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A cultural assessment model for ED patients
A cultural assessment model for ED patients Authors: Gregory A. Bechtel, MPH, PhD, and Ruth Davidhizar, RN, DNS, CS, FAAN, Baton Rouge, La, and Mishawaka, Ind
T
he challenge for emergency nurses today is to meet the needs of a culturally diverse patient population with ever-shrinking ED resources. When cultural barriers are not addressed, difficulties communicating with members of minority groups can exacerbate presenting symptomatology, lead to unnecessary diagnostic and treatment procedures, and significantly increase costs.1 Leininger2 suggests alleviating these problems by “negotiating” culturally competent care. Cultural barriers are also evident as ethnic groups may perceive health, illness, and discharge following treatment in different and often conflicting ways. African Americans may be less than satisfied with discharge teaching,3 while Hispanic American men may legitimize alcohol-related misbehavior because of the perceived strength inherent in machismo.4 However, when emergency nurses use cultural care concepts, the number of barriers encountered is reduced, advocacy is enhanced, and care is ultimately improved.5
The Giger-Davidhizar model of transcultural assessment The Giger and Davidhizar Model of Assessment can provide a framework with which to assess culturally diverse patients (Figure 1).6 Communication One of the most difficult aspects of facilitating the communication process is overcoming ethnocentrism, or viewing one’s own culture as superior to that of others, particularly when communicating issues of pain and psychological distress.7 In a study of women with breast cancer, Asian women sought professional assistance for psychosocial problems at a significantly lower rate than did Anglo women, although they did have different modes of help-seeking behaviors for their emotional concerns.8 Oral instructions may be more important as a teaching mechanism among African Americans than Gregory A. Bechtel is Professor, Graduate Programs in Nursing, Southern University, Baton Rouge, La. Ruth Davidhizar is Dean and Professor, Bethel College, Mishawaka, Ind. For reprints, write: Gregory A. Bechtel, MPH, PhD, School of Nursing, Graduate Nursing Program, PO Box 11794, Baton Rouge, LA 70813-0400. J Emerg Nurs 1999;25:377-80. Copyright © 1999 by the Emergency Nurses Association. 0099-1767/99 $8.00 + 0 18/1/101563
among Asians, who often prefer written instructions. Whereas verbal understanding is important in the communication process, nonverbal communication is also essential in determining whether patients will follow the prescribed treatment.9 Because verbal disagreement with health providers is culturally inappropriate for Asian families, health providers must be cognizant of what is not being said by the client and family. Cultural differences can adversely affect health outcomes in geriatric gynecologic care among minorities both because of distrust and fear of the medical establishment and the lack of knowledge about screening and early detection of disease.10 Efforts by ED staff to incorporate traditional health beliefs and perceived meaning(s) of illness to clients and families by listening and understanding different health beliefs will be appreciated and increase adherence with the mutually prescribed plan of care.11 For example, by incorporating antibiotic therapy with religious rituals and prayers, the likelihood that antibiotics will be taken is increased. This type of incorporation may be accomplished by having patients take allopathic medicines concurrently with herbal therapies or during heightened periods of religious rituals so the linkage between allopathic and traditional therapies becomes integrated.
People from some cultures may verbally agree with a treatment plan out of respect to the provider but then defer to folk remedies or alternative health practices upon discharge.
Space Views of appropriate spatial distance vary between persons of different cultures. Giger and Davidhizar12 identified 4 aspects of behavior patterns that must be assessed to promote a healthy interaction: (1) proximity to others, (2) attachment with objects in the environment, (3) body posture, and (4) movement in the
October 1999 377
JOURNAL OF EMERGENCY NURSING/Bechtel and Davidhizar
Nurse Culturally Unique Individual
Communication
Space
Biological variations
Environmental control
Time
Social organization
Figure 1 Giger and Davidhizar’s transcultural assessment model. (From Giger G, Davidhizar R. Transcultural nursing: assessment and intervention (2nd ed). St Louis: Mosby–Year Book; 1999.)
