MULTICULTURALISM IN THE UNITED STATES
“The United States, already one of the most diverse societies in the world, is becoming increasingly multicultural and multilingual” (Lester, 1998, p. 26). The
The numbers of immigrants and refugees entering the
Value of Diversity
Cultural diversity is the differences among people that result from ethnic, racial, and cultural variables.
“Cultural diversity refers to the differences between people based on a shared ideology and value set of beliefs, norms, customs, and meanings evidenced in a way of life” (American Nurses Association, 1994, p. 2). The
In addition to these advantages, there are also some disadvantages to living and working within such a culturally diverse environment. For example, the amount and types of variances can lead to splitting and ethnocentrism.
Cultural diversity presents special challenges for nurses who must provide care that is congruent with a person’s expectations. Nurses caring for clients who are different from themselves must remember to determine the client’s perception and significance (meaning) of the event (illness). The nurse honors each individual’s differences while understanding that culture influences how clients are viewed and treated within health care settings.
ORGANIZING PHENOMENA OF CULTURE
Cultural factors determine the worth of behaviors, whether behaviors are acceptable, and whether behaviors are incorporated into daily living. When these behavioral concepts are applied to health, they influence the individual’s expectation of health care.Diversity among cultural groups regarding expectations influences health care. The nurse must be sensitive to the client’s cultural context in order to provide care that meets individual needs. Each cultural group has the same basic organizational factors (see the accompanying display). Following is a discussion of the six organizing factors that must be considered when delivering culturally competent care.
Communication
Communication is the vehicle for transmitting and preserving culture. To share complete and accurate information, nurses must be aware of the cultural variances related to communication.
Nurses provide information to clients by using two types of communication: verbal and nonverbal. Verbal communication consists of words, both spoken and written. When cultural variances exist, communication problems may occur. The nurse must validate the meaning of and interpret words to ensure that clients receive the intended message.
For example, a communication barrier exists when different languages are spoken by the client and nurse. In such cases, the use of an interpreter facilitates communication.
The interpreter can either be a bilingual family member or staff member. Even when both client and nurse speak the same language, communication problems may occur because of varying cultural contexts in which words have different meanings to different people.
Nonverbal communication consists of body language (such as facial expressions, posture, and gestures); the use of silence; and paralinguistic cues (voice tone, pitch, and rate). An example of how nonverbal communication can be culturally misunderstood is the presence or absence of eye contact. For example, in Native American and Asian-American cultures, eye contact is considered intrusive and disrespectful. However, in the dominant
Space
An individual’s personal space includes one’s body, the surrounding environment, and objects and people within that environment. Culture determines the amount of social distance tolerated by a person. Members of British, German, and American cultures usually require more personal space than do people of Hispanic and French backgrounds (Giger & Davidhizar, 1999).
Nurses must be aware of the client’s degree of comfort with closeness since diverse groups have varying norms for the use of touch. Touch may be perceived as invasive by clients from some cultures. Who can touch a person, when a person can be touched, and what forms of touch are appropriate are culturally determined. For example, members of the dominant
Orientation to Time
Time orientation (being focused on the past, the present, or the future) varies according to cultural group.
European Americans are future oriented as evidenced by their development of plans, such as retirement savings.
Many Native Americans have a different concept of time in that they tend to live in the present moment (Giger & Davidhizar, 1999). For many Native Americans, watching the clock and timeliness/tardiness have little importance.
Time is considered a circular, rather than a linear, process. Most health care providers value quickness and efficiency, which is interpreted by members of the
Lakota tribe as insincerity and a lack of interest (Kavanagh et al., 1999). The nurse’s nonverbal behavior can be changed to build interpersonal rapport by spending time, sitting down with clients, and demonstrating presence.
Social Organization
Social organization refers to the ways in which groups determine rules of acceptable behavior and roles of individual members. Examples of social organizations
include family and other kinship ties, religious groups, and ethnic groups.
