1. Frederick, Dorothea MSN, RNFA, CNOR
  2. Marinelli, Maria MSN, RNFA, CNOR


Abstract: Adapting to diversity improves patient care.


Article Content

A circulating perioperative nurse working in a children's hospital interviews the parents of a child undergoing a ureteroscopy. Her question set for the interview is based on the Association of periOperative Registered Nurses (AORN) comprehensive surgical checklist:1

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

(1) the child's name


(2) birthdate


(3) procedure and parent signature on consent


(4) site, if applicable, along with marking


(5) allergies


(6) when the child last had solid food


(7) any metal jewelry or history of fractured bones.



The family remarks "yes" to every question, and says, "they will take out kidney." The resident is called for and explains the entire procedure through a translator-that the kidney is not going to be removed, only films taken looking for a stone.


Assuming patients understand the questions they are asked is fraught with problems. Perioperative nurses are presented with a multitude of different cultures and the nature of the nursing profession is to move care along in a timely fashion, especially in the OR. Do perioperative nurses have the time to be culturally competent and manage diversity? For perioperative nurses it involves admitting they do not know everything, asking colleagues for feedback, becoming comfortable with ambiguity and celebrating diversity.2


Part of the difficulty in understanding cultural differences, lies in the fact that difficulties are "not merely conceptual or semantic."3 Understanding culture comes with understanding different political and ideological agendas.3 This may involve errors in viewing others' cultures or behaviors through the learners' lens. The learners then believe that their actions are the only legitimate methods to use and that their way is superior. Harkness and DeMarco4 suggested that ethnocentrism is the belief in the inherent superiority of one's own ethnic group or culture or a tendency to view other groups or cultures from the perspective of one's own. Since culture is learned from interaction and taught by explanation, it is possible for people to learn to function in other cultures as well; lack of critical consideration of other cultures limits this potential.3 Overcoming this lack of critical consideration begins with self-awareness. Broad views influence health and illness beliefs.5 Having a world view of culture, and using a transcultural approach, where one is grounded in one's own culture, but is able to work in a multicultural environment is key to providing culturally sensitive care.5 The website EdChange6 offers readers several resources, such as the Equity and Diversity Awareness Quiz, Class and Poverty Awareness Quiz, and the Digital Sexism Quiz to establish their own self-awareness. Learners become aware that information from media sources, friends, and family is not always true. When using research information, learners find that the real facts emerge and that prior to forming opinions about any specific cultural group people must learn about the differences in groups.


Culturally competent care eliminates misunderstanding and improves patient adherence with treatments.7 Cultural competence is essential to close the disparities in healthcare because of the impact that culture and language have on patients' beliefs about health, disease, and their causative behaviors.8 According to the American Nurses Association, expected outcomes are defined in terms of the healthcare consumer, healthcare consumer cultures, values, and ethical considerations and require nurses to consider culture with individualized care plans.9


One of the major barriers for understanding the cultural background of surgical patients is inadequate communication. The use of professional interpreters improves patients' care in all areas of healthcare, but most important in the surgical arena.10 Once communication is established, it is then important to use a framework for culturally competent clinical practice. (See ETHNIC mnemonic helps communication.)


Melded cultures form subcultures

As people move to new countries and meld with other cultures multiple subcultures form within racial groups. Healthcare workers cannot assume common understanding and knowledge of unwritten rules exists.


The percentage of the population speaking English without true comprehension grew from 8.1% in 2000 to 8.7% in 2007, but stayed at 8.7% in 2011.11 The percentage of individuals speaking a language other than English at home rose from 17.9% in 2000 to 19.7% in 2007, while continuing upward to 20.8% in 2011. Of the 60.6 million people who spoke a language other than English at home in 2011, almost two-thirds (37.6 million) spoke Spanish.11


With increasing diversity in the United States, by the year 2030, 60% of the U.S. population is expected to self-identify as White, non-Hispanic and 40% will self-identify as members of other diverse racial, ethnic, and linguistic groups.12 The diverse Hispanic and Asian groups are currently growing at rates much higher than the total population. The so-called minorities are in the majority in Hawaii, New Mexico, California, and the District of Columbia.12


Cultural background influences evaluations

Cultural attitudes are the beliefs and perspectives that societies consider extremely valuable.13 Nurses are programmed by their cultural groups to interpret and evaluate the behavior and ideas of others in specific ways. Healthcare providers, from an early age, are trained to see things from their own cultural viewpoint. Culture is the nurse's "central lens," but the nurse must then develop self-awareness along with heightened communication techniques and understanding in the clinical arena.8 (See Culture awareness and competence.)


Dialoguing with others, creating new meanings and new rules to meet the needs of a particular situation creates a culture of shared meaning. For people who work in healthcare, it is a developmental process that evolves over an extended period of time.


