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Culturally competent care
Seminars in Oneology Nursing, Vol 17, No 3 (August), 2001: pp 153-158
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OB.JECTD,~S: To define key. eoncept.s m~l sumnmrizJe available guidelines ti~t are important r~,ourees to asMst nurses to prc~qde culturrdly cv~mpetent care.
CULTURALLY COMPETENT CARE
DATA ~)URCI~c;: Med/ine, m u ~ l o g ~ and epidemiologic litcvo.ture, and National ln.stinaes of tleahh doeumems. CONCLUSIONS: Ctmtroversy remains about the most appropriate language to use to describe features ~. diverse
populo~,ns. |MPLRiATIONS FOR NURSING
PnAC FICE. Becoming culturally competent beNns ~, understandir~, term.s and conc~opLs that are essenticd in devek,Tnng cultural awaro~ess, knowledge, rout skills. Sensitivity to language rout the history of the development of some labels are ~mportant.
Frmn t h e Unit~rsity of Texas-tlmg~ton Health Scfenec Center Schtud qf Nursing; mul the Univer~ty of Tex.a.s M. D. Antieta m Caru~r Center, Housam, TX. Marlene Zie|ti Cohen, P,N, PhD: The John S. Dram, bY,/.~t/nSu/shed Prqfessor m On¢x~.~, Nursir~, The l h ~ . ' s ~ , of Tex~Houston H~xlth Scqcnce Cemer, Sctuxd of Nursling and Director of Applied NurMng R~h, The Uni~-,rMty of Te,xas, M. t"). Andcv'son Ce~u:er Center, litm~s't¢m, TX. Cmadalupe Palos, RN, LMSW: Cance'r Program Specialist, Ttue University of "r~cas, M. D. Antietam Canc,er Center, 8et.tion of the Pain Reset~rch (hm~p, llouston, TX. Addr'~ reprint reque.~ts to Me~lene zichi (~hen, RN, PhD, l r ~ of Texo.c;Ilouston, Selurd qf Nurs~'ng, 1100 Hok,orabe Bled, 65rite 5.5331, lfou.~ton, TX 77030.
t'Jol~3night ©2001 by W.B. Smmders Cmnt~any 0749-,~08JA91/1703.0002~15. 00/0 doi:l O.l O . ~ L 2001.259~ ]
M A R L E N E Z I C H I C O H E N AND G U A D A L U P E
PALOS
L
EININGER1 was a pioneer when she introduced in the mid-1950s the need for nurses to develop and use knowledge of diverse eultures. The diversity of the population of the United States has inereased and teehnology and travel inereasingly afford us opportunities to work with persons of different cultures. These faetors make the information in this issue of Seminars in Oneology Nursing devoted to eultural dimensions of oneology nursing even more important as we seek to provide nursing care that is culturally eompetent. This artiele will set the stage by diseussing key eoneepts and some of the resourees available for nurses, beginning with some of the reasons this topie is so important.
NURSING AND CULTURAL DIVERSITY s early as the 19th c e n t u r y it has been noted that nurses • ]k have been primarily white women. 2 In 1994, the Institute of Medieine's com m i t t ee recognized u n d e r r e p r e s e n t a t i o n of minorities in health professions as a national p r i o r i t y ) Nursing statistics also show that minority enrollments and graduates are both lower than needed to reflect the diversity of the population of the United States and lower in 1995 than in 1994. 4 This u n d e r r e p r e s e n t a t i o n has its roots in the very slow and late integration into nursing of members of minority groups. Rigid segregation and discrimination was developed in nursing schools, and persisted into the 1950s for Afriean Amerieans. 5 Native Amerieans also were segregated, and Arizona had the only nursing school established for them. 6 Minority groups have established organizations to meet specific needs. These include the National Association of Colored Graduate Nurses, whieh was only incorporated in the Ameriean Nurses Association in 1951. The National Association of Hispanie Nurses was founded in 1975. In 1972 American Indian Nurses Association was formed, and was renamed the American Indian/Alaska Native Nurses Association in 1978. The Philippine Nurses Association of America was formed in 1979. Recruitment of members of minority groups into nursing is one important way to enhance eulturally competent care.
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SIMILARITIES &ND DIFFERENCES lthough we differ in m a n y ways, we are also similar in many, perhaps more i m p o r t a n t ways. While our perspectives vary, there are similarities. Phenomenologieal philosophy speaks of this. Van Manen 7 deseribed four fundamental existential themes; the lived space (spatiality), the lived body (eorporeality), lived time (temporality), and lived h u m a n relation (relationality or eommunality). This means that we all share the experienee of having a body in spaee and time and live in relationship with others. These basie ideas and experienees are universal and i m p o r t a n t and lead to important similarities despite differences among us. Despite these similarities, we struggle to understand the differenees. Fietion can illuminate our understanding, as in a story in which two women talk about a m a n with whom one of them is involved. She told her friend, "He said even if I was already dead and he knew who did it, he'd kill them. Even if I was already dead." Her friend replied, "I think in Texan that means 'I love you'. ''s This illustrates that one need not be a m e m b e r of a minority group to u n d e r s t a n d cultural differenees. We are all part of different groups with different values and norms. This same book of fietion eontains a n o t h e r story that is relevant to these artieles on diverse eultures. This story described a Navajo w o m a n who found a lump in her breast. She told her friend she did not seek t r e a t m e n t because "my power animal says it's not e a n e e r ''s A biopsy found the t u m o r was malignant. The a u t h o r noted "doetors apparently had stopped using the 'C' word." The w o m a n decided to "stop seeing the doetors" because "my power animal said I don't n e e d them, they eould even be detrimental." tter friend struggled with this and discussed it with her boyfriend. "I want to support her d e c i s i o n . . . I even want to believe in her magic, but she's ignoring hundreds of years of medical researeh. This ugly thing is consuming her and she's not doing anything to stop it." Her boyfriend r e m i n d e d her, "She is doing s o m e t h i n g . . , she's just not doing what you want her to do." This is the heart of what nurses need to do; be sure that patients have the information and support they need and then to respect their deeisions. Understanding their perspectives m a y help, espeeially when their perspectives differ from our own.