Family
General Systems Theory (GST) considers the family to be a system that seeks to maintain balance. From the GST perspective, the family functions as a unit. Thus, if an event affects one family member, all the other members will be affected in one way or another. The various types of family structures are described in the accompanying display. It is vital for the nurse to know who will be involved in making decisions related to health care.
Including the family according to their cultural expectations is a hallmark of quality nursing care. Family patterns usually are of one of three types: linear, collateral, or individualist
In many cultures, the family assumes greater importance than the individual (Figure 16-2). For example, in most Native American tribes, the extended family is the basic family structure. The extended family is also extremely important in Hispanic American cultural groups. In some Hispanic groups, the family may include third and fourth cousins as well as close friends who are not related by ties of kinship.
Pickens (1998) identified the following attributes as necessary for nurses in order to collaborate with families:
• Nonjudgmental attitude (i.e., do not expect all families to be alike and behave similar to one’s own)
• Self-awareness of own preconceptions about family members
• Respect for others’ beliefs and values
• Recognition of families as significant providers of support
• Value the participation of families in caregiving
Gender
Gender roles vary according to cultural context. For example, in families with a patriarchal structure (the man is the head of the household and chief authority figure), the husband/father is the dominant person. Such expectations are the cultural norm for Latino, Hispanic, and traditional Muslim families. The husband/father is the one who makes decisions regarding health care for all family members. Also, in such cultures, the wife is responsible for child care and household maintenance, whereas the father’s role is to protect and support the family members (Luckmann, 2000).
Lifestyle
In addition to an increased heterogeneity of population groups in the
Some specific ways in which nurses can respect clients with differing lifestyles are:
• Be aware of own tendency to be ethnocentric.
• Be sensitive to client’s needs, especially those expressed nonverbally.
• Use self-awareness to determine the impact of own beliefs and values.
Often the nurse and client are of different cultural backgrounds; see Figure 16-4. The nurse must be culturally sensitive in order to promote the development of a therapeutic nurse–client relationship.
Religion
Religious beliefs influence a person’s response to major life events such as birth, illness, and death. Religious practices are often a source of comfort during stressful life events and provide support during the healing process. Crises such as illness and treatment modalities are often the catalyst for increased spiritual needs.
CULTURAL DISPARITIES IN HEALTH AND HEALTH CARE DELIVERY
“Researchers suggest that cultural insensitivity can create more than mere discomfort. It can create real barriers to accessing health care” (Lester, 1998, p. 28).
Language and other cultural differences often present barriers to necessary health care including:
• Appointment procedures
• Transportation
• Directions written in an unfamiliar language.
There are disparities in the health of Americans.
According to the ANA (1998), minorities experience some diseases at a much higher rate than white Americans. The following examples are listed in the ANA’s Position Statement on Discrimination and Racism in Health Care (1998):
• Cancer is the leading cause of death for Chinese and Vietnamese individuals.
• Vietnamese women suffer from cervical cancer at nearly five times the rate of white American women.
• Compared with the general population, Hispanics have a higher incidence of cancer of the stomach, esophagus, pancreas, and cervix.
• African-Americans have a life expectancy that is six years shorter than the life expectancy for white Americans.
• The Native American population has significant rates of diabetes, sudden infant death syndrome, and congenital malformations.
“Overall Native American and Alaskan Native rates of diabetes, tuberculosis, fetal alcohol syndrome, alcohol-related morbidity and mortality, and suicide significantly exceed those of other racial and ethnic groups in the United States” (Kavanagh et al., 1999, p. 10). One of the major objectives established by the U.S. Office of Public Health in its Healthy People 2010 Objectives is the elimination of disparities in health status by providing equitable services for people of all groups (Chrvala & Bulger, 1999).
Vulnerable Populations
As a result of societal changes, more people are at risk for health problems. Groups that are especially susceptible for health-related problems include the poor, the homeless, migrant workers, abused individuals, the elderly, pregnant adolescents, and people with sexually transmitted diseases such as acquired immunodeficiency syndrome (AIDS).
The
The Poor
Poverty affects health status and accessibility to health care services. According to the Centers for Disease Control and Prevention (CDC) (1998), “increase in either income or education increases the likelihood of good health status.