Without an understanding of the impact of culture on concepts related to patients' physical and mental health and illness, a nurse may have difficulty planning and providing efficient and effective care to individuals from cultures other than his or her own.12


One key concept that is especially difficult for healthcare providers to accept is that it is okay to say I do not know. Cultural humility is both difficult to comprehend and to instill in other individuals.14 It is impossible to know everything about every culture, and nurses need to be willing to learn from the patients in their care and to listen to what they say, even if the nurses do not agree with what the patient is requesting or saying. No one can become competent with regard to understanding a culture. What is important is to take the approach that the patient is the expert and that healthcare providers should be the learners when caring for their patients.15


If patients seem disinterested or nonadherent with healthcare instructions or follow-up, nurses need to investigate if cultural factors are an issue. In addition, nurses need to work with patients to incorporate home remedies into the plan of care, and promote positive outcomes.12


Culture is a lens that people use to view phenomena, the end result being that people from different cultures often have different interpretations of the same phenomena.16 Without understanding the impact of culture on concepts surrounding physical and mental health and illness, the nurse may have difficulty planning efficient and effective care for individuals from cultures other than his or her own. Without being aware of patients' underlying cultural beliefs and values, nurses may be puzzled at patient resistance, lack of adherence, or seeming disinterest in health promotion.


Cultural awareness is a professional mindset, essential to the successful interaction of perioperative nurses in this multicultural healthcare environment.11


Working with an increasingly diverse patient population involves both perils and pitfalls.17 Perils involve time and energy commitments needed, inability to change, that is, this is not the way I learned nursing, and believing that adapting to diversity is not within the job description for healthcare providers. Pearls of wisdom involve opportunities for learning, using creativity and innovation, and acquiring global knowledge. It is time to create a preoperative survey that addresses cultural competence, not only asking the AORN comprehensive checklist questions,1 but also specifically asking if patients and/or families speak and understand English. If they do not, appropriate translation must be provided and documented. (See Considerations for a preoperative survey.)


Healthcare challenge summary

Nurses, as healthcare providers, may experience challenges that stem from cultural differences. However, perioperative nurses should not allow these challenges to result in suboptimal patient care. Cultural and ethnic backgrounds shape nurses' views of illness and wellness, and affect their perceptions of healthcare. This view may influence the quality outcomes for the patients undergoing surgical procedures. Although multiple sources contribute to health disparities, evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.18 "Media images depicting persons who are poor, homeless, or mentally ill may influence cultural attitudes. Often criminals in films are portrayed as poor desperate drug-seekers who are a detriment to society."13


After identifying the broad cultural group to which a person identifies himself or herself, use generalization only as a broad beginning point, not letting stereotypical views influence care.13 When healthcare workers use generalization as an endpoint, the result is stereotyping. Begin with generalizations and then interview the patient. Allow the patient to verbalize opinions and provide valuable information concerning personal preferences and then determine what he or she has to say about care concerns. No one is "a stereotype of his culture of origin, but rather a unique blend of the diversity found within each culture, and a unique accumulation of life experiences, and the process of acculturation to other cultures."19


Nurses live in a shrinking world in which people from many cultures interact on a daily basis; cultural awareness must become a professional mindset essential to successful interactions in this multicultural health care environment.


Cultural awareness and competence

Cultural awareness means that caregivers recognize that all persons are shaped by their cultural backgrounds, and that these issues influence their reactions to many types of circumstances.


Cultural competence means that people understand where they learned their worldviews, and that by listening to others, they obtain cultural information and then apply that knowledge to their practice. The most important multicultural resources nurses have are their patients. Instead of trying to define what is culturally important to them nurses should draw them into the conversation and allow them to define themselves.16


ETHNIC mnemonic helps communication

Once communication with the patient has been established, it is then important to use a framework for culturally competent clinical practice such as the ETHNIC framework.20


The ETHNIC mnemonic utilizes each letter for patient interview questions, such as:


* E = explanation, asking what do you think may be the reason you have these symptoms?


* T = treatment, asking what kinds of home remedies have you tried for this illness?


* H = healers, asking what advice have you tried from folk healers or friends to help?


* N = negotiate, asking can we negotiate a mutually acceptable treatment plan that incorporates your beliefs?


* I = intervention, creating a plan incorporating alternative treatments, spirituality, and healers along with medical treatment.


* C = collaboration between the patient and the healthcare provider to arrive at a treatment plan both can accept, one that factors in the patient's cultural practices to ensure patient compliance.20



Used with permission.


Considerations for a preoperative survey


* Be aware of one's own cultural influences.


* Be aware of judging other people's behavior and beliefs according to one's own personal cultural standards.


* Be aware of making assumptions and stereotyping instead of generalizing.


* Understand that behaviors and beliefs within cultures can vary considerably.


* Understand that not all people identify with their cultural or religious background.


* Attempt to increase one's knowledge about different cultural practices and issues and then share this information with others.


* Understand that there are multiple ways to reach the same goals and live life.


* Realize that when people are culturally aware, they understand that all patients in their care are not the same.21




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