A
ISSUES OF LANGUAGE ecoming culturally c o m p e t e n t begins by understanding terms and eoneepts that are essential in developing eultural awareness, knowledge, and skills. Emie and erie are two i m p o r t a n t terms that were based on the linguistie distinetion between p h o n e m i e and phonetic.9,10 Phonemics is the study of sounds used in a language, while phonetics seeks to generalize from studies of individual languages to universals eovering all languages. By analogy, emie eategories are specific to a eulture and erie eategories are eulturally universal. Anthropologists and other researchers who seek to discover the emie perspective look for an understanding of how experiences are defined by "natives" (eg, those persons in a eulture or those having an experience). The erie perspective is the "outsiders'" or researehers' perspective. The etie perspeetive involves observing a eulture without learning how those being studied view the culture or experienee. External criteria are used to examine and e o m p a r e several cultures or groups. Clinieians and researchers seek to u n d e r s t a n d the perspeetive of persons who have the experienee. Tripp-Reimer 11 used this emie/etie distinetion to diseuss disease and illness in a partieularly useful eoneeptualization of these ideas. Disease is the etie eategory, the biomedical perspeetive, and illness is the emie or patients' or elients' perspeerive. In a four-quadrant grid she illustrated that people can have disease with or without illness, and illness with or without disease. This is useful to guide researeh and praetiee to ensure that clinicians and researchers u n d e r s t a n d both the emie and etie perspeetives. T h e r e is eonsiderable debate about the labels and language we use to describe diverse groups, including the terms raee, ethnieity, minority, and culture. The use of raee as a e o n c e p t in research, data eolleetion, or policy reporting for identifieation and data eolleetion purposes has been attaeked as unscientific, vague, raeist, and inaccurate. 12,13 This eoneept emerged with the e o n e e p t of nation during the 16th eentury. ~4 Montague argued that colonization required a "scientific rationale" and raee classification emerged to explain the forees of expansion, oppression, and enslavem e n t of aboriginal populations in Africa and Asia) 4 Both race and ethnieity are ereated by boundaries to separate self (or group) from nonself. Some groups are eonsidered both races and
B
CULTURALLY COMPETENT
ethnic groups. Jews and black South Africans are two such groups, and in both eases race and ethnieity have been used to oppress and exclude these groups at certain points in history, is Goldberg 16 described five fabrications of race and discussed why race is not the same as or consistent with biology, social class, culture, ethnieity, or nation. The biological concept of race dominated until the end of World War II and Nazi racism. Ethnicity is slowly replacing race, although the concepts overlap and are often used synonymously. Dictionary definitions of race and ethnieity overlap. Crews and Bindon 17 suggest race is a sociologic construct that is poorly correlated with biological or cultural features other than the amount of melanin in a person's skin, while ethnieity is a soeioeultural construct that is often coextensive with discernible features of a group. LaVeist is developed a model of race that linked race, an unobservable or latent factor, with physiognomy (judging others from facial features). People are categorized based on physical indicators into cultural and ethnic groups. These groups are then exposed differently to health risks such as poor housing or poorer heath care. When these constructs are used in health research, the purpose is to better understand genetic and environmental factors in disease. However, there are many differences between racial and ethnic groups in disease pattern and culture. Research is needed to examine the interplay of cultural factors and health with communication barriers and racist attitudes that may affect health service delivery. Labels for race and ethnieity differ among federal and national data collection agencies such as the US Census Bureau, the Office of Management and Budget (OMB) and other national public health surveillance systems. The OMB classification, now widely used in the United States, was adopted in 1977 in order to collect data on groups that were discriminated against. 19 The OMB currently recognizes four racial groups; Asian or Pacific Islander, American Indian or Alaskan Native, black, and white. The two ethnic elassifieations are Hispanic origin and not of Hispanic origin, zo The OMB responded to criticism of these categories by establishing a comprehensive review starting in 1993. This review has resulted in a variety of recommendations, including revising the labels for race to include American Indian or Alaska Native, and black or African American. The other labels for race and the ethnicity labels are un-
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changed. These are considered minimum categories and those producing data are encouraged to use greater detail. The category "more than one race" should be included if the criteria for data quality and confidentiality are met. The term "minority" generally includes American Indians and Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islands, blacks/ African Americans, and Hispanies/Latinos. These groups are included in the charge to the Office of Minority Health to advise the Deputy Assistant Secretary for Minority Health and the Office of Public Health and Sciences on public health issues affecting these groups. The US Department of Health and Human Services created the Office of Minority Health in 1985 as a result of the Report of the Secretary's task force on Black and Minority Health (www.omhre.gov/OMH). Anthropologists have defined culture in two major ways. The behavioral/materialist perspective defines culture as what is observed through a group's patterns of behavior and customs, their way of life, and what they produce. Culture also is made up of ideas, beliefs, and knowledge that are used by a group, which is the cognitive formulation. 21-23 Culture emerges out of patterns of daily social life and is a moral process of interpretation and collective experience, composed of many voices, ereated by and, in turn, creator of soeial action located between people. 24 When heritage is defined, religious groups and age cohorts meet these formulations. Culture influences values, behavior or beliefs, and experiences by providing a framework of cultural values that guides an individual's thoughts, actions, and decisions. Applying these definitions to the cancer experienee leads to the idea that the way persons view cancer, react to specific experiences (such as an initial diagnosis), and behave during situations will largely depend on cultural or religious values, beliefs, and practices that they learn from their family, friends, and other members of their culture. Ethnieity or ethnic self identity has been defined as one's sense of belonging to a specific group. 2s Ethnieity may lead to barriers in research and clinical practice. For example, in research regarding ethnic differences in pain management, ethnieity was found to have a negative impact on providing adequate pain management for emergency room patients with bone fractures. 26 Todd et al found that Hispanies were twice as likely to receive insufficient pain management compared to their white counterparts. The investigators of
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this study did not identify other mediating factors, but they did suggest that sociopolitical factors including racism might have affected the medical care given to this ethnic population. Members of ethnic minority groups may share some of the characteristics of a dominant culture, while choosing to maintain their country of origin's or ethnic values, practices, language, and norms. Three processes, assimilation, acculturation, and eneulturation influence cultural values, beliefs, practices, and attitudes toward health and illness, including chronic diseases such as eancer.2S,27-31 Kagawa-Singer 32 defined acculturation as "the ability to function comfortably in another culture by learning the behavior of the other c u l t u r e . . . and assimilation indicates that the individual gives up the beliefs, values, materials, cultures, and practices of their native group and adopts those of the host culture. ''32 Both acculturation and assimilation imply that one must give up their values, beliefs, and practices of their country of origin in order to become a member the host society. Enculturation is a process that allows a balance between the cultural world views of the host society and the country of origin. Eneulturation seems to be the future trend that ethnically diverse populations may choose in order to maintain their cultural heritage. For example, many ethnic groups have built communities within a larger geographical region or community. The immediate community contains businesses, churches, civic groups, and markets that reflect the values, beliefs, practices, and languages of a certain ethnic group. Eneultured communities evolving from Central American Latinos, Vietnamese, Middle Easterners, and others may be found in many US regions and may continue to increase as America becomes more diverse. The most reliable indicators to measure acculturation include ethnic self identification, language used during an interview, country of origin, and length of residence in the United States. 3°,31,-~3 While there are validated instruments available to measure acculturation but not enculturation, tremendous heterogeneity exists within each subgroup. Therefore, applying the constructs of eneulturation and acculturation must be performed with caution. For example, a US-born Asian of Vietnamese ancestry can have the language fluency of a highly assimilated individual with a high level of income and education yet may strongly value traditional Vietnamese practices and beliefs.