This relationship between socioeconomic status and health was observed for persons in every race and ethnic group examined” (p. 52). Living in poverty means being unable to meet the financial demands of basic living expenses, such as food, shelter, and clothing.
Socioeconomic status is determined by family income, educational level, and occupation. “Childhood poverty has long-lasting negative effects on one’s health. Children in low-income families fare less well than children in more affluent families. In 1999, 17% of American children lived in poverty” (U.S. Bureau of the Census, 2000). In
The CDC (1998) has identified the following as health risk factors that are related to lower income:
• Higher prevalence of cigarette smoking
• Greater incidence of obesity
• Elevated blood pressure
• Sedentary lifestyle
• Less likely to be covered by health insurance
• Less likely to receive preventive health care services
Increasing numbers of federally mandated health care initiatives are being implemented to address the historic racial and class disparities in health care.
Entitlement programs imply that the government is legally mandated to provide services to the programs’ eligible populations. Entitlement programs such as Medicare, Medicaid, and Women, Infants, and Children (WIC) were developed, in part, because of social and political pressures. WIC, a special supplemental food program for women, infants, and children, is a
Public Health sponsored program that targets lowincome pregnant and breastfeeding mothers and their children age 5 years or younger. WIC links health care services, food supplements, and health education into a combined service package for eligible members.
Medicaid is a program designed to provide access to health care for medically needy infants, children, and adults. Medicare is an entitlement program that finances health care services for individuals over the age of 65.
Poverty interferes with a child’s ability to be housed, clothed, and fed adequately and can deprive the child of a safe (physical and psychological) environment.
Children with access to health care have the possibility of getting necessary health care services. Children with health insurance (public or private) are much more likely than children without insurance to have a regular and accessible source of health care (U.S. Bureau of the Census, 2000). “There are many reasons why a child’s parent(s) are uninsured . . . related to employment, limited health care benefits, and recent immigration” (Scott, 2000, p. 26).
The Homeless
Even though it is difficult to determine the exact number of homeless people, it is estimated that 350,000 to 6 million people are homeless in the
• Lack of affordable housing
• Increasingly stringent criteria for public assistance
• Decreased availability of social services
• Inadequate or lack of employment
• A history of psychosocial trauma
• Deinstitutionalization of clients from mental health facilities without adequate community support (such as half-way houses and group homes)
Approximately 85% of homeless people are on the streets because they have some form of mental illness or are addicted to alcohol or other drugs (
“We must confront the mistakeotion that hopelessness is a choice . . . It’s important to understand the connection between hopelessness and chronic mental illness, for with understanding can come the sensitivity and compassioecessary to serve this population” (Walker, 1998, p. 27).
Those who are homeless are at greater risk for illness and injuries (Edelman & Mandle, 1997). Hatton (1997) identified the following as major health care needs of homeless women: mental health, sexually transmitted diseases, and substance abuse. Access to basic health care services is limited because the homeless lack health insurance coverage. Those few facilities that do provide services to the homeless are not always accessible due to lack of transportation.
Children are especially vulnerable to the perils of homelessness. Presently, the federal government does not regularly collect data on the number of homeless children in the
The social and political reforms that are needed to create solutions to homelessness have just begun. There is great urgency to meet the immediate needs of the homeless and to provide health care that emphasizes both disease prevention and health promotion.
“Nonprofit nursing centers and clinics try to halt the epidemic of uninsured children” (Scott, 2000, p. 26).
Listed below are a few examples of nursing’s efforts in responding to the needs of vulnerable clients:
• Community Volunteers in Medicine is a nonprofit organization in which nurses, doctors, and dentists volunteer their time and services to treat uninsured people of all ages living in
• Philadelphia-based Regional Nursing Centers Consortium (RNCC) sees approximately 250,000 clients annually. Up to 50% of these clients are uninsured.
• In 1999,
Environmental Control
Environmental control refers to the relationships between people and nature and to a person’s perceived ability to control activities of nature, such as factors causing illness.
