Developing Cultural Competence in Nursing

Developing Cultural Competence in Nursing Christopher Mason Cultural Interview with Patrick de Mendoza The culture in which we are raised greatly influences our attitudes, beliefs, values, and behaviors. Our families taught us how to believe about and treat people who were different than we are. In order to provide sensitive and effective care to persons from cultures that are different from our own, two things must occur: An awareness of one’s own cultural values and beliefs and a recognition of how they influence our attitudes and behaviors. An understanding of the cultural beliefs and values of others and how they are influenced by them (Wintz Cooper, 2009, p. 7). I interviewed Patrick de Mendoza, a 37 year old Mexican-American male. My intentions in conducting this interview were to learn more about how a person from the Hispanic heritage experiences health care in the United States compared to someone of the Caucasian background. Patrick and I are close friends with similar interests. I never saw him as Hispanic, only as American. I never considered us to be very different. The fact is, he is of Mexican and Spanish decent and I am of European and Native American decent. While we have similar ideas on our outlooks to the future, there are differences in the way we were raised and the views we were taught to believe. This article will compare and contrast our views of and encounters with healthcare. When asked about how closely he identified with his ethnic background, he stated, â€Å"90% of my friends are Mexican, as in either 1st or 2nd generation Mexican-American. There is an importance placed on how far away generationally we are from having lived in Mexico. First generation means both parents are full-blooded Mexican. I am 2nd generation.† (P. de Mendoza, personal communication, February 20, 2014) Even though Patrick has been raised in the U.S., his upbringing was based on Mexican traditions. In his home English and Spanish are spoken. He doesn’t speak Spanish fluently and is more comfortable speaking English. He says regarding personal space and dialogue, â€Å"there is very small personal space and dialogue can go to the male or female. However, you have to jump in and speak if you want to be heard. Typically the Spanish dialogue is very energetic.† (P. de Mendoza, personal communication, February 20, 2014) As a Hispanic, Patrick was raised Roman Cat holic. He was taught to not only respect his elders, but to pitch in and help wherever he could to help his family and community. When asked what his culture believed about health, Patrick said that most Mexicans in the United States get what they need when they are sick by crossing the border back to their family or physicians their family knows and uses in Mexico. â€Å"I have a jaded opinion of the American healthcare system knowing that I can get the drugs or treatment I need faster and cheaper in Mexico.† (P. de Mendoza, personal communication, February 20, 2014) Patrick says, â€Å"I personally have a bias against the old school white male clinician that I am likely to see during a doctor visit. It is more textbook question after question and less inviting.† (P. de Mendoza, personal communication, February 20, 2014) Having said that, he did explain that in Mexico you a more likely to see a physician who is more involved and interested in what will make you feel b etter. Funny enough, Patrick laughed and said, â€Å"That’s real too!† (P. de Mendoza, personal communication, February 20, 2014) When I asked Patrick if he would prefer to have a physician from his culture, he said, he would probably be more open with someone from his culture. However, if not, he would hope to see a qualified physician to whom he could relate. On a more positive note, Patrick told me that in the Latin culture mental illness such as schizophrenia and Down syndrome are not looked down upon but instead are accepted by the family and the community. â€Å"You come together as a community to provide whatever they need and to offer support for not just the mentally ill but also for the physically ill, grieving, and the indigent.† (P. de Mendoza, personal communication, February 20, 2014) I asked Patrick what role his culture and religion played in his up-bringing. In a very earnest response, he replied, â€Å"I think in Mexican heritage we really val ue family life.† (P. de Mendoza, personal communication, February 20, 2014) Society did not dictate how he was disciplined even though the Mexican population is Roman Catholic as a culture. When I asked him about his own health, he replied that he becomes quite overwhelmed with the stress of being a pre-school teacher. He added, how a person carries their stress determines how healthy or sickly they may be. Patrick felt he could be healthier and that he could better his own situation using diet, exercise, and stress management. In 2003, the Institute of Medicine recognized that an increasing number of studies focusing on disparities in healthcare validated the view of racial and ethnic minorities as credible assessments. For example the biased views often held by Mexican-Americans toward their physician have a true influence on the patient as well as the physician. While the patient questions competency and may disrespect the physician because he is culturally different and not of the same ethnicity, conversely the physician’s perspective is often influenced by the patient’s avoidance of treatment and difficulty in communication (Blendon et al., 2007). In my interview with Patrick he reinforced this point by saying, â€Å"The relationship you have with a physician or nurse determines the types of questions they are free to ask and how freely you will answer them.