setting. These 4 concepts are particularly important during periods when family members are experiencing emotional chaos, such as during the grieving process.13 Although the desired degree of physical proximity between the client and provider is based on the degree of intimacy and trust mutually established, as a general rule, Hispanics and Asians tend to stand closer to each other than do Euro-Americans. ED nurses should also be aware that members of many cultures are very concerned with modesty and often prefer that health providers of the same sex perform intimate physical and mental examinations.14 Among Muslims, only a female health provider should examine genitalia or be with an undressed patient. Thus the ED nurse should always be cognizant that cultural values and beliefs may significantly affect responses and misinterpretations in communication can lead to diminished health outcomes. Social organization The need for social congruency with one’s cultural group may have an adverse impact on essential care. Access to health providers does not necessarily translate into positive lifestyle behaviors or risk-reduction activities as prescribed by the dominant society.15 People from some cultures may verbally agree with a treatment plan out of respect to the provider but then defer to folk remedies or alternative health practices upon discharge. Keegan16 found that a majority of Mexican Americans do not report their use of complementary health modalities with allopathic health providers because they fear their health values will be discounted. Role perceptions based on gender, age, and religion are all culturally based and significantly
378 Volume 25, Number 5
influence how individuals perceive their illness and who is ultimately responsible for follow-up home care. Whereas Americans seem to be focused on youth and the present, members of other cultures, such as the Hmong, place value and respect on their elders and traditional ways.17 In this culture, all members of the family, including men, help with child care in the postpartum period.18 Time The concept of time is not only based on clock hours and social influences (eg, meals and holidays) but is perceived differently by persons in various cultures. Clock time is frequently more highly valued by the majority of Western cultures, where appointments tend to be kept at the prescribed time. In a culture in which places and persons are more important than social time, activities start when a previous social event has been completed, and to be dominated by adherence to clock time is often considered rude. Persons in different cultures tend to have a time orientation that may focus on either the past, present, or future. Native Americans may refer to historical traditions to deter a future illness. By encouraging these clients to focus on memories of past events, a connection with the traditional ways of the past can be developed and incorporated into a culturally specific and mutually agreed upon plan of care. Beliefs in the traditions of the past take on great importance even when the future is being considered. A client who does not believe a person can influence the future will be unlikely to adhere to a treatment regimen designed to influence health at some point in the future. Thus the ED nurse should evaluate the value
Bechtel and Davidhizar/JOURNAL OF EMERGENCY NURSING
placed on adherence with discharge recommendations and incorporate the client’s specific behavior patterns into the mutually defined plan of care. This could consist of taking medications as part of morning or evening rituals and continuing to take them until certain lunar events are fulfilled (eg, full moon). Environmental control Human attempts to control nature and the environment are as old as recorded history. At its most basic level, locus of control is a significant variable in how people react within the American health care system. In general, the willingness to accept responsibility for one’s health is considered an internal locus of control. Persons who have an external locus of control believe the health care delivery system exists to provide essential care and can become especially frustrated with the complexities of health care in America and the myriad of options available. An external locus of control among migrant farm workers, for example, may reflect a perspective that “whatever will be will be,” and thus preventive care and a health orientation to primary care are often neglected.19,20
In a culture in which places and persons are more important than social time, activities start when a previous social event has been completed, and to be dominated by adherence to clock time is often considered rude. Biological variations References about cultural differences are mushrooming in the literature and have resulted in a field of study known as biocultural ecology.6 Health care providers should understand the biological differences and susceptibility that exist in persons from different cultures. For example, Hispanics are at higher risk for diabetes and African Americans have a higher prevalence of cardiovascular disease, cancer, and diabetes.21 In some cultures, the social definition of disease is related to age; Hautman22 found that Filipina-American women view menopause as a normal part of aging and not symptomatic of a disease process. Thus discharge instructions should reflect the pathology involved from