Attitudes, behaviors, and beliefs of members of ethnic groups can be difficult to predict. CULTURAL COMPETENCE STANDARDS IkND GUIDELINES A
variety of definitions, standards, and guidelines exist to help achieve cultural competence in health care, education, research, and policy decision making. Oneology Nursing Society guidelines define culturally competent care as care that is provided by nurses who use cultural theory, models, and research principles in identit'ying health care needs, providing care, and evaluating the outcomes of that care. 34 Other definitions include the American Academy of Nursing definition that culturally competent care is care that takes into account issues related to diversity, marginalization, and vulnerability due to culture, race, gender, and sexual orientation. 3s This definition includes the medically underserved and those whose sexual orientation may make them less likely to participate in traditional health care systems. Rather than creating new definitions, the OMB adapted definitions of cultural competence from the Office of Women and Minority Health at the Bureau of Primary Itealth Care, ttealth Resources and Services Administration. Three important terms and definitions in this document are: Culture and linguistic competence: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. Competenee: Implies having the eapaeity to funetion effectively as an individual and organization within the context of cultural beliefs, behaviors, and needs presented by consumers and communities. Culture: Refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. The OMB conducted a comprehensive literature review to prepare this document and found more documents regarding the criteria required for linguistic competence than for cultural competence. This reinforces the need to develop a set of accepted definitions, standards, and requirements for providing patient care, designing research, and
CULTURALLY COMPETENT CARE
establishing health care policies that are based on cultural theories and principles. National standards for eulturally and linguistically appropriate services from the OMB evolved from a lengthy proeess of public, regional hearings, publication in the Federal Register, and opportunities for public comment through a website, a6 This lengthy document addresses issues affecting health care praetiee, edueation, research, and poliey decision making. The target audienee for this document ineludes providers, policy makers, accreditation and credentialing agencies (such as Joint Commission on Accreditation of Healtheare Organizations), purehasers, advocates, educators, and patients. The doeument includes a preamble and recommendations for assuring cultural eompetenee in health care. Table 1 presents seven of the 14 recommendations that evolved from this process. This document may be obtained online at http://www.omhre. gov.das. The Oneology Nursing Society document, "Multieultural Outcomes: Guidelines for Cultural Competence," introduces concepts and sMlls necessary for providing quality patient cancer care within a cultural context in order to address cultural competence for elinieal praetiee, education, and research. A framework of 11 domains considered essential to culture is provided. These domains include ethnie identity, eommunieation, time and space, soeial organization, work force issues, health beliefs/ praetiees/praetitioners, nutrition, biologic variation, sexuality and reproduction factors, religion and spirituality, and death rituals. Assessment questions and outeomes for each domain are presented and examples of how the domains can affeet individuals' cancer experience are shown and culturally appropriate solutions for concerns are presented. A model for achieving eultural competence and guidelines for planning, implementing, and evaluating research from a cross-cultural perspective are also ineluded. These guidelines are available through the Oneology Nursing Society office or their website, http:// www.ons.org. Several eoneepts important to beeoming culturally eompetent are: Aeeeptanee: Respeeting and aeeepting the world views of individuals from different cultures. Adaptation: Learning that change is required by all participants in order to work together. Cultural Relevance: Integrating the world views of a speeifie eulture into praetiee, edueation, researeh, and interventions
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TABLE 1. Standards for CuRuraRyand Li~uisticaUy Appropriate HeaRh Care Se~ices~
should: • promote and SUPDort attitudes, behaviors, knowledge,
Cultural Sensitivity: Becoming aware of basic cultural differenees and willing to change one's own world view. Integration: Responding to the needsof a partieular situation by integrating new cultural knowledge and competency that will benefit the group. Oneology nurses build unique relationships with patients and their families because o f the tremendous challenges that aeeompany the cancer experience. The eonfluenee of world views may effect these relationships, especially if the nurses and patients do not share eommon heritage and have never interacted with persons of these heritages. The result may be a cultural dash or the need for cultural negotiation. The outcome de. pends in part on the nurse's level of eultural competency. Culturally sensitive elinieians with an ade-
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quate foundation of c u l t u r a l k n o w l e d g e and skills integrate a cultural assessment into the initial encounter to d e t e r m i n e a p p r o p r i a t e a c tions. Specific questions to address include w h e t h e r a t r a n s l a t o r is n e e d e d , a p p r o p r i a t e a n d inappropriate p a t t e r n s of v e r b a l a n d n o n v e r b a l
communication, a n d i s s u e s of r e l i g i o n , c u l t u r e , and ethnieity. Cultural awareness, sensitivity, knowledge, and skills a r e n e e d e d to i n t e g r a t e e u l t u r a l e o m p e t e n e e i n t o d a i l y p r a c t i c e , e d u e a t i o n , a n d r e s e a r c h to a c h i e v e b e t t e r o u t c o m e s for p a t i e n t s a n d e l i e n t s .