† (P. de Mendoza, personal communication, February 20, 2014) Very personal questions, sexual in nature or concerning abortion are purposefully not answered if a patient assesses the physician as not caring or trust worthy. Trying to get answers out of him as a patient would be very taxing for a physician with whom he felt no bond or trust, even to the detriment of his health. Latin heritage is structured with a religious upbringing of Roman Catholicism that deters conversations concerning contraception and abortion. Abortion is a religious belief not a physician’s advice or a recommendation of a healthcare practitioner. A first visit is very different and although Patrick says he would probably be very reserved, he would give that physician the opportunity to build a trusting relationship. With his healthcare experiences at Kaiser Permanente, in particular, he has had no continuity of care and has received most of his treatment from nurses and nurse practitioners. Exasperated, Patrick commented, â€Å"I am likely to see a physician for about 5 seconds, if at all.† (P. de Mendoza, personal com munication, February 20, 2014) Again he repeated, â€Å"†¦ and that’s real too!† (P. de Mendoza, personal communication, February 20, 2014) Contrary to most Mexican-Americans, Non-Hispanic whites in the United States are in some ways more compelled by logic than culture when sick and dealing with healthcare. As far back in time as I can remember, if I became ill my mother either called the doctor or took me to the doctor’s office for a visit. I believe in western medicine, but my physician spoke the same language I did and I had health insurance that helped to pay for services. Rationally, it makes sense to go to the person who has the knowledge to solve the problem you are having. If you are having car trouble you go to the auto-mechanic. If you are having issues with your roof leaking, you call the roofer. If you are having complications within your body, you call the person who knows the most about the human body. Traditionally, for Caucasians in America whose grandparents’ grandparents were U.S. settlers, that person is a physician. Whether for a slight cold or a broken limb, I saw the doctor. I never had any problems getting an appointment because I never really had to have one. I very simply went to the office and signed in. Usually there was somewhat of a wait, but the time was well worth the medical resolution. I saw the same physician my father always had. When he retired his son took over his practice and he is still my physician today. â€Å"Since our hospitals were built by European Americans for European Americans, their values such as autonomy, independence, and privacy prevail in our institutions. Patients who have immigrated†¦ often value the family over the individual or view the male head of household as the decision maker for the patient† (Galanti, 2001). The hospital staff maintains that patients should want to gain their independence as a part of a healthy outcome (Galanti, 2001). Health outcomes are certainly affected by socio-economic advantage and cultural non-minorities benefit from higher rates of employment, acquisition of insurance, as well as choice and quality of health services. Mental health is another area where Mexican-Americans and Non-Hispanic whites differ. Both populations seem to have contrasting ideas about the causation of psychiatric illness which affect the roles family members play in treatment and recovery. The Hispanic culture is accepting of the person regardless of the ailment. The Mexican perspective accepts and expresses less blame, embarrassment and stigmatization than what I have personally witnessed in my own culture. I had an uncle who was an alcoholic. In the community and in the family people expressed a common feeling of disgust for him. My brothers and I were always told, â€Å"Stay away from Paul, he drinks too much.† Whether a genetic disorder such as Down syndrome or complication from drug use during pregnancy, the child is accepted with open arms and warmth. Patrick proudly stated, â€Å"The family and community comes together as one to pitch in and help those who suffer from perhaps schizophrenia or alcoholism. It is a cultural fundament to actively participate and help.† (P. de Mendoza, personal communication, February 20, 2014) Patrick’s mother suffers from schizophrenia. He says, â€Å"Every one of all ages is expected to chip in and make sure the person suffering is not left behind to suffer alone.† (P. de Mendoza, personal communication, February 20, 2014) Patrick continued with high spirits telling me that Latin America is very conversational rather than a more reserved culture where some things are not discussed. â€Å"There is a comfort in everyone chiming in; no one is labeled or shunned because they share a different opinion from the rest of the group. We are an open forum.