Cultural Competence in Nursing Care

Using the Application of the Staircase Model: Self-Reflection Questions, on page 89 in the textbook, evaluate your cultural competence in relation to caring for patients with disabilities.

You do not need to share the complete assessment but discuss a few of the questions and your responses in detail.

Where you are on the scale?

What will you need as part of your basic nursing education or continuing education to provide safe, competent, and caring nursing interventions to persons with a disability?

Written Assignment Using the Application of the Staircase Model: Self-Reflection Questions, on page 89 in the textbook, evaluate your cultural competence in relation to caring for patients with disabilities. You do not need to share the complete assessment but discuss a few of the questions and your responses in detail. Where you are on the scale? What will you need as part of your basic nursing education or continuing education to provide safe, competent, and caring nursing interventions to persons with a disability? Pages 89 Case scenario A Jewish Patient Yetta is a 71-year-old Jewish patient. She has been a resident of an upscale Lutheran long-term care facility for the past 2 years. Yetta has been married for 50 years and is quite concerned about her husband who has recently fallen ill and now rarely visits her. The couple has three children. Two of them, a daughter and a son who is a physician, are married with children. The third child, another son, has a mental disability. Over the past 15 years, Yetta has suffered from a variety of chronic health problems including multiple sclerosis and related quadriplegia, diabetes mellitus, hypertension, obesity, decubitus ulcers, and depression. As a result of her multiple clinical problems, she is now totally dependent on the staff for assistance with activities of daily living. Since her admission, Yetta has become progressively more demanding and difficult in her interactions with others. Some of the nurses have commented that this behavior is “typical of Jewish patients.” Others have suggested that, perhaps, Yetta is now experiencing a form of dementia. During a state inspection of the facility, Yetta complained to an official 90 that the staff frequently ignored her. Consequently, the institution established a policy that required all nurses caring for Yetta to visit her at least once each hour. A few of the staff members do so grudgingly and avoid going into her room beyond the designated times. In addition, Yetta’s family members visit her infrequently and limit the time of their visits to less than an hour. Yetta spends much of her time checking her watch and calling for the nurses shortly before her scheduled treatments, meals, medications, and procedures. Karen, one of Yetta’s nurses, is frustrated by her patient’s behavior. Like many of the other nurses, she dreads going into Yetta’s room and caring for her, because the patient constantly criticizes everything she does for her and never seems satisfied. One day Karen noticed that the only time that Yetta seemed reasonably comfortable was when she was talking to her about her former lifestyle, during which she was much more active in her synagogue. Cultural Competence in Nursing Care

There was a certain twinkle in her eye as she spoke of the many social events that she and her husband participated in through her synagogue. Yetta stated that in the past they had a close relationship with the rabbi. She also described fond memories of her children’s Bar and Bat Mitzvahs. Karen also noticed that although Yetta’s conversation with her family is often tense, she seems grateful for the Kosher food her family brings during their brief visits. Karen, a Catholic, knew little about the Jewish religion, or Jewish customs and practices. This was her first experience caring for anyone who was of Jewish heritage. She wondered whether Yetta’s behavior might be partially a reflection of her separation from her family, cultural traditions, and religious practices. She also wondered if providing Yetta with opportunities to talk more about herself might be helpful in assisting Yetta to better cope with her health care problems and relationships with health care providers during her stay at this long-term care facility. Karen decided to further investigate Judaism and to learn about ways to incorporate Yetta’s faith and cultural traditions into her care planning. When considering Yetta’s case, ask yourself the following questions. If you are the nurse caring for Yetta: 1. What feelings would you have in caring for this patient? On what are these attitudes and feelings based? 91 2. Where are you on the Cultural Competency Staircase regarding the care of this patient? 3. How will you progress to the next level? (see Chapter 1) 4. What are your feelings, attitudes, and beliefs about the role spirituality and religion play in coping with illness? 5. Does your religious affiliation differ from the patient’s in this case? How might this impact your ability to assist her with spiritual/religious care? 6. How much do you know about the values, traditions, religious, and health beliefs of Jewish patients? What are some ways the nurse might learn? 7. How easily would you be able to communicate with the patient and her family to assess the patient’s cultural/spiritual needs? 8. What cultural assessment tool would you use to collect data about this patient’s spiritual needs? Discussion Board Complete the Application of the Staircase Model: Self-Reflection Questions (page 99 in text). Take the time to really reflect on your responses to each question relating to the case. 1. Where am I on the staircase in relation to this patient? How can I move to the next level? 2. How familiar am I and the nursing and medical staff with the religious beliefs, values, and attitudes of people who are Jehovah’s Witnesses? 3. What major differences exist in health beliefs of followers of this religion and other Christian traditions? How different is this religion from my own? 4. What feelings and attitudes do I have about Mr. Jackmon’s beliefs about receiving blood? 5. How helpful are these attitudes toward the development of cooperative between myself and the patient? 6. Are there alternative ways of treating this patient’s hemoglobinemia? 7. On what religious beliefs does Mr. Jackmon base his refusal of blood, despite his need for it? 8. From whom could the nursing staff gain more insight about the patient’s health care beliefs? 9. What strategies might be useful in meeting the physiological and psychological needs of this patient? 10.What resources might the nursing staff utilize to assist them? Do you have any specific cultural, spiritual or religious preferences you would like your health care providers to know about and honor? Case scenario A JEHOVAH’S WITNESS PATIENT Tyrone Jackmon, a 46-year-old African American male patient, was admitted to a surgical trauma unit with multiple bilateral fractures of upper and lower extremities, multiple contusions, and a pelvic fracture. Cultural Competence in Nursing Care