REFERENCES 1. Leininger M: Transeultural nursing research to transform nursing education and praetice: 40 years. Image J Nurs Scholar 29:341-347, 1997 2. Reverby 8: Ordered to Care: The Dilemma of Ameriean Nursing, 1850-1945. London, Cambridge, 1987 3. Lewin M, Rice B: Balancing the Scales of Opportunities in Health Care: Ensuring Racial and Ethnic Diversity in the Health Professions. Washington, DC, National Academy Press, 1994 4. National League for Nursing, Center for Research in Nursing Education and Community Health. Nursing Data Review 1997. New York, National League for Nursing Press, 1997 5. Carnegie M: The Path We Tread-Blacks in Nursing Worldwide 1854-1994 (3rd ed). New York, National League for Nursing, 1995 6. Morris D, Wykle M: Minorities in nursing, in Annual Review of Nursing Research. New York, Springer, 1994, pp 175-189 7. van Marten M: Researehing Lived Experience: Human Science for an Action Sensitive Pedagogy. Ontario, Canada, Althouse Press, 1994 8. Houston P: Cowboys are my Weakness. New York, Pocket Books, 1992 9. Pike K: Language in Relation to a Unified Theory, of the Structure of Human Behavior. Glendale, CA, Summer Institute of Linguisties, 1954 10. Pike K: Language in Relation to a Unified Theory of the Structure of Human Behavior. The Hague, The Netherlands, Mouton, 1956 11. Tripp-Reimer T: Reeonceptualizing the eonstruet of health: Integrating emie and etie perspeetives, ires Nurs Health 7:101-109, 1984 12. MeKenny NR, Bennett CE: Regarding data on race and ethnicity: The census bureau experience. Public Health Pep 109:16-25, 1994 13. Williams DR: Raee and health: Basic questions, emerging directions. Ann Epidemiol 7:322-333, 1997 14. Montague A (ed): The Concept of Race. Toronto, Canada, Collier Macmillan, 1968 15. Herman A: Toward a eoneeptualization of race in epidemiologie researeh. Ethnieity Dis 6:7-20, 1996 16. Goldberg D: Racist Culture: Philosophy and the Polities of Meaning. Cambridge, M.A, Blackwell, 1993, pp 61-89 17. Crews D, Bindon J: Ethnieity as a taxonomic tool in biomedieal and biosoeial research. Ethn Dis 1:42-49, 1991 18. Le Veist T: Why we should eontinue to study raee...But do a better job: An essay on raee, raeism and health. Ethn Dis 6:21-29, 1996 19. Evinger S: How shall we measure our nation's diversity9 Chance 8:7-14, 1995 20. Offiee of Management and Budget: Standards for the Classification of Federal Data on Raee and Ethnicity. Washing-
ton DC, Office of Federal Statistical Policy and Standards, US Department of Commerce, 1978 (http://www.whitehouse.gov/ omb/fedreNdireetive_lS.html) (Accessed March 2001) 21. Fetterman D: Ethnography Step by Step. Newbury Park, CA, Sage, 1989 22. Harris M: The Rise of Anthropologieal Theory. New York, Thomas Y. Crowell, 1968 23. Spradley J, MeCurdy D: The Cultural Experienee: Ethnography in Complex Soeiety. Chicago, Seienee Research Assoeiates, 1972 24. Lewis-Fernandez R, Kleinman A: Cultural psychiatry: Theoretieal, elinieal, and researeh issues. Cult Psyehiatry 18: 433-448, 1995 25. Bates MA, Edward WT: Ethnic variations in the ehronie pain experience, gthn Dis 2:63-83, 1992 26. Todd KIt, 8amaroo N, Hoffman aR: Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 269:1537-1539, 1993 27. Speetor RE: Cultural Diversity in Health and Illness (ed 5). Englewood Cliffs, Na, Prentice Hall Health, 2000 28. Fejos P: Man, magie and medicine, in Ooldstein I (ed): Medicine and Anthropology. New York, International University Press, 1959, pp 11-35 29. Gordon M: Assimilation in American Life. London, Oxford, 1964 30. Zimmerman MA, Ramirez-Valles J, Washienko tLM, et al: The development of a measure of eneulturation for Native American youth. Am J Community Psychol 24:295-310, 1996 31. Suarez L, Pulley L: Comparing acculturation scales and their relationship to eaneer screening among older MexieanAmeriean women, d Natl Cancer Inst Monogr 18:41-47, 1995 32. Ragawa-Singer M: Cultural systems, in McCorlde R, Grant M, Frank-Stromberg M (eds): Cancer Nursing. A Comprehensive Textbook (ed 2). Philadelphia, Sannders, 1996, pp 38-52 33. Marin BVO, Marin G: Research with Hispanic Populations. Newbury Park, CA, Sage Publications, 1992 34. Brandt J, Ishida D, Itano d, et al: Oneology Nursing Society Multieultural Outcomes: Guidelines for Cultural Competence. Pittsburgh, Ontology Nursing Society, 2000 35. Meleis AI, Isenberg M, Koerner dE, et al: Diversity, Marginalization, and Culturally Competent Health Care: Issues in Knowledge Development. Washington, DC, American Academy of Nursing, 1995 36. US Department of Health and Human Serviees: Assuring Culture Competence in Health Care: Recommendation for National Standards and an Outeomes-Foeused Research Agenda. Office of Minority Health, Public Health Service, www. omhre.gov/elas/eulturalla.htm (Accessed April 2001)
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OB.JECTD,~S: To define key. eoncept.s m~l sumnmrizJe available guidelines ti~t are important r~,ourees to asMst nurses to prc~qde culturrdly cv~mpetent care.