a patient’s cultural perspective, the client’s health belief system, and the community resources that will support recovery. Cultural differences can also contribute to either noncompliance or poor compliance with therapy. Unfortunately, in many cases, lack of knowledge limits the ability of health care professionals to differentiate environmental, familial, and genetic predisposition to disease states.23 Although research is being conducted on biological differences relating to ethnic groups, it lags behind the knowledge available regarding other cultural phenomena.24 For example, the development of pain measurement instruments remains culturally centered, even though significant differences exist among members of different cultural groups in their perception and response to pain management.25
Discussion The Giger and Davidhizar Transcultural Assessment Model provides a framework to systematically assess the role of culture on health and illness and has been used extensively in a variety of settings and by diverse disciplines.26 This model does not presuppose that every person within an ethnic or cultural group will act or behave in a similar manner. In fact, Giger and Davidhizar6 emphasize that a culturally appropriate model must recognize differences in groups while avoiding stereotypical approaches to client care. In addition, the 6 cultural phenomena described are not mutually exclusive but are related and often interact. Whereas the phenomena vary with application across cultural groups, the 6 concepts of the model are evident in every cultural group. References 1. Andrea J, Renner P. Interpreting needs of the ED patient: one California hospital’s 3-week study. J Emerg Nurs 1995;21:510-2. 2. Leininger MM. Cultural care diversity & universality: a theory of nursing. New York: National League for Nursing; 1991. 3. Clark CA, Pokorny ME, Brown ST. Consumer satisfaction with nursing care in a rural community hospital emergency room. J Nurs Care Qual 1996;10:49-57. 4. Kantor GK. Alcohol and spouse abuse ethnic differences. Recent Dev Alcohol 1997;13:57-79. 5. Wright F, Cohen S, Caroselli C. Diverse decisions: how culture affects ethical decision making. Crit Care Nurs Clin North Am 1997;9:63-74. 6. Giger J, Davidhizar R. Transcultural nursing: assessment and intervention (2nd ed). St. Louis: Mosby–Year Book; 1999. 7. Davidhizar R, Shearer R, Giger JN. Pain and the culturally diverse patient. Today’s Surg Nurse 1997;19:36-9. 8. Kagawa-Singer M, Wellisch DK, Durvasula R. Impact of breast cancer on Asia American and Anglo American women. Cult Med Psychiatry 1997;21:449-80.
October 1999 379
JOURNAL OF EMERGENCY NURSING/Bechtel and Davidhizar
9. Davies P. Non-verbal communication with patients. Br J Nurs 1994;3:220-3. 10. Haynes MO. Geriatric gynecologic care of minorities. Clin Obstet Gynecol 1996;39:946-58. 11. Ahmann E. “Chunky stew:” Appreciating cultural diversity while providing health care for children. Pediatr Nurs 1994;20:320-4. 12. Giger J, Davidhizar R. Culture and space. Adv Clin Care 1990;5:8-11. 13. Haberecht J, Prior D. International perspectives. Spiritual chaos: an alternative conceptualization of grief. Int J Palliative Nurs 1997;3:209-13. 14. de Paula T, Lagana K, Gonzalez-Ramirez L. Mexican Americans: culture and nursing care. San Francisco: UCSF Nursing Press; 1996. 15. Reed BW, Wineman J, Bechtel GA. Using a health risk appraisal to determine an Appalachian community’s health care needs. J Cult Div 1995;2:131-5. 16. Keegan L. Use of alternative therapies among Mexican Americans in the Texas Rio Grande Valley. J Holistic Nurs 1996;14:277-94. 17. Buckwalter KC. A cultural look at aging. J Gerontol Nurs 1997;23:5-6. 18. Jambunathan J, Stewart S. Hmong women: postpartum family support and life satisfaction. J Fam Nurs 1997;3:149-66.
380 Volume 25, Number 5
19. Bechtel GA, Shepherd MA, Rogers PW. Family, culture and health practices among migrant farmworkers. J Community Health Nurs 1995;12:15-22. 20. Morrison SD, Rienzo BA, Frazee C. Developing health education for Hispanic migrant preschool youth. J Health Educ 1995;26:207-10. 21. US Department of Health and Human Services. Healthy People 2000: Healthy People 2000 Midcourse Review and 1995 Revisions, 1995. Washington, DC: US Government Printing Office. 22. Hautman MA. Changing womanhood: perimenopause among Filipina-Americans. J Obstet Gynecol Neonatal Nurs 1996;25:667-73. 23. O’Nell TD, Mitchell CM. Alcohol use among American Indian adolescents: the role of culture in pathological drinking. Soc Sci Med 1996;42:565-78. 24. Kagawa-Singer M. Socioeconomic and cultural influences on cancer care of women. Semin Oncol Nurs 1995;11:109-19. 25. Moore R, Brodsgaard I, Miller ML, Mao TK, Dworkin SF. Consensus analysis: reliability, validity, and informant accuracy in use of American and Mandarin Chinese pain descriptors. Ann Behav Med 1997;19:295-300. 26. Davidhizar R, Dowd SB, Giger JN. Educating the culturally diverse healthcare student. Nurse Educ 1998;23:38-42.
