Cultural Competence in Healthcare, Exams of Nursing

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TRANSCULTURAL

HEALTH CARE

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Library of Congress Cataloging-in-Publication Data

Transcultural health care : a culturally competent approach / [edited by] Larry D. Purnell. — 4th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8036-3705- I. Purnell, Larry D. [DNLM: 1. Cultural Competency—United States. 2. Delivery of Health Care—United States. 3. Cultural Diversity—United States.

4. Ethnic Groups—United States. W 84 AA1]

362.1089—dc 2012016099

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v

Foreword

Knowing is not enough, we must apply. Willing is not enough, we must do. Goethe

Goethe’s quote is considered a call to action by organ- izations as prestigious as the Institute of Medicine, and it remains one of my favorite quotes today. It has such incredible implications for health care, particu- larly as we struggle with the extended time it takes to translate research into practice. In fact, oftentimes, de- spite strong evidence, we are slow in enacting the changes we need to improve the health care and nurs- ing we deliver. In some cases we are waiting for the “indisputable” evidence, and in other cases we are sim- ply being resistant to change. But occasionally the need for change is thrust upon us, momentum builds, and the realization emerges that there isn’t a need to prove the obvious before acting but a need to act as the obvious is all around us. This has become the case with cultural competence in health care. My knowing about the importance of cultural com- petence developed as I grew up in my bilingual, bicul- tural Puerto Rican family, where perspectives about health and health care were incredibly varied, and at times at odds with Western medicine. My knowing grew, as I trained to be a health-care professional in underserved and diverse settings such as Newark, New Jersey, and New York City, where we saw pa- tients from all cultures, classes, and racial/ethnic back- grounds. What became crystal clear to me was that while we were learning the best medications to treat hypertension or the most advanced algorithms for di- agnosing and treating disease, if we couldn’t commu- nicate effectively with our patients or get them to buy into, agree with, and cooperate with what we were try- ing to accomplish, then all that medical knowledge was worth nothing. Whether a doctor, a nurse, or other health professional, caring for patients required an understanding of the sociocultural factors that might impact their health beliefs and behaviors, rang- ing from how they presented their symptoms, to how they viewed disease and illness, to what informed their health care, diagnostic, and treatment choices. Cases where we couldn’t bring our knowledge to bear to ease suffering or cure disease because of “cultural differ- ences” with patients were the ones that kept us up at night and were the most frustrating and disappointing

of all. Along the way I also learned to appreciate that we all have culture and that the tools and skills I needed to learn to communicate clearly with patients wouldn’t just be helpful in the care of those who were culturally different from me, but to any patient with whom I interacted. For at the end of the day, there were always three cultures in the room—my culture; the patient’s culture; and the cultures of medicine, nursing, and other health professions—making every encounter cross-cultural in one way or another. Despite these almost daily epiphanies during my training, there were few resources available that might provide me with guidance on how to become an effec- tive communicator and caregiver in this new world I was entering. Fortunately, this has changed. New models have been developed, leaders have emerged, and health-care professionals no longer need to go blindly into cross-cultural encounters without guid- ance, as there are real and practical approaches that facilitate improved understanding, communication, and care. Knowing is not enough, we must apply. Transcultural Health Care: A Culturally Compe- tent Approach builds on a framework for cultural competence—which is essential in the care of the individual—by bringing together health-care providers of various backgrounds and disciplines to share their knowledge, expertise, and experiences in the field with particulars about different populations. This information is presented to provide details about the social and cultural fabric of different cultural groups, with the important caveat that it is not to be used to stereotype patients within these groups, as each pa- tient is an individual and diversity can be as extensive within groups as it is among groups. It is from this principle—that learning background information about cultural groups can help health-care providers both develop a “radar” for potential pitfalls when caring for them and serve as a springboard for in- quiry with the individual patient—that Transcultural Health Care emerges. Why is this book, and this edition, so timely? In the past, arguments about the importance of cultural competence were based primarily on making the case that our nation was becoming increasingly diverse and that as health-care professionals we need to be pre- pared to care for patients of different sociocultural backgrounds. This is an important argument, no

vii

Preface

The Purnell Model for Cultural Competence and its accompanying organizing framework continue to be used in education, clinical practice, administration, and research. The Model and selected chapters have been translated into Arabic, Flemish, French, Korean, Portuguese, Spanish, Turkish, and Korean, attesting to its value on a worldwide basis. In addition, many health-care organizations have adapted the organizing framework as a cultural assessment tool, and numer- ous students in the United States and overseas have used the Model to guide research for theses and dissertations. The Model is increasingly being used as a guide to help ensure organizational cultural competence. This fourth edition of Transcultural Health Care: A Culturally Competent Approach has been revised based upon responses from students, faculty, and practicing health-care professionals such as nurses, physicians, emergency medical technicians, nutrition- ists, and people in noetic sciences. In addition, this edi- tion is divided into two units. Unit 1, Foundations for Cultural Competence: Individual and Organizational, has the following features:

• An expanded chapter on the overview of transcul- tural diversity and health care
• A separate chapter on the Purnell Model for Cultural Competence, with specific questions in the organizing framework instead of objectives
• A separate chapter on individual competence and evidence-based practice
• A separate chapter on organizational cultural competence
• A separate chapter on global health

Unit 2 is entitled Aggregate Data for Cultural- Specific Groups. As in previous editions, we have made a concerted effort to use nonstereotypical language when describing cultural attributes of specific cultures, recognizing that there are exceptions to every descrip- tion provided and that the differences within a cultural group are determined by variant cultural characteris- tics. One important change on the Model is that the pri- mary and secondary characteristics of culture are now

called “variant cultural characteristics” at the sugges- tion of gay, lesbian, and transgendered communities. The first time a cultural term is used in a chapter, it is in boldface type and is defined in the glossary. Because faculty and clinical practitioners have found the Appendix—Cultural, Ethnic, and Racial Diseases and Illnesses—valuable, it remains in the book. Abstracts are included in the main textbook for each culturally specific full chapter located on Davis Plus. Space and cost concerns limit the number of chapters that are included in the book; therefore, additional cul- tural groups are on Davis Plus. Also on Davis Plus are student resources such as review questions, Web sites of interest, case studies, and reflective exercises. Additional faculty resources on Davis Plus include PowerPoint slides with clicker check questions for each chapter and a question bank. Specific criteria were used for identifying the groups represented in the book and those included in elec- tronic format. Groups included in the book were selected based on any of the following six criteria:

• The group has a large population in North America, such as people of Appalachian, Mexican, German, and African American heritage.
• The group is relatively new in its migration status, such as people of Haitian, Somali, and Arab heritage.
• The group is widely dispersed throughout North America, such as people of Iranian, Korean, Hindu, and Filipino heritage.
• The group is of particular interest to readers, such as people from Amish heritage.
• The group is of particular interest to students and staff from other countries, such as European Americans. A particular strength of each chapter is that it has been written by individuals who are intimately famil- iar with the specific culture. Again, we have strived to portray each culture comprehensively, positively, and without stereotyping. We hope you enjoy the book.

Larry D. Purnell

Jayalakshmi Jambunathan, PhD, MSN, BSN, MA BSc Professor, CON UW Oshkosh Director, Research and Evaluation and Assistant Dean UW Oshkosh Oshkosh, Wisconsin

Galina Khatutsky, MS Research Analyst RTI International Waltham, Massachusetts

Sema Kuguoglu, PhD, BSN, RN Professor Emeritus, University of Mamara Funded Professor, University of Gazikent Istanbul and Gaziantep, Turkey

Anahid Kulwicki, PhD, RN, FAAN Professor and Associate Dean for Research Director of the PhD in Nursing Program Florida International University Miami, Florida

Ginette Lazure, PhD Professeure titulaire Université Laval Pavillon Ferdinand-Vandry Médecine, Québec

Stephen R. Marrone, EdD, RN-BC, CTN-A Deputy Nursing Director State University of New York SUNY Downstate Medical Center Brooklyn, New York

Susan Mattson, RNC-OB, CTN-OB, PhD, FAAN Professor Emerita Arizona State University College of Nursing and Health Innovation Scottsdale, Arizona

Afaf Ibrahim Meleis, PhD, DrPS (hon), FAAN Margaret Bond Simon Dean of Nursing University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Mahmoud Hanafi Meleis, PhD, PE Retired Nuclear Engineer Philadelphia, Pennsylvania

Cora Munoz, PhD, RN Professor Emerita/Adjunct Professor Capital University Columbus, Ohio

