Understanding Health Perspectives and Privilege in Nursing Practice
As nurses, we are expected to make decisions and represent our patients. Nurses are constantly exposed to today’s society and a diverse population that relies on their expertise to provide consistent and culturally appropriate care to each patient. Due to the large diversity of the population in the United States, this task has become quite difficult for nurses. This diversity has long been described as a “melting pot” of human cultures, races, customs, beliefs, and a plethora of other differences that comprise humanity. This paper investigates various aspects of cultural competence in nursing in the United States (U.S.) and at this nurses’ workplace, Inspira Health Network, a four-facility Magnet-designated organization in Southern New Jersey.
Inspira Health Network is a New Jersey-based provider of general acute and ambulatory healthcare services based in Camden, Cumberland, and Salem Counties. Vineland, Elmer, Woodbury, and Bridgeton are the four campuses of the organization. Inspira Health Network is a 501(c)(3) non-profit organization. Inspira Health Network provides non-discriminatory healthcare services to all individuals, regardless of race, color, creed, gender, national origin, or ability to pay. Furthermore, Inspira Health Network adheres to criteria that include providing health care services to all individuals regardless of ability to pay, including charity care, self-pay, Medicare and Medicaid patients, and/or patients who meet certain criteria defined by the New Jersey Department of Health and Senior Services free of charge or at rates lower than established rates (Inspira Health Network, 2013). (2012).
Inspira Health Network and population diversity in the United States
Despite the existence of immigration laws, the United States continues to change dramatically in terms of racial and ethnic differences from year to year. According to the United States Census Bureau (2015), the country’s population of more than 320 million people will grow by more than 20 million by 2020. The United States Census Bureau reports percentage estimates of ethnic makeup in the United States as of 2013, and the area served by Inspira Health Network is:
| County | Cumberland | Salem | Camden | New Jersey | U.S. |
| Race/Ethnicity | |||||
| White | 73.6% | 81.7% | 70.4% | 75.8% | 62% |
| Black | 22% | 15.5% | 21% | 14.5% | 13.2% |
| Latino | 24.8% | 6.1% | 15.4% | 16.7% | 17.1% |
| Asian | 1.4% | 1% | 5.6% | 9.2% | 5.3% |
| Poverty Level | 13.4% | 10.5% | 10.4% | 8.7% | 16% |
(United States Census Bureau, 2012)
This cultural shift affects millions of people who come to this country and will require nursing care at some point in their lives. The non-white Americans in the areas served by Inspira are almost all higher than the national average, and poverty rates are close to the national average.
Also, when assessing care needs, we must consider the professionals who will be providing it. Cultural diversity among nurses becomes a top priority in order to improve cultural competence in care. Another issue we face is a lack of representation of certain ethnic groups in nursing. As the United States becomes more diverse, the need for culturally competent care rises to the top of the agenda. According to the 2008 National Sample Survey of Registered Nurses (NSSRN), minority nurses made up 16.8% of the registered nurse (RN) workforce. The RN population is made up of 5.4% African Americans, 3.6% Hispanics, 5.8% Asian/Native Hawaiians, 0.3% American Indian/Alaska Natives, and 1.7% multi-racial nurses (AACN, 2014). These are startlingly low figures, given that non-white ethnic groups account for one-third of the US population. It is clear that the populations who require culturally diverse care have the lowest representation in the nursing profession.
Minority Population Vulnerability
End-of-life care, chronic disease, and effective communication will be the most obvious areas of vulnerability for these culturally diverse patients. End-of-life care has been a source of contention in the United States healthcare system. While some believe that everything should be done for patients, others believe that services such as palliative and hospice care allow patients to die with dignity and respect. According to the National Hospice and Palliative Care Organization, approximately 93.1% of hospice patients are white or non-Hispanic. Hispanics and African Americans appear to have the lowest participation in these types of services, which could be due to a lack of cultural delivery or understanding of services. According to the study, approximately 6.9% of Hispanics and 8.6% of African American patients and families use hospice care. These populations face barriers that prevent them from taking advantage of hospice services that are available to dying patients. “The challenge remains to make hospice and palliative care services fully available to diverse communities,” says the National Hospice and Palliative Care Organization (Schim et al., 2006). Most cultures have different perspectives on death, so the clinical nurse’s competency must be as diverse as the care provided. This means that nurses must be trained in competency relevant to the populations they will be caring for, as well as educate clients about the availability of services and the purpose of care. This task will be difficult for some staff, but it will raise awareness, change attitudes for those reached, and increase willingness to accept services among various cultures and populations.