T
he challenge for emergency nurses today is to meet the needs of a culturally diverse patient population with ever-shrinking ED resources. When cultural barriers are not addressed, difficulties communicating with members of minority groups can exacerbate presenting symptomatology, lead to unnecessary diagnostic and treatment procedures, and significantly increase costs.1 Leininger2 suggests alleviating these problems by “negotiating” culturally competent care. Cultural barriers are also evident as ethnic groups may perceive health, illness, and discharge following treatment in different and often conflicting ways. African Americans may be less than satisfied with discharge teaching,3 while Hispanic American men may legitimize alcohol-related misbehavior because of the perceived strength inherent in machismo.4 However, when emergency nurses use cultural care concepts, the number of barriers encountered is reduced, advocacy is enhanced, and care is ultimately improved.5
The Giger-Davidhizar model of transcultural assessment The Giger and Davidhizar Model of Assessment can provide a framework with which to assess culturally diverse patients (Figure 1).6 Communication One of the most difficult aspects of facilitating the communication process is overcoming ethnocentrism, or viewing one’s own culture as superior to that of others, particularly when communicating issues of pain and psychological distress.7 In a study of women with breast cancer, Asian women sought professional assistance for psychosocial problems at a significantly lower rate than did Anglo women, although they did have different modes of help-seeking behaviors for their emotional concerns.8 Oral instructions may be more important as a teaching mechanism among African Americans than Gregory A. Bechtel is Professor, Graduate Programs in Nursing, Southern University, Baton Rouge, La. Ruth Davidhizar is Dean and Professor, Bethel College, Mishawaka, Ind. For reprints, write: Gregory A. Bechtel, MPH, PhD, School of Nursing, Graduate Nursing Program, PO Box 11794, Baton Rouge, LA 70813-0400. J Emerg Nurs 1999;25:377-80. Copyright © 1999 by the Emergency Nurses Association. 0099-1767/99 $8.00 + 0 18/1/101563
among Asians, who often prefer written instructions. Whereas verbal understanding is important in the communication process, nonverbal communication is also essential in determining whether patients will follow the prescribed treatment.9 Because verbal disagreement with health providers is culturally inappropriate for Asian families, health providers must be cognizant of what is not being said by the client and family. Cultural differences can adversely affect health outcomes in geriatric gynecologic care among minorities both because of distrust and fear of the medical establishment and the lack of knowledge about screening and early detection of disease.10 Efforts by ED staff to incorporate traditional health beliefs and perceived meaning(s) of illness to clients and families by listening and understanding different health beliefs will be appreciated and increase adherence with the mutually prescribed plan of care.11 For example, by incorporating antibiotic therapy with religious rituals and prayers, the likelihood that antibiotics will be taken is increased. This type of incorporation may be accomplished by having patients take allopathic medicines concurrently with herbal therapies or during heightened periods of religious rituals so the linkage between allopathic and traditional therapies becomes integrated.
People from some cultures may verbally agree with a treatment plan out of respect to the provider but then defer to folk remedies or alternative health practices upon discharge.
Space Views of appropriate spatial distance vary between persons of different cultures. Giger and Davidhizar12 identified 4 aspects of behavior patterns that must be assessed to promote a healthy interaction: (1) proximity to others, (2) attachment with objects in the environment, (3) body posture, and (4) movement in the
October 1999 377
JOURNAL OF EMERGENCY NURSING/Bechtel and Davidhizar
Nurse Culturally Unique Individual
Communication
Space
Biological variations
Environmental control
Time
Social organization
Figure 1 Giger and Davidhizar’s transcultural assessment model. (From Giger G, Davidhizar R. Transcultural nursing: assessment and intervention (2nd ed). St Louis: Mosby–Year Book; 1999.)