A person’s belief about the causation of disease will determine the type of treatment (if any) sought.
According to Andrews and Boyle (1998), there are three types of health belief systems: magicoreligious, biomedical, and holistic. The magicoreligious belief system is based on the concept that health and illness are determined by supernatural forces (such as a Higher Power or the gods). The biomedical belief system states that illness is a result of an impairment in physical or biochemical processes. The holistic belief system views health as a result of harmony among the elements of nature; conversely, disease is caused by disharmony.
Folk Medicine
Most cultures have preferences about health care, including:
• The type of care that is necessary and appropriate
• When care/treatment should be sought
• The appropriate caregiver
Because the presence of a folk medicine system (also referred to as alternative medicine) can present challenges to nurses caring for clients from diverse cultures, knowledge of basic beliefs about illness, factors contributing to illness, and home remedies is necessary.
Folk healers are knowledgable about cultural norms and are usually familiar to the one seeking care (Edelman & Mandle, 1997). Table 16-3 presents the various healers within different cultures and describes common folk healing practices within these cultures. Nurses must be able to relate care and treatment to the client’s cultural context to incorporate informal caregivers, healers, and other members of the clients’ support system as allies in treatment. “The patient-centered orientation of nursing makes it imperative that nurses be able to respond to the unique cultural needs of different people. Nurses are challenged to provide effective caring and curing in varied cultural contexts” (Lester, 1998, p. 26).
Biologic Variations
Biologic variations that distinguish one cultural group from another include enzymatic differences and susceptibility to disease (Andrews & Boyle, 1998; Giger & Davidhizar, 1999). Enzymatic differences account for diverse responses of some groups to dietary therapy and drugs (Table 16-4). Nutritional variations include food preferences that may contribute to health problems (Table 16-5).
TRANSCULTURAL NURSING
The American Nurses Association (1994) states that culture is a central concept of nursing. Acknowledgment and acceptance of cultural differences and understanding of culturally specific responses to illness are prerequisites for providing safe and effective care.
The conceptual framework for understanding cultural diversity and providing culturally competent care is based on Leininger’s transcultural nursing theory.
Transcultural nursing, according to Leininger (1978), focuses on the study and analysis of different cultures and subcultures with respect to cultural care, health beliefs and health practices, with the goal of providing health care within the context of the client’s culture.
A basic assumption of transcultural nursing is that when health care providers see problems from the client’s cultural viewpoint, they are more open to understanding, appreciating, and working effectively with these clients (Figure 16-6). Other assumptions of transcultural nursing theory are:
• Every culture has some kind of system for health care that is based on values and behaviors.
• Cultures have certain methods for providing health care. These methods of care are often unknown to nurses from other cultures (Leininger, 1978).
Due to rapid globalization, every nurse must have an understanding of human conditions in diverse societies.
Nurses do not need to travel to foreign countries to engage in international nursing. Nurses encounter cultural diversity everywhere—from inner city hospitals to suburban clinics, from technologically sophisticated institutions to homes in rural, inner city, and suburban areas.
Cultural Competence
Community, social and kinship ties, religion, language, food, and cultural perceptions of illness are all areas that need to be considered by the nurse when working with culturally diverse clients. Cultural diversity challenges nurses to bridge cultural gaps with clients by providing culturally relevant care. An understanding of the client’s cultural context permits nurses to become familiar with the client as a person instead of focusing only on the illness or problem.
Cultural competence is the process through which the nurse provides care that is appropriate to the client’s cultural context. Culturally competent nurses are those who demonstrate knowledge and understanding of the client’s culture; accept and respect cultural differences; and adapt care to be congruent with the client’s culture (Purnell & Paulanka, 1998). Culturally competent nurses have knowledge about cultural values related to health and illness. Also, nurses who provide care in a culturally sensitive manner are flexible in their approaches and thinking. Campinha-Bacote (1999) defines five elements of cultural competence; see Table 16-6 for an explanation of each element.