CULTURALLY COMPETENT CARE
DATA ~)URCI~c;: Med/ine, m u ~ l o g ~ and epidemiologic litcvo.ture, and National ln.stinaes of tleahh doeumems. CONCLUSIONS: Ctmtroversy remains about the most appropriate language to use to describe features ~. diverse
populo~,ns. |MPLRiATIONS FOR NURSING
PnAC FICE. Becoming culturally competent beNns ~, understandir~, term.s and conc~opLs that are essenticd in devek,Tnng cultural awaro~ess, knowledge, rout skills. Sensitivity to language rout the history of the development of some labels are ~mportant.
Frmn t h e Unit~rsity of Texas-tlmg~ton Health Scfenec Center Schtud qf Nursing; mul the Univer~ty of Tex.a.s M. D. Antieta m Caru~r Center, Housam, TX. Marlene Zie|ti Cohen, P,N, PhD: The John S. Dram, bY,/.~t/nSu/shed Prqfessor m On¢x~.~, Nursir~, The l h ~ . ' s ~ , of Tex~Houston H~xlth Scqcnce Cemer, Sctuxd of Nursling and Director of Applied NurMng R~h, The Uni~-,rMty of Te,xas, M. t"). Andcv'son Ce~u:er Center, litm~s't¢m, TX. Cmadalupe Palos, RN, LMSW: Cance'r Program Specialist, Ttue University of "r~cas, M. D. Antietam Canc,er Center, 8et.tion of the Pain Reset~rch (hm~p, llouston, TX. Addr'~ reprint reque.~ts to Me~lene zichi (~hen, RN, PhD, l r ~ of Texo.c;Ilouston, Selurd qf Nurs~'ng, 1100 Hok,orabe Bled, 65rite 5.5331, lfou.~ton, TX 77030.
t'Jol~3night ©2001 by W.B. Smmders Cmnt~any 0749-,~08JA91/1703.0002~15. 00/0 doi:l O.l O . ~ L 2001.259~ ]
M A R L E N E Z I C H I C O H E N AND G U A D A L U P E
PALOS
L
EININGER1 was a pioneer when she introduced in the mid-1950s the need for nurses to develop and use knowledge of diverse eultures. The diversity of the population of the United States has inereased and teehnology and travel inereasingly afford us opportunities to work with persons of different cultures. These faetors make the information in this issue of Seminars in Oneology Nursing devoted to eultural dimensions of oneology nursing even more important as we seek to provide nursing care that is culturally eompetent. This artiele will set the stage by diseussing key eoneepts and some of the resourees available for nurses, beginning with some of the reasons this topie is so important.
NURSING AND CULTURAL DIVERSITY s early as the 19th c e n t u r y it has been noted that nurses • ]k have been primarily white women. 2 In 1994, the Institute of Medieine's com m i t t ee recognized u n d e r r e p r e s e n t a t i o n of minorities in health professions as a national p r i o r i t y ) Nursing statistics also show that minority enrollments and graduates are both lower than needed to reflect the diversity of the population of the United States and lower in 1995 than in 1994. 4 This u n d e r r e p r e s e n t a t i o n has its roots in the very slow and late integration into nursing of members of minority groups. Rigid segregation and discrimination was developed in nursing schools, and persisted into the 1950s for Afriean Amerieans. 5 Native Amerieans also were segregated, and Arizona had the only nursing school established for them. 6 Minority groups have established organizations to meet specific needs. These include the National Association of Colored Graduate Nurses, whieh was only incorporated in the Ameriean Nurses Association in 1951. The National Association of Hispanie Nurses was founded in 1975. In 1972 American Indian Nurses Association was formed, and was renamed the American Indian/Alaska Native Nurses Association in 1978. The Philippine Nurses Association of America was formed in 1979. Recruitment of members of minority groups into nursing is one important way to enhance eulturally competent care.
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SIMILARITIES &ND DIFFERENCES lthough we differ in m a n y ways, we are also similar in many, perhaps more i m p o r t a n t ways. While our perspectives vary, there are similarities. Phenomenologieal philosophy speaks of this. Van Manen 7 deseribed four fundamental existential themes; the lived space (spatiality), the lived body (eorporeality), lived time (temporality), and lived h u m a n relation (relationality or eommunality). This means that we all share the experienee of having a body in spaee and time and live in relationship with others. These basie ideas and experienees are universal and i m p o r t a n t and lead to important similarities despite differences among us. Despite these similarities, we struggle to understand the differenees. Fietion can illuminate our understanding, as in a story in which two women talk about a m a n with whom one of them is involved. She told her friend, "He said even if I was already dead and he knew who did it, he'd kill them. Even if I was already dead." Her friend replied, "I think in Texan that means 'I love you'. ''s This illustrates that one need not be a m e m b e r of a minority group to u n d e r s t a n d cultural differenees. We are all part of different groups with different values and norms. This same book of fietion eontains a n o t h e r story that is relevant to these artieles on diverse eultures. This story described a Navajo w o m a n who found a lump in her breast. She told her friend she did not seek t r e a t m e n t because "my power animal says it's not e a n e e r ''s A biopsy found the t u m o r was malignant. The a u t h o r noted "doetors apparently had stopped using the 'C' word." The w o m a n decided to "stop seeing the doetors" because "my power animal said I don't n e e d them, they eould even be detrimental." tter friend struggled with this and discussed it with her boyfriend. "I want to support her d e c i s i o n . . . I even want to believe in her magic, but she's ignoring hundreds of years of medical researeh. This ugly thing is consuming her and she's not doing anything to stop it." Her boyfriend r e m i n d e d her, "She is doing s o m e t h i n g . . , she's just not doing what you want her to do." This is the heart of what nurses need to do; be sure that patients have the information and support they need and then to respect their deeisions. Understanding their perspectives m a y help, espeeially when their perspectives differ from our own.