Irena Papadopoulos, PhD, MA (Ed), BA, RN, RM, NDN, FHEA Professor Middlesex University Highgate Hill, London, UK Ghislaine Paperwalla, BSN, RN Research Nurse in Immunology Veterans Administration Medical Center Miami, Florida Jeffrey R. Ross, MAT, MA, BFA ESL Teacher and Tutor Springfield School System and the University of Akron Akron, Ohio Ratchneewan Ross, PhD, MSc (Public Health), RN Associate Professor and Director of International Activities Kent State University Kent, Ohio Susan W. Salmond, EdD, RN, CNE, CTN Dean and Professor University of Medicine and Dentistry of New Jersey Newark, New Jersey Stephanie Myers Schim, PhD, RN, PHCNS-BC Associate Professor Wayne State University College of Nursing Detroit, Michigan Janice Selekman, DNSc, RN Professor Nursing University of Delaware Newark, DE Jessica A. Steckler, MS, RN-BC CEO The Firm of Jessica A. Steckler Erie, Pennsylvania Marshelle Thobaben, RN, PHN, MS, FNP, PMHNP Department Chair, Professor Humboldt State University Arcata, California Hsiu-Min Tsai, RN, PhD Dean of Academic Affairs and Associate Professor Chang Gung University of Science and Technology Tao-Yuan, Taiwan

x Contributors

Anna Frances Z. Wenger, PhD, RN, FAAN Professor and Director Emeritus of Nursing Goshen College Goshen, Indiana

Marion R. Wenger, PhD Professor of Linguistics and Foreign Languages Goshen College Goshen, Indiana

Cecilia A. Zamarripa, RN, CWON University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Rick Zoucha, APRN, BC, DNSc, CTN Associate Professor Duquesne University School of Nursing Pittsburgh, Pennsylvania

Contributors xi

xiii

Reviewers

Kristie Berkstresser, MSN, RN, CNE, BC Assistant Professor of Nursing HAAC—Central Pennsylvania’s Community College Lancaster, Pennsylvania

Judy Shockey Carter, MSN Ed, RN Assistant Professor Anderson University Anderson, Indiana

Sabrina L. Dickey, RN, BSN, MSN Assistant Faculty in Nursing Florida State University Tallahassee, Florida

David N. Ekstrom, PhD, RN Associate Professor Pace University, College of Health Professions Lienhard School of Nursing New York, New York

Mary L. Padden, RNC,APN-C, FN-CSA Assistant Professor, Nursing Cumberland County College Vineland, New Jersey

Priscilla L. Sagar, EdD, RN, ACNS-BC, CTN Professor of Nursing Mount Saint Mary College Newburgh, New York Lisabeth M. Searing, PhD, MSN, RN Assistant Professor Illinois Wesleyan University, School of Nursing Bloomington, Illinois Gale Sewell, RN, MSN, CNE Assistant Professor Indiana Wesleyan University Marion, Indiana Jeanine Tweedie, MSN, RN, CNE Nursing Faculty Hawaii Pacific University Kaneohe, Hawaii Mai-Neng Lee Xiong, BSN Director of Nursing People Incorporated Mental Health Services St. Paul, Minnesota

• INDIVIDUAL AND ORGANIZATIONAL UNIT 1: FOUNDATIONS FOR CULTURAL COMPETENCE:
• Chapter 1 Transcultural Diversity and Health Care
• Chapter 2 The Purnell Model for Cultural Competence
  • (with inclusion of the International Standards) Chapter 3 Individual Competence and Evidence-Based Practice
• Chapter 4 Organizational Cultural Competence
• Chapter 5 Perspectives on Nursing in a Global Context
• UNIT 2: AGGREGATE DATA FOR CULTURAL-SPECIFIC GROUPS
• Chapter 6 People of African American Heritage
• Chapter 7 The Amish
• Chapter 8 People of Appalachian Heritage
• Chapter 9 People of Arab Heritage
• Chapter 10 People of Chinese Heritage
• Chapter 11 People of Cuban Heritage
• Chapter 12 People of European American Heritage
• Chapter 13 People of Filipino Heritage
• Chapter 14 People of German Heritage
• Chapter 15 People of Haitian Heritage
• Chapter 16 People of Hindu Heritage
• Chapter 17 People of Hmong Heritage
• Chapter 18 People of Japanese Heritage
• Chapter 19 People of Jewish Heritage
• Chapter 20 People of Korean Heritage
• Chapter 21 People of Mexican Heritage
• Chapter 22 People of Polish Heritage
• Chapter 23 People of Puerto Rican Heritage
• Chapter 24 People of Russian Heritage
• Appendix Cultural, Ethnic, and Racial Diseases and Illnesses
  • American Indians and Alaska Natives ABSTRACTS
  • People of Baltic Heritage: Estonians, Latvians, and Lithuanians
  • People of Brazilian Heritage
  • People of Egyptian Heritage
  • People of French Canadian Heritage
  • People of Greek Ancestry
  • People of Guatemalan Heritage
  • People of Iranian Heritage
  • People of Irish Heritage
  • People of Italian Heritage
  • People of Somali Heritage
  • People of Thai Heritage
  • People of Turkish Heritage
  • People of Vietnamese Heritage
• GLOSSARY
• INDEX