† (P. de Mendoza, personal communication, February 20, 2014) Culture and ethnicity create a unique pattern of beliefs and perceptions as to what â€Å"health† or â€Å"illness† actually mean. In turn, this pattern of beliefs influences how symptoms are recognized, to what they are attributed and how they are interpreted, and effects how and when health services are sought. (Anderson, Scrimshaw, Fullilove, Fielding, Normand, 2003, p. 68) Utilization or lack thereof is not always due to an absence of medical facilities or health insurance. Sometimes there isn’t a language barrier that keeps someone from having a conversation with a healthcare practitioner. Even as there is a growing population of medical professionals of the Hispanic ethnicity as well as other minorities, generally most Mexican-Americans expect their primary practitioner to be an older white male. In Patrick’s view, this acts as a deterrent to the United States healthcare system for most Mexican-Americans. While Patrick’s idea of the physician’s ethnicity may inhibit most of his Mexican-American friends; this is an image of a provider that I am used to. As bravado as Patrick’s culture is, for 8 of 9 of his closest friends the head of the family is the grand-ma, abuelita. â€Å"We often take the opinion of our elders, grand-mother or uncle who you know are on your side.† (P. de Mendoza, personal communication, February 20, 2014) At this point Patrick has an HMO. He says, â€Å"Doctors are not advocating for me.† (P. de Mendoza, personal communication, February 20, 2014) If he sought a physician’s advice, the recommendation always comes from family and friends. Longstanding in Mexican culture, many tend to go over the boarder to have procedures performed. Patrick said, â€Å"I don’t know if it is of the same quality as U.S. healthcare, but unless you have a really good job with excellent insurance coverage and a strong bond with your physician, then you trust the people your family go to when they are sick.† (P. de Mendoza, personal communication, February 20, 2014) Shocking to me, he added, â€Å"I have friends that are in the military with great healthcare, but they still go to Mexico to get procedures they need because their families went there.† (P. de Mendoza, personal communication, February 20, 2014) The Clinical Nurse Leader character was formed by the AACN in 2006 to afford headship across all aspects of our health care organization (Shipman, Stanton, Hankins, Odom-Bartel, 2013). Patrick felt that miscommunication and a lack of cultural understanding leads to mistrust. He said, The more you trust a doctor the better relationship you have and the more inclined you are to talk about your personal issues and relationships. When I’m referring to going over the border, I’m speaking of seeing the family doctor. It does say a lot to have a family doctor because you have a history with someone who can identify with your beliefs (P. de Mendoza, personal communication, February 20, 2014). As a Clinical Nurse Leader, we are responsible for advocating for the patient and for fostering communication between patients, their families or care takers and nurses and physicians alike. The involvement of a CNL in patient treatment could soon be as prevalent in health care facilities as physician assistants and nurse practitioners are now. CNLs could put programs in place for retaining and recruiting diverse staff. This would provide a deeper well of knowledge of beliefs and practices from many cultures not just one or two. Another obligation of all practitioners and specifically Nurse Leaders is to ensure that educational materials are available that are culturally and linguistically appropriate for each clients’ cultural history. Our patients should feel as though their Clinical Nurse Leaders have given them the tools to actively be involved in their own health treatment. These are basic cultural competencies that, when implemented, further the cultural riches within he alth facilities already available to diverse communities. A Clinical Nurse Leader, having specific training in cultural awareness, will hopefully creatively lessen communication barriers, facilitate the integration of larger knowledge bases of ethnic health beliefs, as well as better conditions and practices. To provide an equal quality of healthcare to everyone hardly means treating all patients the same. In order to give optimal health care to everyone, all professionals must consider humanity’s many differences, attempt to know each client, and tailor treatment to the individual. We could also work with area providers in sensitivity training helping them to become aware of their beliefs that work to marginalize other ethnicities. (Anderson et al., 2003, p. 72) I hope that these accomplishments and goals toward quality of care are realized in the near future. It is senseless for a country as advanced as the United States is to have such a miraculous body of medical and biologic knowledge, if we fail to use that information to optimize the health situations of all the people that make-up our society. Patrick felt his health was not at its best due to the amount of stress he experiences. He felt his health could be transformed by more positive thinking, setting realistic goals, eating better, and exercising. As Clinical Nurse Leaders, we should be promoting inter-professional team care and embracing not an alternative system, but a complimentary treatment approach to the patient as a whole. References Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. .E., Normand, J., (2003). Culturally competent healthcare systems: a systematic review. American journal of preventive medicine, 24(3), 68–79. doi: 10.1016/S0749-3797(02)00657-8 Blendon, R. J., Buhr, T., Cassidy, E. F., Perez, D. J., Hunt, K. A., Fleischfresser, C., . . . Herrmann, M. J. (2007). Disparities In Health: Perspectives Of A Multi-Ethnic, Multi-Racial America. doi: 10.1377/hlthaff.26.5.1437 Galanti, G. A. (2001). The challenge of serving and working with diverse populations in American hospitals. Diversity Factor, 9(3), 21-26. Shipman, S., Stanton, M., Hankins, J., Odom-Bartel, R. (2013). INCORPORATION OF THE CLINICAL NURSE LEADER IN PUBLIC HEALTH PRACTICE. 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