A
ISSUES OF LANGUAGE ecoming culturally c o m p e t e n t begins by understanding terms and eoneepts that are essential in developing eultural awareness, knowledge, and skills. Emie and erie are two i m p o r t a n t terms that were based on the linguistie distinetion between p h o n e m i e and phonetic.9,10 Phonemics is the study of sounds used in a language, while phonetics seeks to generalize from studies of individual languages to universals eovering all languages. By analogy, emie eategories are specific to a eulture and erie eategories are eulturally universal. Anthropologists and other researchers who seek to discover the emie perspective look for an understanding of how experiences are defined by "natives" (eg, those persons in a eulture or those having an experience). The erie perspective is the "outsiders'" or researehers' perspective. The etie perspeetive involves observing a eulture without learning how those being studied view the culture or experienee. External criteria are used to examine and e o m p a r e several cultures or groups. Clinieians and researchers seek to u n d e r s t a n d the perspeetive of persons who have the experienee. Tripp-Reimer 11 used this emie/etie distinetion to diseuss disease and illness in a partieularly useful eoneeptualization of these ideas. Disease is the etie eategory, the biomedical perspeetive, and illness is the emie or patients' or elients' perspeerive. In a four-quadrant grid she illustrated that people can have disease with or without illness, and illness with or without disease. This is useful to guide researeh and praetiee to ensure that clinicians and researchers u n d e r s t a n d both the emie and etie perspeetives. T h e r e is eonsiderable debate about the labels and language we use to describe diverse groups, including the terms raee, ethnieity, minority, and culture. The use of raee as a e o n c e p t in research, data eolleetion, or policy reporting for identifieation and data eolleetion purposes has been attaeked as unscientific, vague, raeist, and inaccurate. 12,13 This eoneept emerged with the e o n e e p t of nation during the 16th eentury. ~4 Montague argued that colonization required a "scientific rationale" and raee classification emerged to explain the forees of expansion, oppression, and enslavem e n t of aboriginal populations in Africa and Asia) 4 Both race and ethnieity are ereated by boundaries to separate self (or group) from nonself. Some groups are eonsidered both races and
B
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ethnic groups. Jews and black South Africans are two such groups, and in both eases race and ethnieity have been used to oppress and exclude these groups at certain points in history, is Goldberg 16 described five fabrications of race and discussed why race is not the same as or consistent with biology, social class, culture, ethnieity, or nation. The biological concept of race dominated until the end of World War II and Nazi racism. Ethnicity is slowly replacing race, although the concepts overlap and are often used synonymously. Dictionary definitions of race and ethnieity overlap. Crews and Bindon 17 suggest race is a sociologic construct that is poorly correlated with biological or cultural features other than the amount of melanin in a person's skin, while ethnieity is a soeioeultural construct that is often coextensive with discernible features of a group. LaVeist is developed a model of race that linked race, an unobservable or latent factor, with physiognomy (judging others from facial features). People are categorized based on physical indicators into cultural and ethnic groups. These groups are then exposed differently to health risks such as poor housing or poorer heath care. When these constructs are used in health research, the purpose is to better understand genetic and environmental factors in disease. However, there are many differences between racial and ethnic groups in disease pattern and culture. Research is needed to examine the interplay of cultural factors and health with communication barriers and racist attitudes that may affect health service delivery. Labels for race and ethnieity differ among federal and national data collection agencies such as the US Census Bureau, the Office of Management and Budget (OMB) and other national public health surveillance systems. The OMB classification, now widely used in the United States, was adopted in 1977 in order to collect data on groups that were discriminated against. 19 The OMB currently recognizes four racial groups; Asian or Pacific Islander, American Indian or Alaskan Native, black, and white. The two ethnic elassifieations are Hispanic origin and not of Hispanic origin, zo The OMB responded to criticism of these categories by establishing a comprehensive review starting in 1993. This review has resulted in a variety of recommendations, including revising the labels for race to include American Indian or Alaska Native, and black or African American. The other labels for race and the ethnicity labels are un-
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changed. These are considered minimum categories and those producing data are encouraged to use greater detail. The category "more than one race" should be included if the criteria for data quality and confidentiality are met. The term "minority" generally includes American Indians and Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islands, blacks/ African Americans, and Hispanies/Latinos. These groups are included in the charge to the Office of Minority Health to advise the Deputy Assistant Secretary for Minority Health and the Office of Public Health and Sciences on public health issues affecting these groups. The US Department of Health and Human Services created the Office of Minority Health in 1985 as a result of the Report of the Secretary's task force on Black and Minority Health (www.omhre.gov/OMH). Anthropologists have defined culture in two major ways. The behavioral/materialist perspective defines culture as what is observed through a group's patterns of behavior and customs, their way of life, and what they produce. Culture also is made up of ideas, beliefs, and knowledge that are used by a group, which is the cognitive formulation. 21-23 Culture emerges out of patterns of daily social life and is a moral process of interpretation and collective experience, composed of many voices, ereated by and, in turn, creator of soeial action located between people. 24 When heritage is defined, religious groups and age cohorts meet these formulations. Culture influences values, behavior or beliefs, and experiences by providing a framework of cultural values that guides an individual's thoughts, actions, and decisions. Applying these definitions to the cancer experienee leads to the idea that the way persons view cancer, react to specific experiences (such as an initial diagnosis), and behave during situations will largely depend on cultural or religious values, beliefs, and practices that they learn from their family, friends, and other members of their culture. Ethnieity or ethnic self identity has been defined as one's sense of belonging to a specific group. 2s Ethnieity may lead to barriers in research and clinical practice. For example, in research regarding ethnic differences in pain management, ethnieity was found to have a negative impact on providing adequate pain management for emergency room patients with bone fractures. 26 Todd et al found that Hispanies were twice as likely to receive insufficient pain management compared to their white counterparts. The investigators of
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this study did not identify other mediating factors, but they did suggest that sociopolitical factors including racism might have affected the medical care given to this ethnic population. Members of ethnic minority groups may share some of the characteristics of a dominant culture, while choosing to maintain their country of origin's or ethnic values, practices, language, and norms. Three processes, assimilation, acculturation, and eneulturation influence cultural values, beliefs, practices, and attitudes toward health and illness, including chronic diseases such as eancer.2S,27-31 Kagawa-Singer 32 defined acculturation as "the ability to function comfortably in another culture by learning the behavior of the other c u l t u r e . . . and assimilation indicates that the individual gives up the beliefs, values, materials, cultures, and practices of their native group and adopts those of the host culture. ''32 Both acculturation and assimilation imply that one must give up their values, beliefs, and practices of their country of origin in order to become a member the host society. Enculturation is a process that allows a balance between the cultural world views of the host society and the country of origin. Eneulturation seems to be the future trend that ethnically diverse populations may choose in order to maintain their cultural heritage. For example, many ethnic groups have built communities within a larger geographical region or community. The immediate community contains businesses, churches, civic groups, and markets that reflect the values, beliefs, practices, and languages of a certain ethnic group. Eneultured communities evolving from Central American Latinos, Vietnamese, Middle Easterners, and others may be found in many US regions and may continue to increase as America becomes more diverse. The most reliable indicators to measure acculturation include ethnic self identification, language used during an interview, country of origin, and length of residence in the United States. 3°,31,-~3 While there are validated instruments available to measure acculturation but not enculturation, tremendous heterogeneity exists within each subgroup. Therefore, applying the constructs of eneulturation and acculturation must be performed with caution. For example, a US-born Asian of Vietnamese ancestry can have the language fluency of a highly assimilated individual with a high level of income and education yet may strongly value traditional Vietnamese practices and beliefs.