CULTURAL COMPETENCE AND NURSING PROCESS
Cultural sensitivity is requisite in every phase of the nursing process. The nurse’s role in providing culturally competent care includes performing a cultural assessment, formulating nursing diagnoses, identifying expected client outcomes, planning care to assist clients in achieving the expected outcomes, intervening to address the client’s nursing diagnoses, and evaluating the plan of care. In its Guide to Nurses for Providing Culturally Sensitive Care, the
Assessment
Caring for a client from a different culture can be challenging to the nurse. Using the client’s strengths and respecting the client’s values are essential components of effective nursing care. To begin providing culturally competent care, the nurse should use questions to gather information about the client’s cultural background. The factors pertinent to cultural assessment are listed in the accompanying display.
The questions in the Cultural Assessment Interview Guide, shown in Figure 16-7, can either be incorporated into a general nursing assessment tool or used separately as a cultural assessment tool.
Nursing Diagnosis
Diagnoses approved by the North American Nursing Diagnosis Association (NANDA, 2001) are used extensively by nurses. However, one stated disadvantage to NANDA diagnostic statements is that sometimes the diagnoses are worded in ways that result in cultural bias (Luckmann, 2000). The accompanying display lists some diagnoses that may be culturally biased.
Consider the following examples of ways in which these diagnoses may be used in a culturally inappropriate manner:
• Applying the diagnosis impaired verbal communication to clients who speak a language different from the nurse
• Using the diagnosis noncompliance with a client who rejects a prescribed treatment method in order to adhere to their culturally sanctioned folk healing methods
It may be more appropriate to use another term instead of noncompliant. Ward-Collins (1998) suggests “nonadherent” by stating that this term may present less of a stigma to clients than “noncompliant.”
Planning and Outcome Identification
Cultural groups are not homogeneous; there are individual variations in personality, behavior, and expectations.
It is important not to consider one member of a particular group to be like all the others of that same group.
In order to develop effective plans of care, nurses need to understand the following (American Nurses Association, 1994):
• Cultural groups’ perspectives on life processes (e.g, birth, death)
• Cultural definitions of health and illness
• How cultural groups maintain wellness
• Culture’s perspectives on the causes of illness
• Use of healers in the cure and care of illness
• The influence of the nurse’s cultural background on the delivery of care
It is also necessary to consider how the client’s beliefs may impact the plan of care. Cultural beliefs greatly influence perceptions about health and, therefore, may create barriers to adhering to prescribed treatment plans. Culture influences the following:
• Perceptions of illness versus health
• Responses to illness
• Perceptions about the significance of symptoms
• The types of treatment approaches (i.e., alternative and/or conventional) (Muscari, 1998, p. 27).
Implementation
Caring for culturally diverse clients requires three major nursing interventions: self-awareness, use of a nonjudgmental approach, and client education. Each of these aspects are discussed in the following section. The accompanying display provides guidelines for providing culturally sensitive care for clients at home.
Self-Awareness
In an increasingly diverse society, the nurse must be aware of the potential for bias or misunderstanding.
Self-awareness can be used to help nurses recognize their own stereotypes, biases, and prejudgments about clients who are culturally different. Further experience, introspection, and study empower nurses to appreciate their own cultures and the strengths of other cultures.
Nonjudgmental Approach
A nonjudgmental attitude is essential in the provision of culturally sensitive care. When caring in a manner sensitive to the client’s cultural background, the nurse enables the client to offer open, honest feedback, to disagree, or to discuss real or perceived problems. A health care partnership is the outcome of this approach. “A key component of successful interactions with culturally diverse patients is to avoid using stereotypical, judgmental words” (Ward-Collins, 1998, p. 30).
Client Education
Educating clients is an integral part of nursing practice.
Education must be relevant not only to the client’s needs but also must be provided in a culturally sensitive manner. Lester (1998) states “you need to present the information in a way that the patient grabs onto what is important to her. We need to learn how to present teaching so that people can hear it. If people can’t hear it, then we will not succeed in what we are trying to teach” (p. 29). See the Client Teaching Checklist for culturally sensitive teaching guidelines.