Mr. Jackmon was a victim of a multiple-car collision near his place of employment. Remarkably he was awake, alert, and oriented during his admission to the unit. Mr. Jackmon arrived at the unit accompanied by his wife of 20 years. Shortly after his transfer to the floor, the nurses received his laboratory reports by phone and learned that Mr. Jackmon’s hemoglobin was 6g/dL on admission to the emergency room. Following the report from the ER nurse, the primary nurse, Susan, immediately contacted the physician to determine if blood products were to be administered. The physician had ordered two units of packed red blood cells to be given over the next 6 hours. When Susan met with the patient to obtain the nursing history, Mr. Jackmon informed her that he was a Jehovah’s Witness and would not accept blood as it was “against his religion.” Susan explained to the patient that without the transfusion, Mr. Jackmon’s hemoglobin was likely to drop even more. Still, Mr. Jackmon refused. Susan felt strongly that the patient should change his mind about accepting the transfusion, since his hemoglobin was so low. Susan decided to discuss the matter with Rachel, another staff nurse on the unit. Rachel explained to Susan that there were alternatives to being transfused with packed cells when the patient objected to having a blood transfusion. Rachel added that she believed it was important to respect the patient’s religious values. Susan called the physician so that he might meet with the patient to discuss the dilemma and determine the next course of action. Both nurses were anxious to stabilize Mr. Jackmon medically and recognized that the patient was becoming anxious about his medical 99 Both nurses were anxious to stabilize Mr. Jackmon medically and recognized that the patient was becoming anxious about his medical situation.

Despite his anxiety, Mr. Jackmon remained alert and oriented, and steadfast in his religious commitment. Later, that afternoon, a second laboratory report revealed a hemoglobin of 3g/dL. Susan feared that time might be running out for Mr. Jackmon and something needed to be done soon. Perhaps it was the morphine he was receiving for pain that was clouding his judgment, one of the nurses remarked. “I don’t understand some of these patients, how can you help them when they won’t try to help themselves?” WHAT NURSES NEED TO KNOW ABOUT THEMSELVES Application of the Staircase Model: Self-Reflection Questions In attempting to address Mr. Jackmon’s case, ask yourself the following questions if you are the nurse caring for Mr. Jackmon: Take the time to really reflect on your responses to each question relating to the case. 1. Where am I on the staircase in relation to this patient? How can I move to the next level? 2. How familiar am I and the nursing and medical staff with the religious beliefs, values, and attitudes of people who are Jehovah’s Witnesses? 3. What major differences exist in health beliefs of followers of this religion and other Christian traditions? How different is this religion from my own? 4. What feelings and attitudes do I have about Mr. Jackmon’s beliefs about receiving blood? 5. How helpful are these attitudes toward the development of cooperative between myself and the patient? 6. Are there alternative ways of treating this patient’s hemoglobinemia? 7. On what religious beliefs does Mr. Jackmon base his refusal of blood, despite his need for it? 8. From whom could the nursing staff gain more insight about the patient’s health care beliefs? 9. What strategies might be useful in meeting the physiological and psychological needs of this patient? 10.What resources might the nursing staff utilize to assist them? Cultural Competence in Nursing Care