Attitudes, behaviors, and beliefs of members of ethnic groups can be difficult to predict. CULTURAL COMPETENCE STANDARDS IkND GUIDELINES A
variety of definitions, standards, and guidelines exist to help achieve cultural competence in health care, education, research, and policy decision making. Oneology Nursing Society guidelines define culturally competent care as care that is provided by nurses who use cultural theory, models, and research principles in identit'ying health care needs, providing care, and evaluating the outcomes of that care. 34 Other definitions include the American Academy of Nursing definition that culturally competent care is care that takes into account issues related to diversity, marginalization, and vulnerability due to culture, race, gender, and sexual orientation. 3s This definition includes the medically underserved and those whose sexual orientation may make them less likely to participate in traditional health care systems. Rather than creating new definitions, the OMB adapted definitions of cultural competence from the Office of Women and Minority Health at the Bureau of Primary Itealth Care, ttealth Resources and Services Administration. Three important terms and definitions in this document are: Culture and linguistic competence: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. Competenee: Implies having the eapaeity to funetion effectively as an individual and organization within the context of cultural beliefs, behaviors, and needs presented by consumers and communities. Culture: Refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. The OMB conducted a comprehensive literature review to prepare this document and found more documents regarding the criteria required for linguistic competence than for cultural competence. This reinforces the need to develop a set of accepted definitions, standards, and requirements for providing patient care, designing research, and
CULTURALLY COMPETENT CARE
establishing health care policies that are based on cultural theories and principles. National standards for eulturally and linguistically appropriate services from the OMB evolved from a lengthy proeess of public, regional hearings, publication in the Federal Register, and opportunities for public comment through a website, a6 This lengthy document addresses issues affecting health care praetiee, edueation, research, and poliey decision making. The target audienee for this document ineludes providers, policy makers, accreditation and credentialing agencies (such as Joint Commission on Accreditation of Healtheare Organizations), purehasers, advocates, educators, and patients. The doeument includes a preamble and recommendations for assuring cultural eompetenee in health care. Table 1 presents seven of the 14 recommendations that evolved from this process. This document may be obtained online at http://www.omhre. gov.das. The Oneology Nursing Society document, "Multieultural Outcomes: Guidelines for Cultural Competence," introduces concepts and sMlls necessary for providing quality patient cancer care within a cultural context in order to address cultural competence for elinieal praetiee, education, and research. A framework of 11 domains considered essential to culture is provided. These domains include ethnie identity, eommunieation, time and space, soeial organization, work force issues, health beliefs/ praetiees/praetitioners, nutrition, biologic variation, sexuality and reproduction factors, religion and spirituality, and death rituals. Assessment questions and outeomes for each domain are presented and examples of how the domains can affeet individuals' cancer experience are shown and culturally appropriate solutions for concerns are presented. A model for achieving eultural competence and guidelines for planning, implementing, and evaluating research from a cross-cultural perspective are also ineluded. These guidelines are available through the Oneology Nursing Society office or their website, http:// www.ons.org. Several eoneepts important to beeoming culturally eompetent are: Aeeeptanee: Respeeting and aeeepting the world views of individuals from different cultures. Adaptation: Learning that change is required by all participants in order to work together. Cultural Relevance: Integrating the world views of a speeifie eulture into praetiee, edueation, researeh, and interventions
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TABLE 1. Standards for CuRuraRyand Li~uisticaUy Appropriate HeaRh Care Se~ices~
should: • promote and SUPDort attitudes, behaviors, knowledge,
Cultural Sensitivity: Becoming aware of basic cultural differenees and willing to change one's own world view. Integration: Responding to the needsof a partieular situation by integrating new cultural knowledge and competency that will benefit the group. Oneology nurses build unique relationships with patients and their families because o f the tremendous challenges that aeeompany the cancer experience. The eonfluenee of world views may effect these relationships, especially if the nurses and patients do not share eommon heritage and have never interacted with persons of these heritages. The result may be a cultural dash or the need for cultural negotiation. The outcome de. pends in part on the nurse's level of eultural competency. Culturally sensitive elinieians with an ade-
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quate foundation of c u l t u r a l k n o w l e d g e and skills integrate a cultural assessment into the initial encounter to d e t e r m i n e a p p r o p r i a t e a c tions. Specific questions to address include w h e t h e r a t r a n s l a t o r is n e e d e d , a p p r o p r i a t e a n d inappropriate p a t t e r n s of v e r b a l a n d n o n v e r b a l
communication, a n d i s s u e s of r e l i g i o n , c u l t u r e , and ethnieity. Cultural awareness, sensitivity, knowledge, and skills a r e n e e d e d to i n t e g r a t e e u l t u r a l e o m p e t e n e e i n t o d a i l y p r a c t i c e , e d u e a t i o n , a n d r e s e a r c h to a c h i e v e b e t t e r o u t c o m e s for p a t i e n t s a n d e l i e n t s .
