Culturally Competent Care

To prepare:

·        Reflect on your experiences as a nurse and on the information provided in this week’s Learning Resources on diversity issues in health assessments.

·        Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient assigned to you.

·        My original patient case scenario assigned to me: TJ, a 32-year-old pregnant lesbian, is being seen for an annual physical exam and has been having vaginal discharge. Her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank. She is currently taking prenatal vitamins and takes over the counter Tylenol for aches and pains on occasion. She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.

·        Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.

·        Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?

 

Assignment:

*use peer-reviewed scholarly sources no older than 5 years old.

*Use 2 peer-reviewed scholarly sources for each student response.

  • The text/pdf book is not considered a scholarly source e.g. Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2018). Seidel’s Guide to Physical Examination. Mosby.

*Respond to two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.

The case scenario of the two colleagues: AG is a 54-year-old Caucasian male who was referred to your clinic to establish care after a recent hospitalization after having a seizure related to alcohol withdrawal. He has hypertension and a history of alcohol and cocaine abuse. He is homeless and is currently living at a local homeless shelter. He reports that he is out of his amlodipine 10 mg which he takes for hypertension. He reports he is abstaining from alcohol and cocaine but needs to smoke cigarettes to calm down since he is not drinking anymore.

 

First Student Response to Case Scenario of AG, 54 yr old Caucasian male:

Cultural and linguistic competence is defined as “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” (Cultural Competence in Health and Human Services | Npin, 2020). Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowledge of core cultural issues, while also involving the recognition of one’s own culture, values, and biases to promote effective patient-centered communication skills (Ball et al., 2018). Health and human service organizations are recognizing the need to enhance services for culturally and linguistically diverse populations to enhance the healthcare system and promote effective patient care (Cultural Competence in Health and Human Services | Npin, 2020). In the following case scenario, there are several socioeconomic, spiritual, lifestyle, and other culture factors that affect how the patient responds to a disease process, including medication adherence:

AG is a 54-year-old Caucasian male who was referred to your clinic to establish care after a recent hospitalization after having a seizure related to alcohol withdrawal. He has hypertension and a history of alcohol and cocaine abuse. He is homeless and is currently living at a local homeless shelter. He reports that he is out of his amlodipine 10 mg which he takes for hypertension. He reports he is abstaining from alcohol and cocaine but needs to smoke cigarettes to calm down since he is not drinking anymore.

 

Culturally competent care requires that healthcare providers be sensitive to patient’s heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background to prevent stereotyping of patients (Ball et al., 2018). There are several components to my patient’s health history that are concerning, specifically his report of being out of his amlodipine and smoking cigarettes to ‘calm down.’ These are concerns because both smoking and uncontrolled hypertension put my patient at greater risk for heart disease and stroke (Smoking and Heart Disease and Stroke, 2021). Adherence to prescribed antihypertensive medications is found to be a potential major factor to adequality control systolic and diastolic blood pressure (Wannasirikul et al., 2016). One area the nurse practitioner needs to focus on when conducting a health history and interview with this patient is to gain a better understanding of the patient’s knowledge and education status, particularly in regards to hypertension and medication adherence. Health literacy (HL) is one way to measure this, and has been indicated as producing vigorous effectiveness on improving health practices and health outcomes (Wannasirikul et al., 2016). HL is affected by variables of literacy, cognitive ability, culture and society, and individual characteristics (Wannasirikul et al., 2016). HL has the significantly largest negative direct effect on blood pressure (Wannasirikul et al., 2016). By gaining an understanding of the patient’s educational background, the nurse practitioner can better educate the patient at an appropriate level (Wannasirikul et al., 2016).

When beginning the interview processes, taking into account the patient’s general appearance (i.e. clothing, hygiene, body language) can help direct the interview to gain an overall understanding of the patient. Patients also communicate nonverbally, and understanding this is advantageous to both the provider and the patient (Ball et al., 2018). Confidentiality is an essential element in the interview process that allows the patient to become comfortable and therefore share more information with the provider (Ball et al., 2018). Sensitive areas that the provider may encounter with this patient include potential shame for his drinking and/or illicit drug use, his current living situation, and his lack of adherence with his blood pressure medication. Maintaining a nonjudgmental tone of voice as well as body language will help the patient feel more comfortable and hopefully overcome these sensitive topics (Ball et al., 2018). The following are five examples of potential interview questions one may ask the patient in the scenario:

1.       I respect your values and your beliefs; what do I need to know to provide care for you?

2.       What are your thoughts around your health and maintaining a lifestyle that doesn’t include alcohol or cigarettes?

3.       Do you want to quit drinking alcohol or smoking cigarettes?

4.       What have you done in the past to stop drinking alcohol or smoking cigarettes? Have you ever been to a treatment facility in the past?

5.       Tell me about your living situation. Do you find you are able to care for your high blood pressure with your current living situation?