Evaluation
The final phase of the nursing process, evaluation, is extremely important in determining the client’s achievement of expected outcomes and the efficacy of nursing interventions in delivery of culturally sensitive care.
Provision of culturally competent care requires that the nurse view the client as a partner of the health care team. It is important to demonstrate caring behaviors rather than just tolerating cultural variations in client’s behavior. Awareness of cultural similarities and variations allow nurses to accept and appreciate the impact of culture on health care.
KEY CONCEPTS
• Every aspect of a person’s life is influenced by one’s culture.
• Behavior affecting health is culturally determined.
• Culture is a dynamic structure of behaviors, ideas, attitudes, values, habits, beliefs, customs, languages, rituals, ceremonies, and practices that are unique to a particular group of people. This structure of knowledge, behaviors, and values provides a group with a “blueprint” for behavior.
• Cultural norms are transmitted from one generation to another.
• Ethnicity is described as a sense of belongingness that is shared by other members of that same group. Ethnic groups are usually composed of people with the same racial composition.
• Race refers to a grouping of people based on biologic similarities. Members of a racial group have similar physical characteristics, such as blood type, facial features, and color of skin, hair, and eyes.
• Members of some racial and ethnic groups have experienced oppression in the forms of racism, sexism, and classism.
• The dominant values of the
• There is great value in cultural diversity, including a broader perspective of others, enhanced problemsolving ability and creativity, and improved productivity in the workplace.
• The six organizing phenomena of culture are communication, space, orientation to time, social organization, environmental control, and biologic variations.
• Transcultural nursing is based on the belief that wheurses view problems from the client’s cultural viewpoint, they are more open to understanding and working more effectively with clients from other cultures.
• Understanding and accepting cultural differences and responses to illness are prerequisites for providing quality nursing care.
• The provision of culturally sensitive care is achieved through the use of approaches such as non-judgmental attitudes and self-awareness and tools such as cultural assessment guides and client education strategies.
Medical Ethics
Definition
Medical ethics refers to the discussion and application of moral values and responsibilities in the areas of medical practice and research. While questions of medical ethics have been debated since the beginnings of Western medicine in the fifth century B.C., medical ethics as a distinctive field came into prominence only since World War II. This change has come about largely as a result of advances in medical technology, scientific research, and telecommunications. These developments have affected nearly every aspect of clinical practice, from the confidentiality of patient records to end-of-life issues. Moreover, the increased involvement of government in medical research as well as the allocation of health care resources brings with it an additional set of ethical questions.
Description
The Hippocratic tradition
Medical ethics generally traces its origins to the ancient Greek physician Hippocrates (460–377 BC), who is credited with defining the first ethical standard in medicine: “Do no harm.” The oath attributed to Hippocrates was traditionally recited by medical students as part of their medical school’s graduation ceremonies. A modernized version of the Hippocratic Oath that has been approved by the American Medical Association (AMA) reads as follows:
You do solemnly swear, each by whatever he or she holds most sacred
That you will be loyal to the Profession of Medicine and just and generous to its members
That you will lead your lives and practice your art in uprightness and honor
That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice
That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it
That whatsoever you shall see or hear of the lives of men or women which is not fitting to be spoken, you will keep inviolably secret
These things do you swear. Let each bow the head in sign of acquiescence
And now, if you will be true to this your oath, may prosperity and good repute be ever yours; the opposite, if you shall prove yourselves forsworn.
Religious traditions and medical ethics
Ancient
The Enlightenment and the nineteenth century
The eighteenth century in
In the middle of the nineteenth century, physicians in the
Viewpoints
Theoretical approaches to medical ethics
PHILOSOPHICAL FRAMEWORKS. Since the early Middle Ages, questions of medical ethics have sometimes been discussed within the framework of specific philosophical positions or concepts. A follower of Immanuel Kant (1724–1804), for example, would test an ethical decision by the so-called categorical imperative, which states that one should act as if one’s actions would serve as the basis of universal law. Another philosophical position that sometimes appears in discussions of medical ethics is utilitarianism, or the belief that moral virtue is based on usefulness. From a utilitarian perspective, the best decision is that which serves the greatest good of the greatest number of people. An American contribution to philosophical approaches to medical ethics is pragmatism, which is the notion that practical results, rather than theories or principles, provide the most secure basis for evaluating ethical decisions.