setting. These 4 concepts are particularly important during periods when family members are experiencing emotional chaos, such as during the grieving process.13 Although the desired degree of physical proximity between the client and provider is based on the degree of intimacy and trust mutually established, as a general rule, Hispanics and Asians tend to stand closer to each other than do Euro-Americans. ED nurses should also be aware that members of many cultures are very concerned with modesty and often prefer that health providers of the same sex perform intimate physical and mental examinations.14 Among Muslims, only a female health provider should examine genitalia or be with an undressed patient. Thus the ED nurse should always be cognizant that cultural values and beliefs may significantly affect responses and misinterpretations in communication can lead to diminished health outcomes. Social organization The need for social congruency with one’s cultural group may have an adverse impact on essential care. Access to health providers does not necessarily translate into positive lifestyle behaviors or risk-reduction activities as prescribed by the dominant society.15 People from some cultures may verbally agree with a treatment plan out of respect to the provider but then defer to folk remedies or alternative health practices upon discharge. Keegan16 found that a majority of Mexican Americans do not report their use of complementary health modalities with allopathic health providers because they fear their health values will be discounted. Role perceptions based on gender, age, and religion are all culturally based and significantly
378 Volume 25, Number 5
influence how individuals perceive their illness and who is ultimately responsible for follow-up home care. Whereas Americans seem to be focused on youth and the present, members of other cultures, such as the Hmong, place value and respect on their elders and traditional ways.17 In this culture, all members of the family, including men, help with child care in the postpartum period.18 Time The concept of time is not only based on clock hours and social influences (eg, meals and holidays) but is perceived differently by persons in various cultures. Clock time is frequently more highly valued by the majority of Western cultures, where appointments tend to be kept at the prescribed time. In a culture in which places and persons are more important than social time, activities start when a previous social event has been completed, and to be dominated by adherence to clock time is often considered rude. Persons in different cultures tend to have a time orientation that may focus on either the past, present, or future. Native Americans may refer to historical traditions to deter a future illness. By encouraging these clients to focus on memories of past events, a connection with the traditional ways of the past can be developed and incorporated into a culturally specific and mutually agreed upon plan of care. Beliefs in the traditions of the past take on great importance even when the future is being considered. A client who does not believe a person can influence the future will be unlikely to adhere to a treatment regimen designed to influence health at some point in the future. Thus the ED nurse should evaluate the value
Bechtel and Davidhizar/JOURNAL OF EMERGENCY NURSING
placed on adherence with discharge recommendations and incorporate the client’s specific behavior patterns into the mutually defined plan of care. This could consist of taking medications as part of morning or evening rituals and continuing to take them until certain lunar events are fulfilled (eg, full moon). Environmental control Human attempts to control nature and the environment are as old as recorded history. At its most basic level, locus of control is a significant variable in how people react within the American health care system. In general, the willingness to accept responsibility for one’s health is considered an internal locus of control. Persons who have an external locus of control believe the health care delivery system exists to provide essential care and can become especially frustrated with the complexities of health care in America and the myriad of options available. An external locus of control among migrant farm workers, for example, may reflect a perspective that “whatever will be will be,” and thus preventive care and a health orientation to primary care are often neglected.19,20
In a culture in which places and persons are more important than social time, activities start when a previous social event has been completed, and to be dominated by adherence to clock time is often considered rude. Biological variations References about cultural differences are mushrooming in the literature and have resulted in a field of study known as biocultural ecology.6 Health care providers should understand the biological differences and susceptibility that exist in persons from different cultures. For example, Hispanics are at higher risk for diabetes and African Americans have a higher prevalence of cardiovascular disease, cancer, and diabetes.21 In some cultures, the social definition of disease is related to age; Hautman22 found that Filipina-American women view menopause as a normal part of aging and not symptomatic of a disease process. Thus discharge instructions should reflect the pathology involved from