WHAT NURSES NEED TO KNOW ABOUT THE PATIENT 100 An assessment model that may be useful in this case example was developed by Berlin and Fowkes (1982) and can be found at www.ncbi.nlm.nih.gov/pmc/articles/PMC1011028/?page=5. In this model, the authors use the mneumonic LEARN and identify five steps in the cultural assessment process. The framework was first developed by the authors to enhance physician-patient communication and promote better compliance of treatment plans. The model has since been used by all health care providers as a tool in improving cross-cultural communication. During the first step the nurse listens to the client to determine his understanding of his illness and related problems. At Step 2, the nurse explains his or her perception of the problem. At Step 3, the nurse acknowledges similarities and differences in perception between the patient and the nurse. Campinha-Bacote urges nurses to “recognize differences, but build on similarities.” At the next step, the nurse makes recommendations in collaboration with the patient and in the final step negotiates a mutually agreed on plan of treatment. Some hospitals are already beginning to utilize cultural assessment tools in obtaining patient admission histories. Collecting this kind of data early on enhances the nurse’s understanding of the patient’s needs and provides a foundation from which nurses can build an arsenal of knowledge about future patients who share the same cultural backgrounds or faith traditions. It is important for nurses to recognize that while many commonalities exist between members of the same ethnic, cultural, or religious groups, there are often individual differences in attitudes and beliefs. For example, “not all patients who identify themselves as Jehovah’s Witness agree with the blood policy” (McInroy, 2005, p. 271). Cultural Competence in Nursing Care

Listen The nurse caring for this patient must focus attention on the patient’s health-related beliefs, religious orientation and values, and treatment efficacy. Obviously, this is a critical time in this patient’s hospitalization. Mr. Jackmon’s immediate clinical problem is not only anxiety producing, but also life threatening. Nevertheless, the patient’s perspective on his illness and preferred treatment approach must be heard. Explain It is equally important that the patient fully understand the consequences of his health care decisions, but that he also be given adequate information about alternative methods of treating his hemoglobinemia. Today there are many strategies for replacing blood loss in patients who do not wish to be 101 many strategies for replacing blood loss in patients who do not wish to be transfused. These methods include treatment with recombinant human erythropoietin, albumin, and recombinant activated factor VII. Autologous autotransfusion and isovolemic hemodilution may also be used (Hughes, Ullery, & Barrie, 2008). Many Jehovah’s Witnesses, but not all, will submit to autologous blood transfusions. Acceptance of this approach will depend on the method in which the blood is retrieved (Giger & Davidhizar, 2008). It is important for nurses to recall that for Jehovah’s Witnesses, “the determination to abstain from blood is based on references to scripture” (Andrews & Boyle, 2003). Since many Jehovah’s Witnesses are strong believers in the Bible, it may be useful to provide time and privacy for scripture reading as a means of offering emotional and spiritual support (Andrews & Hanson, 2003). Acknowledge As McInroy (2005) states, “it is imperative that the nurse acts as a voice for the patient and respects his/her autonomy” (p. 270). Nurses can also act as advocate for this patient by making his values and beliefs known to other members of the health care staff. During the initial assessment, the nurses caring for Mr. Jackmon must fully determine the patient’s level of understanding about the nature of his illness, its cause, possible consequences, and methods of treatment. It is equally important for the nurse to be knowledgeable about the value that this patient places on his religious and spiritual beliefs. Several authors provide information about caring for clients who are Jehovah’s Witnesses that will aid nurses in providing care for members of this religious group (Andrews & Boyle, 2003; Geiger & Davidhizar, 2008; Spector, 2004). With this knowledge, nurses will be able to conduct a thoughtful and comprehensive evaluation of the patient’s cultural background and health care attitudes and beliefs to plan an effective treatment approach. Spirituality and Jehovah’s Witnesses According to the Watch Tower Society (2009) there are millions of Jehovah’s Witnesses in more than 230 lands. The world headquarters for the Jehovah’s Witnesses is located in Brooklyn, New York. There are also more than 100 branch offices around the world. The King James version of the Christian Bible serves as the basis of Jehovah’s Witnesses’ religious beliefs. Members believe in the value of a strict interpretation of the scriptures as the Word of God and a guide for life. Jehovah, the Hebrew name for 102 and precious to Him. Cultural Competence in Nursing Care