Chronic disease is more common in some cultures, posing a problem in terms of care competency. Inspira provides chronic disease outreach programs such as CHF and diabetes. These programs attempt to reach patients in their homes and communities in order to reduce readmissions and increase compliance. For the most part, these programs will not consider ethnicity when allocating services, which may result in less comprehensive communication than if the communication was delivered in a more culturally competent manner. Missed opportunities for screening due to a lack of familiarity with the prevalence of conditions among certain minority groups are one example of the negative impact of ignoring culture and ethnic background. The high prevalence of diabetes among the Latino population in the Inspira service area is something that can be overlooked if ethnic maladies are not taken into account in care. Failure to account for different responses to medication, a lack of knowledge about traditional remedies, and diagnostic errors caused by miscommunication can all lead to harmful drug interactions. Broch and Fraserirector (2000)
Patients can communicate in a variety of ways at Inspira. This includes mobile applications, self-patient medical record retrieval, and a variety of other publications. Given the large Hispanic or Latino, and Asian populations in the United States and the immediate area surrounding Inspira, language barriers are a major concern. Inspira Health Network does not employ interpreters because they can be expensive, which some facilities cannot afford. Some of the staff speak Spanish or have learned it in order to communicate with patients who do not speak English. For patients who do not speak English, the hospital has a language line on each floor where they can communicate with patients and families. Although the language line is a valuable resource, it may not be used at times due to inconvenience or the need for immediate care. Patients who would otherwise thrive under the care of a culturally competent nurse may suffer as a result of a lack of or misuse of these communication tools.
Cultural Competency Standards
There are numerous resources for cultural competency standards that include theory and evidence. Nursing theory is the mechanism through which nurses function, and the nursing professional practice model at Inspira aligns with Dorothy Orem’s Self-Care Requisites conceptual theory. Orem proposed that certain patient characteristics, dubbed “basic conditioning factors and power components,” have an impact on self-care. This means that, according to Orem, each culture has its own set of contributing factors and components that influence their ability to care for themselves. Culturally competent nursing delivery is required for effective self-care in patients and disease management. Furthermore, nursing care systems, such as diabetes disease management, are used to increase self-care among patients from various cultures. Internal or external factors that can affect a patient’s ability to participate in self-care are referred to as basic conditioning factors. Furthermore, basic conditioning factors may influence the type and amount of self-care that a patient requires, which may vary depending on cultural competency. Power components are characteristics that enable an individual to perform self-care activities and are culturally specific (Dalton, 2012).
Although organizations such as Inspira use specific theories to guide care, there are global nursing organizations that also have input into cultural care standards. The Transcultural Nursing Society is a major proponent of cultural nursing knowledge (TCN). According to the TCN, culturally competent care can only take place when cultural care values are understood and serve as the foundation for meaningful care. The TCN, in collaboration with the American Academy of Nursing and the Expert Panel for Global Nursing, has established the following guidelines for culturally competent care:
Social Justice is the first standard.
Standard 2: Critical Thinking
Cultural Knowledge (Standard 3)
Practice that is Culturally Competent
Cultural Competence in HealthCare Systems and Organizations is standard.
Patient Advocacy and Empowerment (Standard 6)
Norm 7: Multicultural Workforce
Standard 8: Culturally Competent Care Education and Training
Cross-Cultural Communication Standard 9
Cross-Cultural Leadership is standard.
Policy Development is standard.
Evidence-Based Practice and Research (Standard 12) (TCN, 2014)
Of course, standards and values are only as good as the nurses who consistently meet them. Social justice is one standard of care that all nurses, without a doubt, achieve on a daily basis. As nurses, we excel at providing care to everyone in need, regardless of socioeconomic status, ethnicity, religious beliefs, or background. Concurrently, we must assess our performance in terms of maintaining competence in the cultural and spiritual needs of the diverse patients we serve. It is our responsibility as professionals to seek logic in views on family, traditions, practices, and health beliefs, as well as to learn about the interventions we use to treat them. Some nurses never learn cross-cultural communication skills. When dealing with patients from other cultures, this is the ability to take time, patience, good listening, and awareness. Nurse communication can become lost in the hustle and bustle of a busy workday. Simply taking the time to listen to our patients will help to improve cross-cultural communication and personal and professional relationships.
Standards’ Influence on Nursing Care
To bridge the gap between cultural competency and patient care, organizations strive for compliance on a yearly basis. Nursing continuing education typically focuses on topics like cultural diversity, among many other required competencies. At Inspira, nurses must demonstrate competency in the fundamentals of cultural diversity by completing Healthstream modules on a yearly basis. As previously stated, Inspira is located in an area where cultural diversity is primarily confined to Latino and Asian cultures, with the occasional European culture thrown in for good measure. Despite this, the nursing staff at Inspira is as diverse as that of any larger city, thanks to an influx of nurses from the Philippines, the Middle East, and Jamaica. Break rooms appear to be a coalition of different ethnic backgrounds and beliefs at times, which translates into a somewhat better understanding of diverse patient population needs.
Although the basic overview provided in yearly competencies can assist nurses with basic assumptions of certain ethnic practices, nurses’ knowledge should not be limited to this. Knowledge of health customs from various cultures can aid in the delivery of nursing care. Herbal remedies, for example, are used as fads and commercially by Americans, but for some cultures, the use of herbs is a part of daily life. The use of herbs by various ethnicities is especially common during times of illness or disease. For example, according to a study on the use of herbal supplements by Israeli cancer patients, “disclosure of herbal use was reported by 154 of the 305 patients (50.5%) interviewed by physicians.” During the initial follow-up with physicians, the use of 85 single herbs and 30 different herbal formulas was documented. “14 quality of life-related indications for herbal use were reported by patients” (Almor, Lev, Schiff, Linn, & Ben-Ayre, 2014). Without nursing cultural competence, not knowing the prevalence of herbal remedy use among Israeli cancer patients could result in interactions and side effects that would be unknown.