a patient’s cultural perspective, the client’s health belief system, and the community resources that will support recovery. Cultural differences can also contribute to either noncompliance or poor compliance with therapy. Unfortunately, in many cases, lack of knowledge limits the ability of health care professionals to differentiate environmental, familial, and genetic predisposition to disease states.23 Although research is being conducted on biological differences relating to ethnic groups, it lags behind the knowledge available regarding other cultural phenomena.24 For example, the development of pain measurement instruments remains culturally centered, even though significant differences exist among members of different cultural groups in their perception and response to pain management.25
Discussion The Giger and Davidhizar Transcultural Assessment Model provides a framework to systematically assess the role of culture on health and illness and has been used extensively in a variety of settings and by diverse disciplines.26 This model does not presuppose that every person within an ethnic or cultural group will act or behave in a similar manner. In fact, Giger and Davidhizar6 emphasize that a culturally appropriate model must recognize differences in groups while avoiding stereotypical approaches to client care. In addition, the 6 cultural phenomena described are not mutually exclusive but are related and often interact. Whereas the phenomena vary with application across cultural groups, the 6 concepts of the model are evident in every cultural group. References 1. Andrea J, Renner P. Interpreting needs of the ED patient: one California hospital’s 3-week study. J Emerg Nurs 1995;21:510-2. 2. Leininger MM. Cultural care diversity & universality: a theory of nursing. New York: National League for Nursing; 1991. 3. Clark CA, Pokorny ME, Brown ST. Consumer satisfaction with nursing care in a rural community hospital emergency room. J Nurs Care Qual 1996;10:49-57. 4. Kantor GK. Alcohol and spouse abuse ethnic differences. Recent Dev Alcohol 1997;13:57-79. 5. Wright F, Cohen S, Caroselli C. Diverse decisions: how culture affects ethical decision making. Crit Care Nurs Clin North Am 1997;9:63-74. 6. Giger J, Davidhizar R. Transcultural nursing: assessment and intervention (2nd ed). St. Louis: Mosby–Year Book; 1999. 7. Davidhizar R, Shearer R, Giger JN. Pain and the culturally diverse patient. Today’s Surg Nurse 1997;19:36-9. 8. Kagawa-Singer M, Wellisch DK, Durvasula R. Impact of breast cancer on Asia American and Anglo American women. Cult Med Psychiatry 1997;21:449-80.
October 1999 379
JOURNAL OF EMERGENCY NURSING/Bechtel and Davidhizar
9. Davies P. Non-verbal communication with patients. Br J Nurs 1994;3:220-3. 10. Haynes MO. Geriatric gynecologic care of minorities. Clin Obstet Gynecol 1996;39:946-58. 11. Ahmann E. “Chunky stew:” Appreciating cultural diversity while providing health care for children. Pediatr Nurs 1994;20:320-4. 12. Giger J, Davidhizar R. Culture and space. Adv Clin Care 1990;5:8-11. 13. Haberecht J, Prior D. International perspectives. Spiritual chaos: an alternative conceptualization of grief. Int J Palliative Nurs 1997;3:209-13. 14. de Paula T, Lagana K, Gonzalez-Ramirez L. Mexican Americans: culture and nursing care. San Francisco: UCSF Nursing Press; 1996. 15. Reed BW, Wineman J, Bechtel GA. Using a health risk appraisal to determine an Appalachian community’s health care needs. J Cult Div 1995;2:131-5. 16. Keegan L. Use of alternative therapies among Mexican Americans in the Texas Rio Grande Valley. J Holistic Nurs 1996;14:277-94. 17. Buckwalter KC. A cultural look at aging. J Gerontol Nurs 1997;23:5-6. 18. Jambunathan J, Stewart S. Hmong women: postpartum family support and life satisfaction. J Fam Nurs 1997;3:149-66.
380 Volume 25, Number 5
19. Bechtel GA, Shepherd MA, Rogers PW. Family, culture and health practices among migrant farmworkers. J Community Health Nurs 1995;12:15-22. 20. Morrison SD, Rienzo BA, Frazee C. Developing health education for Hispanic migrant preschool youth. J Health Educ 1995;26:207-10. 21. US Department of Health and Human Services. Healthy People 2000: Healthy People 2000 Midcourse Review and 1995 Revisions, 1995. Washington, DC: US Government Printing Office. 22. Hautman MA. Changing womanhood: perimenopause among Filipina-Americans. J Obstet Gynecol Neonatal Nurs 1996;25:667-73. 23. O’Nell TD, Mitchell CM. Alcohol use among American Indian adolescents: the role of culture in pathological drinking. Soc Sci Med 1996;42:565-78. 24. Kagawa-Singer M. Socioeconomic and cultural influences on cancer care of women. Semin Oncol Nurs 1995;11:109-19. 25. Moore R, Brodsgaard I, Miller ML, Mao TK, Dworkin SF. Consensus analysis: reliability, validity, and informant accuracy in use of American and Mandarin Chinese pain descriptors. Ann Behav Med 1997;19:295-300. 26. Davidhizar R, Dowd SB, Giger JN. Educating the culturally diverse healthcare student. Nurse Educ 1998;23:38-42.