CASUISTRY. Casuistry can be defined as a case-based approach to medical ethics. An ethicist in this tradition, if confronted with a complicated ethical decision, would study a similar but simpler case in order to work out an answer to the specific case under discussion. As has already been mentioned, casuistry has been used as a method of analysis for centuries in Jewish medical ethics.
THE “FOUR PRINCIPLES” APPROACH.
Another approach to medical ethics was developed in the 1970s by a philosopher, Tom Beauchamp, and a theologian, James Childress, who were working in the
· the principle of autonomy, or respecting each person’s right to make their own decisions
· the principle of beneficence, or doing good as the primary goal of medicine
· the principle of nonmaleficence, or refraining from harming people
· the principle of justice, or distributing the benefits and burdens of a specific decision fairly
One limitation of the “Four Principles” approach is that different persons involved in an ethical decision might well disagree about the relative weight to be given to each principle. For example, a patient who wants to be taken off a life-support system could argue that the principle of autonomy should be paramount, while the clinical staff could maintain that the principles of beneficence and nonmaleficence are more important. The principles themselves do not define or imply a hierarchical ranking or ordering.
Current issues in medical ethics
One well-known writer in the field of medical ethics has recently written an article listing what he considers “cutting-edge” topics in medical ethics. While space does not permit discussion of these subjects here, they serve as a useful summary of the impact of technology and globalization on medical ethics in the new millennium:
· End-of-life care. Medical advances that have led to a dramatic lengthening of the life span for adults in the developed countries and a corresponding increase in the elderly population have made end-of-life care a pressing issue.
· Medical error. The proliferation of new medications, new surgical techniques, and other innovations means that the consequences of medical errors are often very serious. All persons involved in health care have an ethical responsibility to help improve the quality of care.
· Setting priorities. The fair allocation of health care resources is one example of setting priorities.
· Biotechnology. Medical ethicists are still divided over the legitimacy of stem cell research, cloning, and other procedures that advances in biotechnology have made possible.
· “Health.” The expansion of the Internet and other rapid changes in information technology have raised many questions about the confidentiality of electronic medical records as well as the impact of online education on medical training.
· Global bioethics. Global bioethics represents an attempt to consider the ethical problems confronting the poorer countries of the world, rather than concentrating on medical issues from the perspective of the wealthy countries. Of the 54 million deaths that occur each year around the world, 46 million occur in lowand middle-income countries.
Professional implications
One implication for physicians is the importance of studying ethical issues during one’s professional education. Many medical, dental, and nursing schools now include courses in their curricula that deal with such topics as moral decision-making, definitions of life and death, the ethical complexities of professional-patient relationships, and the moral safeguards of medical research. As of 2000, more than 25 universities in the
A second implication is recognizing the necessity of interdisciplinary conversation and cooperation. Physicians can benefit from the insights of scholars in the social sciences, philosophy, theology, law, and history. At the same time, they have much to offer professionals in other fields on the basis of their clinical experience.
Nursing ethics is a branch of applied ethics that concerns itself with activities in the field of nursing. Nursing ethics shares many principles with medical ethics, such as beneficence, non-maleficence and respect for autonomy. It can be distinguished by its emphasis on relationships, human dignity and collaborative care.
Development of subject
The nature of nursing means that nursing ethics tends to examine the ethics of caring rather than ‘curing’ by exploring the relationship between the nurse and the person in care. arly work to define ethics in nursing focused more on the virtues that would make a good nurse, rather than looking at what conduct is necessary to respect the person in the nurse’s care. However, recently, the ethics of nursing has also shifted more towards the nurse’s obligation to respect the human rights of the patient and this is reflected in a number of professional codes for nurses. For example, this is made explicit in the latest code from the International Council of Nurses.
