Cultural Considerations in Healthcare

At its core, effective medical care and attention is person-centred.

This relies on healthcare professionals understanding that each patient is an individual with distinct, beliefs, behaviours and requirements.

It is vital you adapt your practice to address the wants and reasonable expectations of the patient (Medical Board of Australia 2014).

Cultural awareness is interlinked with this – healthcare professionals must be conscious of their own culture and beliefs, and ensure that they are respectful of the beliefs and cultures of others.

It is also worth remembering, however, that these differences can all-too-often have the potential to complicate the nurse-patient relationship and, henceforth, the provision of health services (Medical Board of Australia 2014).

Learning to nurture cultural respect and inclusion is vital to reducing health disparities and to facilitate and improve access to high-quality healthcare that is directly responsive to a patient’s needs (Zamanzadeh et al. 2015).

Cultural Diversity in Australia

Statistics from the most recent national census reveal how truly diverse Australia is as a nation.

Only two thirds (67%) of the Australian population were born in Australia. Of the 6,163,667 overseas-born persons, nearly one in five (18%) arrived since the start of 2012 (ABS 2016).

As of 2016, there were over 300 separately identified languages spoken in Australian homes. More than one-fifth (21%) of Australians spoke a language other than English at home (ABS 2016).

In 2016, nearly half (49%) of Australians had either been born overseas (first generation Australian) or one or both parents had been born overseas (second generation Australian) (ABS 2016).

Culture Defined

Culture is the values, customs, social structures, beliefs and patterns of human activity and the symbolic structures that provide meaning and significance to human behaviour (Engebretson 2016).

It is the combination of these as well as ideas, skills, arts, and other capabilities of a people or a group as a whole – and it is more than any of these elements and constantly in flux (Engebretson 2016).

Culture is influenced by political and economic conditions and varies with factors including age, gender, class, education and personality (Engebretson 2016).

Culture is largely tactic, which is to say, it is not generally expressed or discussed at a conscious level – most culturally derived actions are based on implicit cues (Engebretson 2016). This is one reason why healthcare professionals are wise to avoid making assumptions and should work toward understanding a patient’s culture beyond what may seem obvious to them.

We take for granted the way in which the following can differ between cultures and regions: eye contact, touch, decision-making, compliments, health-beliefs, healthcare practices, personal space, and modesty (Ferwerda 2016).

Cultural-Awareness in Nursing

Cultural awareness and sensitivity is vital to nursing. While we like to believe in the ideal that all Australians have access to a high standard of healthcare, this is not always the case.

Patients from diverse cultural backgrounds (including First-Nation Peoples) experience almost twice as many adverse effects as English-speaking patients (Multicultural Health Communication 2013).

People of a non-English speaking background are more likely to experience medication errors, misdiagnosis, incorrect treatment, poorer pain management and poorer outcomes in general (Ferwerda 2016).

The potential of error in the absence of culturally-aware nursing is vast. Misunderstandings, miscommunication, and culturally-unsafe care by healthcare professionals are often reported (Johnstone and Kanitisaki 2006). Patients of a non-Anglo-Saxon background have cited feelings of powerlessness, vulnerability, loneliness and fear (Garrett et al. 2008).

Variations in Illness Between Cultural Groups

It is worth keeping in mind that there is a variance in the prevalence of illnesses between cultural groups. This is due to genetic differences, dietary, cultural, environmental, socioeconomic or a combination of all of these factors (Collins 2003 quoted by Engebretson 2016).

Key determinants of health include but are not limited to: education and income, adequate and healthy housing, air quality, and health insurance (Centre for Disease Control of Prevention 2011 quoted by Engebretson 2016).

Culturally-Safe Practice

There may be situations in your job when cultural-beliefs and wishes clash with best practice. This is where culturally-safe practice is crucial.

Culturally safe and sensitive practice is defined by the Medical Board of Australian as:

• Good medical practice guided by genuine efforts to understand and meet the cultural needs and contexts of different patients to obtain good health outcomes, which requires:
  • Having knowledge of, respect for, and sensitivity towards, the cultural needs of the community.
  • Acknowledging and understanding the social, economic, cultural and behavioural factors that underpin health, both at individual and community levels.
  • Possessing the understanding that your own culture and beliefs (and biases) influence your interactions with patients.
  • Recommending improved patient engagement and health care outcomes.

(Medical Board of Australia 2014)

Transcultural Nursing – What is it and How to Apply it to Practice

Transcultural nursing is a term that seems to be gaining traction in recent years.

In essence, it is nursing that seeks to provide care that acknowledges and is congruent with a patient’s culture, values, beliefs and practices – the crux of which is good communication between the healthcare professional, the patient and their family.

To ensure that they are able to provide culturally-considerate nursing, an individual must first consider their own cultural biases and how these may impact their practice.

In addition, it requires:

• Sensitivity to the cultural practices and beliefs of others;
• Training for staff regarding culturally safe practices;
• Undertaking cultural assessments as part of routine clinical practice;
• Use of professional interpreting services (as opposed to relying on family) in all conversations with non-English speaking residents involving issues of significant information; and
• Commitment on an organisational level that recognises and supports cultural diversity among residents and staff.

(Care Search 2018)

The following acronyms may be useful to keep in mind while on the ward.

The ACCESS Model for Transcultural Care:

A - Assessment

• Emphasis on the cultural aspects of a client’s lifestyle, health beliefs, and health practices.

C - Communication

• Awareness in variations between verbal and non-verbal responses.