Without stereotyping the patient, I would hypothesize that the patient would need to completely trust the provider prior to divulging information for the health history because of his current living and socioeconomic status. With that being said, it is important that although addressing sensitive issues may be difficult to discuss (e.g. sex, drug or alcohol use), they are important to address, especially in a direct and firm manner (Ball et al., 2018). The CAGE questionnaire is one model for discussing the use of alcohol; CAGE stands for Cutting down, Annoyance by criticism, Guilty feeling Eye-openers (Ball et al., 2018). Other screening tools include the TACE model and CRAFFT questionnaire (Ball et al., 2018). Discovering a problem early may lead to better treatment outcomes for the patient (Ball et al., 2018).

References

Ball, Jane W., Dains, Joyce E., Flynn, John A., Solomon, Barry S., Stewart, Rosalyn W., & Stewart, Rosalyn W. (2018). Seidel’s guide to physical examination: An interprofessional approach (mosby’s guide to physical examination) (9th ed.). Mosby.

Cultural competence in health and human services | npin. (2020, October 21). Centers for Disease Control and Prevention. https://npin.cdc.gov/pages/cultural-competence

Smoking and heart disease and stroke. (2021, March 2). Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/diseases/heart-disease-stroke.html

Wannasirikul, P., Termisirikulchai, L., Sujirarat, D., Benjakul, S., & Tanasugarn, C. (2016). Healthcare literacy, medication adherence, and blood pressure level among hypertensive older adults treated at primary health care centers. Southeast Asian Journal of Tropical Medicine and Public Health47(1), 109–120.

 

Second Student Response to Case Scenario AG, 54 yr old Caucasian male:

In today’s world, it is important for physicians and nurse practitioners to be culturally competent. Being culturally competent requires providers to be sensitive to patient’s heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background (Ball et al., 2018). As a nurse practitioner, it should be your goal to reduce health disparities and provide equal care no matter the patient’s cultural background. During an assessment, the nurse practitioner should be aware of any healthcare diversity, and adapt how they do their assessment-based recommendations to accommodate diversity. It is important to acknowledge your unconscious biases as a provider and seek to try and understand the patient’s unique cultural and personal health beliefs and what the patient’s health expectations are (Ball et al., 2018). To conduct the right assessment as an NP you need to be culturally aware, understand the exceptional case of the patient’s condition, provide individualized care, and understand there may be cultural diversity that affects his care.

Research has shown that socioeconomic status is affected by individual’s health outcomes and health care they receive (Arpey et al., 2017). Socioeconomic status involves educational literacy and financial security.  Lower life expectancy and more chronic conditions are associated with lower socioeconomic status (SES) (Arpey et al., 2017).  Healthcare, environmental exposure, and health behavior can be affected based on someone’s socioeconomic status that can lead to many chronic health issues including hypertension, cardiovascular disease, diabetes, cancer, and low birth weight. For the patient in our case study, his socioeconomic status includes poverty, hypertension, alcoholism, drug abuse, and homelessness.  Due to poverty and our patient’s low socioeconomic status, our patient is at higher risk to develop alcohol-related mortality (Collins, 2016). Poverty leading to homelessness adds physiological stressors along with increasing the risk of not being able to get the proper medical attention due to the possibility of lack of financial support. Unable to afford medications and get proper treatment for drug and alcohol use is one of the major effects of poverty. This could be why the patient is out of his medication. He might also not understand the importance of being compliant with medications. An important part of the NP’s assessment should be health literacy. Does he understand that smoking and alcohol can increase his blood pressure? The NP should assess for any barriers to learning. They should bring awareness to resources available to help get with funding his medications along with drug and alcohol rehabs. Thru patient teaching and education on hypertension, drug and alcohol abuse, and effects of medication noncompliance can help educate the patient to make further health care decisions.

Sensitivity issues

As the nurse practitioner, being able to conduct a good assessment on the patient in our scenario, you would need to be culturally sensitive. Being aware that cultural differences and similarities between people exist without rating them as positive or negative, and right or wrong is what it means to be culturally sensitive (Ball et al., 2018). You also need to consider the patient’s religion. Does he have any religious boundaries that may affect his care? Our patient is affected because of his poor lifestyle choices, as the nurse practitioner, you need to set your beliefs aside, and remain unbiased, avoid judging the patient for his choices or make assumptions. It is easy to judge people, but as a provider, you need to be someone the patient can trust and is not going to be looked down upon for his lifestyle. It is important to use active listening skills, to hear that patient, and focus on an individualized plan of care. By gaining trust the patient will open up to you about his health concerns and you will be able to provide the resources and the education he may need.

Five Questions

When did you last see the doctor? Do you see them regularly for your prescription medication?

Do you have a ride to and from your appointments?

What are your family dynamics like?

Has anyone ever been concerned about how much you drink?

Do you have any thoughts of feeling down or hopeless? Any thoughts of harming yourself?

References

Collins S. E. (2016). Associations Between Socioeconomic Factors and Alcohol Outcomes. Alcohol research: current reviews, 38(1), 83–94.

Arpey, N. C., Gaglioti, A. H., & Rosenbaum, M. E. (2017). How Socioeconomic Status Affects Patient Perceptions of Health Care: A Qualitative Study. Journal of Primary Care & Community Health, 8(3), 169–175. https://doi.org/10.1177/2150131917697439

Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2018). Seidel’s Guide to Physical Examination. Mosby.

 

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