Distinctive nature
Although much of nursing ethics can often appear similar to medical ethics, there are some factors that differentiate it. Generally, the focus of nursing ethics is more on developing a caring relationship than concerns about broader principles, such as beneficence and justice. For example, a concern to promote beneficence may well be expressed in traditional medical ethics by the exercise of paternalism. However, this approach would not be compatible with nursing ethics. This is because nursing theory seeks a collaborative relationship with the person in care. Themes that emphasizes respect for the autonomy and dignity of the patient by promoting choice and control over their environment are commonly seen. This is in contrast to paternalistic practice where the health professional chooses what is in the best interests of the person from a perspective of wishing to cure them.
The distinction can be examined from different ethical angles. Despite the move toward more deontological themes by some, there continues to be an interest in virtue ethics[6] iursing ethics and some support for an ethic of care. This is considered by its advocates to focus more on relationships than principles and therefore to reflect the caring relationship iursing more accurately than other ethical views.
Some themes iursing ethics
Nurses seek to defend the dignity of those in their care. In terms of standard ethical theory, this is aligned with having a respect for people and their autonomous choices. People are then enabled to make decisions about their own treatment. Amongst other things this grounds the practice of informed consent that should be respected by the nurse. Although much of the debate lies in the discussion of cases where people are unable to make choices about their own treatment due to being incapacitated
or having a mental illness that affects their judgement.
A way to maintain autonomy is for the person to write an advance directive, outlining how they wish to be treated in the event of them not being able to make an informed choice, thus avoiding unwarranted paternalism.
Another theme is confidentiality and this is an important principle in many nursing ethical codes. This is where information about the person is only shared with others after permission of the person, unless it is felt that the information must be shared to comply with a higher duty such as preserving life.
Also related to information giving is the debate relating to truth telling in interactions with the person in care. There is a balance between people having the information required to make an autonomous decision and, on the other hand, not being unnecessarily distressed by the truth. Generally the balance is in favour of truth telling due to respect for autonomy, but sometimes people will ask not to be told, or may lack the capacity to understand the implications.
By observing the principles above, the nurse can act in a way that respects the dignity of the individual in their care.
Although this key outcome iursing practice is sometimes challenged by resource, policy or environmental constraints in the practice area.
Nursing values are fundamental to the practice of nursing. They guide standards for action, provide a framework for evaluating behaviour and influence practice decisions. Despite the importance that can be attributed to nursing values, acknowledgement of them is difficult to find in the current debate about how interprofessional working is changing the healthcare system in which nurses currently work. This article argues that the professioeeds to demonstrate that values are not only a theoretical concept but also that they can, and do, have a profound impact on the practical working life of nurses delivering care in collaboration with other professions.
What Does Our Vision Mean?
· Trusted Nurses- We aspire to achieve the faith and confidence of those we serve and to be their first choice when they need healthcare services for themselves, their families and friends. We earn their trust based on clinical quality, patient safety, service excellence and integrity.
· Caring for Patients’ and Others’ – We provide superior clinical quality and world class service in a patient-first environment. We are the “corner stone” in the interdisciplinary team’s ability to achieve ideal outcomes. We build lasting relationships with our patients, physicians, community, other employees and each other. We recognize individuals and groups for their quality patient care and nursing excellence.
· Advancing Practice- We drive superior clinical outcomes through evidence-based, practice-driven protocol’s and the advancement of our practice utilizing formal and continuing education.
What Do Our Values Mean?
· Caring – Anticipating and meeting the needs of our patients, physicians, and co-workers
· Integrity- Communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards
· Respect- Treat each individual with the highest professionalism and dignity
· Commitment – Pledge to support the vision of nursing, the hospital and the system
· Loyalty – Dedicate ourselves to our patients, their families, our community and our profession
· Excellence – Continue to learn and provide the superior clinical practice to our patients in a healthy work environment.
OUR VALUES ARE:
1. Concepts that give meaning to an individual’s life.
2. Influenced by society, family, religion, ect.
3. Serve as a framework for decision-making.
TYPES OF VALUES
A. Intrinsic.
B. Extrinsic
C. Personal
D. Professional