REFERENCES 1. Leininger M: Transeultural nursing research to transform nursing education and praetice: 40 years. Image J Nurs Scholar 29:341-347, 1997 2. Reverby 8: Ordered to Care: The Dilemma of Ameriean Nursing, 1850-1945. London, Cambridge, 1987 3. Lewin M, Rice B: Balancing the Scales of Opportunities in Health Care: Ensuring Racial and Ethnic Diversity in the Health Professions. Washington, DC, National Academy Press, 1994 4. National League for Nursing, Center for Research in Nursing Education and Community Health. Nursing Data Review 1997. New York, National League for Nursing Press, 1997 5. Carnegie M: The Path We Tread-Blacks in Nursing Worldwide 1854-1994 (3rd ed). New York, National League for Nursing, 1995 6. Morris D, Wykle M: Minorities in nursing, in Annual Review of Nursing Research. New York, Springer, 1994, pp 175-189 7. van Marten M: Researehing Lived Experience: Human Science for an Action Sensitive Pedagogy. Ontario, Canada, Althouse Press, 1994 8. Houston P: Cowboys are my Weakness. New York, Pocket Books, 1992 9. Pike K: Language in Relation to a Unified Theory, of the Structure of Human Behavior. Glendale, CA, Summer Institute of Linguisties, 1954 10. Pike K: Language in Relation to a Unified Theory of the Structure of Human Behavior. The Hague, The Netherlands, Mouton, 1956 11. Tripp-Reimer T: Reeonceptualizing the eonstruet of health: Integrating emie and etie perspeetives, ires Nurs Health 7:101-109, 1984 12. MeKenny NR, Bennett CE: Regarding data on race and ethnicity: The census bureau experience. Public Health Pep 109:16-25, 1994 13. Williams DR: Raee and health: Basic questions, emerging directions. Ann Epidemiol 7:322-333, 1997 14. Montague A (ed): The Concept of Race. Toronto, Canada, Collier Macmillan, 1968 15. Herman A: Toward a eoneeptualization of race in epidemiologie researeh. Ethnieity Dis 6:7-20, 1996 16. Goldberg D: Racist Culture: Philosophy and the Polities of Meaning. Cambridge, M.A, Blackwell, 1993, pp 61-89 17. Crews D, Bindon J: Ethnieity as a taxonomic tool in biomedieal and biosoeial research. Ethn Dis 1:42-49, 1991 18. Le Veist T: Why we should eontinue to study raee...But do a better job: An essay on raee, raeism and health. Ethn Dis 6:21-29, 1996 19. Evinger S: How shall we measure our nation's diversity9 Chance 8:7-14, 1995 20. Offiee of Management and Budget: Standards for the Classification of Federal Data on Raee and Ethnicity. Washing-
ton DC, Office of Federal Statistical Policy and Standards, US Department of Commerce, 1978 (http://www.whitehouse.gov/ omb/fedreNdireetive_lS.html) (Accessed March 2001) 21. Fetterman D: Ethnography Step by Step. Newbury Park, CA, Sage, 1989 22. Harris M: The Rise of Anthropologieal Theory. New York, Thomas Y. Crowell, 1968 23. Spradley J, MeCurdy D: The Cultural Experienee: Ethnography in Complex Soeiety. Chicago, Seienee Research Assoeiates, 1972 24. Lewis-Fernandez R, Kleinman A: Cultural psychiatry: Theoretieal, elinieal, and researeh issues. Cult Psyehiatry 18: 433-448, 1995 25. Bates MA, Edward WT: Ethnic variations in the ehronie pain experience, gthn Dis 2:63-83, 1992 26. Todd KIt, 8amaroo N, Hoffman aR: Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 269:1537-1539, 1993 27. Speetor RE: Cultural Diversity in Health and Illness (ed 5). Englewood Cliffs, Na, Prentice Hall Health, 2000 28. Fejos P: Man, magie and medicine, in Ooldstein I (ed): Medicine and Anthropology. New York, International University Press, 1959, pp 11-35 29. Gordon M: Assimilation in American Life. London, Oxford, 1964 30. Zimmerman MA, Ramirez-Valles J, Washienko tLM, et al: The development of a measure of eneulturation for Native American youth. Am J Community Psychol 24:295-310, 1996 31. Suarez L, Pulley L: Comparing acculturation scales and their relationship to eaneer screening among older MexieanAmeriean women, d Natl Cancer Inst Monogr 18:41-47, 1995 32. Ragawa-Singer M: Cultural systems, in McCorlde R, Grant M, Frank-Stromberg M (eds): Cancer Nursing. A Comprehensive Textbook (ed 2). Philadelphia, Sannders, 1996, pp 38-52 33. Marin BVO, Marin G: Research with Hispanic Populations. Newbury Park, CA, Sage Publications, 1992 34. Brandt J, Ishida D, Itano d, et al: Oneology Nursing Society Multieultural Outcomes: Guidelines for Cultural Competence. Pittsburgh, Ontology Nursing Society, 2000 35. Meleis AI, Isenberg M, Koerner dE, et al: Diversity, Marginalization, and Culturally Competent Health Care: Issues in Knowledge Development. Washington, DC, American Academy of Nursing, 1995 36. US Department of Health and Human Serviees: Assuring Culture Competence in Health Care: Recommendation for National Standards and an Outeomes-Foeused Research Agenda. Office of Minority Health, Public Health Service, www. omhre.gov/elas/eulturalla.htm (Accessed April 2001)