xvii

Contents – Davis Plus

American Indians and Alaska Natives

People of Baltic Heritage: Estonians, Latvians, and Lithuanians

People of Brazilian Heritage

People of Egyptian Heritage

People of French Canadian Heritage

People of Greek Ancestry

People of Guatemalan Heritage

People of Iranian Heritage

People of Irish Heritage

People of Italian Heritage

People of Somali Heritage

People of Thai Heritage

People of Turkish Heritage

People of Vietnamese Heritage

xix

Introduction

The Purnell Model for Cultural Competence and its organizing framework continue to be used in educa- tion, clinical practice, administration, and research by nurses, physicians, and other health-care providers. The Model has been translated into Arabic, Flemish, French, German, Korean, Portuguese, Spanish, and Turkish. Health-care organizations have adapted the organizing framework as a cultural assessment tool and to guide research for theses and dissertations in the United States and overseas. The Model’s useful- ness has been established in the global arena, recog- nizing and including the client’s culture in assessments, health-care planning, interventions, and evaluations. The Model has proven useful with organizational cultural competence as well. Transcultural Health Care: A Culturally Competent Approach continues to be revised based upon feedback from students and clinical health-care providers, as well as educators from associate degree, baccalaureate, master’s, and doctoral programs. Their reviews and suggestions are appreciated. This edition has been divided into two units. Unit 1 contains five chapters. Chapter 1, Transcultural Diver- sity and Health Care, gives an overview of transcultural health and nursing care along with essential terminology related to culture. Chapter 2 is an extensive description the Purnell Model for Cultural Competence, along with recommended questions to ask and observations to make when doing a cultural assessment or formulating questions for qualitative research. Chapter 3, Individual Competence and Evidence-Based Practice, includes in- ternational standards on culturally competent care and an extensive section on searching literature for evidence- based cultural research. Chapter 4, Organizational Cul- tural Competence, provides a crosswalk with the Purnell Model and CLAS Standards. Chapter 5, Perspectives on Nursing in a Global Context, addresses health-care organizations that have a global context, the forces that shape global health and nursing, and international migration. Unit 2 consists of aggregate data on culturally spe- cific groups, 18 of which are covered in the book and an additional 14 on DavisPlus. We continue to make a concerted effort to use nonstereotypical language when describing cultural attributes of specific cultures,

recognizing that there are exceptions to every descrip- tion provided. Aggregate data are true for the group but not necessarily for the individual. Therefore, readers are encouraged to look at the variant cultural characteristics when viewing aggregate data on any population. An attempt has been made to include both the sociological and anthropological perspectives of culture. Given the world diversity and the diversity within cultural groups, it is impossible to cover each group more extensively. Space and cost concerns limit the number of chapters that are included in the book; therefore, additional cultural groups, PowerPoint slides, interactive exercises, test banks, useful Web sites, and additional case studies are included on Davis Plus. Specific criteria were used for identifying the groups represented in the book and those included in elec- tronic format. Groups included in the book were selected based on any of the following six criteria:

• The group has a large population in North America, such as people of African American, Appalachian, Chinese, German, Irish, and Mexican heritage.
• The group is relatively new in its migration status, such as people of Arab, Haitian, and Cuban heritage.
• The group is widely dispersed throughout North America, such as people of Filipino, Hindu, Iranian, and Korean heritage.
• The group has little written about it in the health- care literature, such as people of Guatemalan, Russian, Somali, and Thai heritage.
• The group holds significant disenfranchised status, such as American Indians.
• The group was of particular interest to readers in previous editions, such as people from Amish heritage. We have strived to portray each culture positively and without stereotyping. Individual chapter authors made every attempt to incorporate the latest research at the time of writing.

Larry D. Purnell