Among other values shared by members of this religion are: loving their fellow man, teaching others about God’s Kingdom, and avoiding political and social controversies. Many Jehovah’s Witnesses are conscientious objectors as they do not support any acts of war or aggression against their fellow man. Additionally, other taboos of the religion include a disdain for gambling, lying, stealing, taking revenge, fornication, premarital relations, incest, and homosexuality. Members hold meetings for bible study in Kingdom Hall, the Witnesses’ place of worship. Jehovah’s Witnesses recognize Jesus as the son of God, but do not celebrate traditional Christian holidays such as Christmas and Easter. They do observe the night of the Last Supper as a memorial of Christ’s death on a day that corresponds to Nisa 14 of the Jewish calendar, which occurs sometime in March or April (Andrews & Boyle, 2003). Members of the Jehovah’s Witnesses congregation do not believe in magical spells or practice faith or spiritual healing, nor do they celebrate birthdays, as they believe that this practice is derived from ancient false religions. Within the congregations volunteer “elders” or “overseers” serve as leaders and provide spiritual comfort and guidance, without pay or special status, to the congregants. All members and elders willingly visit the sick and pray with them, so this is an excellent resource for nurses seeking psychological support for patients who are members of this religion. Naturally, a better place to start, in this particular case, is with the patient’s own family. Family Roles and Traditions Based on biblical beliefs, Jehovah’s Witnesses consider the husband the head of the household and he is expected to honor and respect his wife, serve as spiritual leader for the family, and provide food, clothing, and shelter for the family. The wife is expected to assist her husband in caring for the children and teaching them the tenets of the religion. Children are required to obey their parents and to study the Bible with them. Within the marriage partners are encouraged to be forgiving through marital difficul- ties and to use the Bible in confronting these issues.

Divorce is frowned on and adultery is the only acceptable grounds for divorce for a Jehovah’s Witness. In light of this background information about Jehovah’s Witnesses, one realizes that there are many facets of this patient’s situation that represent either a real or perceived threat to his personal integrity. As breadwinner and head of household, he may worry about his family’s ability to sustain themselves through what is potentially a long-term illness with loss of 103 themselves through what is potentially a long-term illness with loss of employment days. Once the patient’s health situation is stabilized, culturally sensitive nurses in cooperation with social workers and the patient’s family can work together to find methods of support. Health Care Beliefs and Values All life is deeply valued and respected by Jehovah’s Witnesses; therefore, abortion, suicide, euthanasia, and violence against others are all unacceptable practices. Unhealthful practices that do not support a healthy life, such as smoking, taking drugs, and excessive drinking are also forbidden by practicing members of this group (Andrews & Boyle, 2003). Cultural Competence in Nursing Care

Blood is also considered sacred and Jehovah’s Witnesses consider it wrong to eat the meat of an animal that has not been appropriately bled (Watch Tower Bible and Tract, 2011). Some members of this religious group also consider it wrong to accept a blood transfusion even when the patient’s own blood is the source. They believe that this is a serious sin against God. At times, children have been made wards of the court when physicians, seeking authorization for transfusions, have believed that a medical condition necessitated a blood transfusion (Andrews & Boyle, 2003). Nonblood volume expanders, surgical procedures without accompanying blood transfusions, surgical procedures, and biopsies are accepted by Jehovah’s Witnesses, but adherence to God’s laws is valued over sustaining one’s life. Applying Principles of Cultural Competency Nurses caring for Mr. Jackmon will need to recognize that the ability to provide culturally sensitive and congruent health care is jeopardized when the desire to impose one’s own values (in this case, regarding adherence to Western medical practices) conflicts with the desire to do …Cultural Competence in Nursing Care