C - Cultural negotiation and compromise

• Awareness of aspects of other people’s culture as well as understanding the client’s views and how they articulate their problems.

E - Establishing respect and rapport

• Forster a therapeutic relationship that portrays genuine respect for the client’s cultural beliefs and values.

S - Sensitivity

• Provide culturally-sensitive care to a culturally diverse group.

S - Safety

• Create a space for clients to derive a sense of cultural safety.

• Emphasis on the cultural aspects of a client’s lifestyle, health beliefs, and health practices.

C - Communication

• Awareness in variations between verbal and non-verbal responses.

C - Cultural negotiation and compromise

• Awareness of aspects of other people’s culture as well as understanding the client’s views and how they articulate their problems.

E - Establishing respect and rapport

• Forster a therapeutic relationship that portrays genuine respect for the client’s cultural beliefs and values.

S - Sensitivity

• Provide culturally-sensitive care to a culturally diverse group.

S - Safety

• Create a space for clients to derive a sense of cultural safety.

(Narayanasamy 2002)

ABCD for Cultural Assessment

Learn and remember the ABCD model of Kagawa-Singer & Backhall (2001), and make it part of your routine to take time to discuss the following with your patient and their family:

A - Attitudes

• Traditional healing practices as well as Western healthcare.
• What illness and care mean to them and their family.
• How they prefer to communicate about death and dying and diagnosis and prognosis.

B - Beliefs

• The patient and their family’s religious and spiritual beliefs – particularly in relation to death, dying, the afterlife, and healing.
• How they and their family cope with suffering.
• How you can accommodate their spiritual and religious needs.

C - Context

• Determine the historical and political context of the patient’s and their family’s lives, this may include:
• • Place of birth;
  • Refugee or immigrant status;
  • Poverty;
  • Experience with discrimination;
  • Health disparities;
  • Language spoken; and
  • Degree of integration within their ethnic community and the degree of assimilation into Western culture.

D - Decision-making style

• Within their culture, find out whether they prefer to make decisions as a group or if it is mostly up to the individual.

E - Environment

• Determine whether there are community resources available to the patient and their family.

(Kagawa-Singer & Backhall 2001)

Challenges

There will be times in which you may find differing cultural practices and beliefs at odds with your practice and therefore hard to navigate. You may offend the patient or you might witness something that differs from your beliefs/moral codes. Sensitivity and communication should be the tools you rely on in these situations.

If in doubt, simply ask patients:

"Are there any religious or cultural practices that affect the way you wish to be cared for?"

- as opposed to making assumptions (Care Search 2018).

Consequences

The primary consequences of cultural neglect are poorer outcomes for people of diverse or marginalised backgrounds and, on a more general level, distrust for the healthcare industry (Ferwerda 2016).

Key Lessons

Ultimately, keeping these frameworks in mind and undertaking cultural assessments will help healthcare professionals provide safe and person-centred care to all people regardless of their race, ethnicity, culture or language.

Additional Resources

• Transcultural Nursing: https://www.ausmed.com/cpd/articles/transcultural-nursing-australia.
• Cultural Competence and Patient Safety: https://www.ausmed.com/cpd/articles/cultural-assessment.

References

• Australian Bureau of Statistics 2016, ‘2071.0 - Census of Population and Housing: Reflecting Australia - Stories from the Census, 2016,’ ABS, viewed 9 July 2019, https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0...Data%20Summary~30.
• Care Search 2018, 'Cultural Considerations', Care Search, viewed 9 July 2019, https://www.caresearch.com.au/caresearch/tabid/2446/Default.aspx.
• Engebretson, JC 2016, 'Cultural Diversity and Care', in Holistic Nursing A Handbook for Practice, eds. Dossey BM & Keegan L, 7th edn., Jones & Bartlett.
• Ferwerda, J 2016, ‘How To Care For Patients From Different Cultures’, Nurse.Org, 15 September, viewed 9 July 2019, https://nurse.org/articles/how-to-deal-with-patients-with-different-cultures/.
• Garrett, PW, Dickson, HG, Young, L, Whelan, AK & Forero, R 2008, ‘What do non-English-speaking patients value in acute care? Cultural competency from the patient’s perspective: a qualitative study’, Ethnicity and Health, vol. 13, no. 5, pp. 479-496.
• Johnstone, M & Kanitsaki, O 2006, ‘Culture, language, and patient safety: Making the link’, International Journal for Quality in Health Care, vol. 18, no. 5, pp. 383-388.
• Kagawa-Singer, M & Backhall, L 2001, ‘Negotiating Cross-Cultural Issues at End-of-Life’, Journal of American Medical Association, vol. 286, no. 23, pp. 2993-3001.
• Medical Board of Australia 2014, 'Good Medical Practice: A Code of Conduct For Doctors in Australia', Medical Board of Australia, viewed 9 July 2019, https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx.
• Multicultural Health Communication 2013, Fast Facts on Language Culture and Patient Safety, Multicultural Health Communication, viewed 9 July 2019
• Narayanasamy, A 2002, ‘The ACCESS Model: A Transcultural Nursing Practice Framework’, British Journal of Nursing, vol. 11, no. 9, pp. 643-50, viewed 10 July 2019.
• Zamanzadeh, V, Jasemi, M, Valizadeh, L, Keogh, B, Taleghani, F 2015, 'Effective Factors in Providing Holistic Care: A Qualitative Study', Indian J Palliat Care, May-Aug; 21(2): pp.214–224.

(Answers: b, a, c)