Another area of concern for lack of cultural competence is during physician-patient interactions, such as consent for surgery and procedures. Surgeons or physicians may speak to patients about specific procedures, and the patients may have no idea what they have agreed to. Especially in cultures where doctors and people with perceived wisdom are revered, it is the nurse’s responsibility to ensure that the patient understands everything that is going on. The main goal of informed consent is to ensure that the patient is well-informed and understands what consent entails. If we fail to consider the cultural aspects of this type of situation, nurses may find themselves in an ethical quandary that jeopardizes both the patient’s and the organization’s integrity. In this scenario, having the ability to demonstrate cultural competence is critical.
Solutions
The obvious solution to cultural competence is for all nurses to actively participate in cultural knowledge acquisition at all times. Of course, as nurses, we understand that our work lives can be just as hectic as our personal lives, leaving little time for in-depth immersion in different cultures. As a result, nursing programs must devote a larger portion of their curriculum to cultural diversity. By emphasizing the importance of cultural knowledge, nursing programs can instill it in students from an early age. Furthermore, if nursing boards require more knowledge of cultural competency, it is reasonable to assume that nursing programs will provide the necessary information. It becomes a challenge that organizations must face for experienced nurses. In addition to yearly competency through education departments, using surveys and promoting workshops can help nurses reflect on their views of other cultures and become aware of the need for cultural competency.
In this era of healthcare, patient satisfaction has been a major focus for organizations. Patient satisfaction has risen to the top of leadership agendas at Inspira and is likely to remain there as it is linked to reimbursement. Patient satisfaction is influenced by cultural competence. When patients feel understood, they are more likely to feel the compassion that nurses have for them and their situation. Patient satisfaction and cultural competency, according to ANA President Rebecca M. Patton, go hand in hand with standards of care. In a statement about the ANA receiving a grant for culturally competent education, she said, “Clearly, cultural competency is a major responsibility for nurses because it sits right at the nexus of health care and social justice.” This program will be a valuable resource for nurses seeking to gain the necessary knowledge and behaviors to promote a compassionate culture in health care.” Tennessee Nurse (2010a)
Another way that organizations like Inspira can promote cultural competency is by ensuring access to healthcare. People from various cultures frequently avoid seeking medical attention due to the high cost of healthcare. Raising awareness of programs such as the Affordable Care Act and Charity Care in the communities we live in is a civic duty of our organization and ourselves as nurses. We can open our doors and change the lives of many more culturally and ethnically diverse populations in our own communities by providing access to care.
Conclusion
Finally, culturally competent care is an aspect of nursing culture that nurses must learn from the start of their careers. Organizations like Inspira, which promotes workplace diversity by hiring nurses and employees from all over the world, are paving the way for the future of diversity in the healthcare industry. As nurses, it is our oath-bound duty to promote well-being and aggressively care for patients of all races and creeds. In exchange, we will have the satisfaction of knowing that we did everything we could for our patients and that they truly felt the compassion and understanding that we have in our hearts for them.
Reference
Almor, L., Lev, E., Schiff, E., Linn, S., & Ben-Ayre, E. (2014). Bridging cross-cultural gaps: monitoring herbal use during chemotherapy in patients referred to integrative medicine consultation in Israel. Supportive Care in Cancer, 579.
American Association of Colleges of Nursing | Enhancing Diversity in the Workforce. (2014, January 21). Retrieved from http://www.aacn.nche.edu/media- relations/fact-sheets/enhancing-diversity
ANA receives grant to support nurses’ cultural competency: cultural competency program aims to help reduce health care disparities, increase patient satisfaction, and promote human dignity. (2010). Tennesse Nurse, 73(1), 10.
Brach, C., & Fraserirector, I. (2000). Can cultural competency reduce racial and ethnic health disparities? Medical Care Research and Review, 57(4), 181-217.
Dalton, J. M. (2012). Diabetes disease management in a home care setting. Home Health Care Practice Management, 24(1), 38-49.
Inspira Health Network, (2012). Friends and Family. Retrieved from http://www.inspirahealthnetwork.org/
Schim Myers, S., Doorenbos, A. Z., & Borse, N.N. (2006). Enhancing Cultural Competence Among Hospice Staff. American Journal of Hospice & Palliative Care, 23(5), 404-411
Transcultural Nursing Society. (2014). Transcultural Nursing Standards of Practice. Retrieved from http://www.tcns.org/TCNStandardsofPractice.html
United States Census Bureau. (2012). Quick Facts. Retrieved from http://quickfacts.census.gov/
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Question 
Briefly introduce a person you have recently cared for in your nursing practice. (Be sure not to include any identifying information that would be protected by HIPAA!) Discuss the person’s view of the cause of their health condition, the person’s health literacy, and the person’s identity on the continuum of privilege-disadvantage (Table 4 in the Lor article on p. 361). What was (or would be) your approach to care for him/her in a culturally competent way?
Culturally Competent Care
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