Australia is home to one of the most culturally diverse populations in the world, and the population continues to grow (National Health and Medical Research Council, 2006). This expanding diversity creates a potpourri of cultural attitudes, beliefs and values unlike the dominant Westernised view. The cultural differences impact on how people understand and experience end-of-life in the country. Customary practices of caring for the terminally ill that permeates in most African communities differ vastly from that of Australian’s individualistic culture (Hiruy & Mwanri, 2013). African culture is of a collectivistic nature whereby autonomy is devalued and the communities or families are expected to care for the sick. As with most ethnic minority groups, this culture can become altered or suppressed when subjected to the influences of another overriding culture (Kirmayer, 2012).
For these reasons, the aim of the paper is to facilitate an understanding of the process to achieve culturally competent care. This paper begins with a description of an interaction between a student nurse who held a western set of values and a patient of African origin. The paper then discusses the cultural biasness against the minority group as well as the power relationships involved resulting in the suppression of the African end of life practices. A reflective discussion regarding the best approach to deliver culturally competent care during the interaction will also be presented.
Talib (pseudonym) was an African man in his 80s who was transferred to the palliative care ward following an episode of cardiac arrest. When the student nurse first encountered Talib and his family, they appeared to be reserved and kept to themselves most of the time. Talib’s family took on the task of nursing Talib and refused to leave him alone even during the night shift. Talib’s family members also regularly communicated on behalf of Talib even though the patient was fluent in English. Accordingly, the student nurse’s provision of nursing care was limited. The first day of Talib’s stay on the ward also saw the arrival of over 80 visitors. In African culture, members of the community are expected to visit and pay their respects to someone nearing the end of life (Hiruy & Mwanri, 2013). This practice is especially significant in Talib’s case as he was a well-respected leader of his community.
Though the intentions of these visitors were directed by their culture, the norms of the ward did not permit such practices. Initially, the ward tried to accommodate the sudden influx of visitors. Other nurses were involved with the additional task of crowd-controlling and reminding the visitors to be considerate of other patients. As the visitors became more disruptive and unmanageable, hospital security was called in to escort them out. Moreover, the sheer number of visitors arriving to pay their respects was exhausting Talib who appeared to be fatiguing and sleeping throughout these visits. The student nurse and her preceptor discussed with the family regarding the regulation of visitors. This created conflicts within the family as Talib’s daughter felt her father needed some respite from the visitors. However, Talib’s sister wanted him to receive a send-off that was worthy of his status. The situation was contained when the student nurse and her preceptor raised the issue with the medical practitioners who imposed a restriction on the number of visitors allowed.
Cultural biasness and its impact
Each person is a bearer of his or her own culture, values and attitudes and hence is subjected to ethnocentric tendencies and cultural imposition (Wells, 2000). In an interview of over 90 English nurses, ethnocentric practices and cultural biasness against ethnic minority group were still reported in current nursing practices (Vydelingum, 2006). Self-assessment can pave the way to caring effectively for a patient or family from another culture as healthcare providers develop culturally sensitivity to differences (Calvillo et al., 2009). Nurses who cultivate a habit of reflecting on their own cultural values, attitudes, beliefs and practices will be more aware of the influence of their own culture on work practices (Culley, 2006). When nursing the culturally different, nurses need to perceive and understand the significance of those differences and how that can be responded to within the nursing practice.
Within the Australian context, there is a focus on the empowerment of patients (Williamson & Harrison, 2010). While involving patients with healthcare discussions is a step towards attaining empowerment, this may not be the case in a collectivistic culture. Many cultures do not share the principal value of individualism (Davis, 1999). In collectivist cultures, individuals do not concern themselves with healthcare decisions, instead family members or community are often the designated arbiters (Kanitsaki, 2003). As Talib’s cultural practice dictates that the responsibility of his care belongs to his family, the student found it difficult to engage with the patient and his family and establish a therapeutic relationship with them. The student was also frustrated at the lack of opportunities to communicate directly with Talib. She felt that she was not able to identify his healthcare needs and thus, not able to deliver any nursing care.
In addition, the student nurse also received a culture shock with regards to the response of the community. The number of people who poured in to visit Talib was beyond her comprehension. Due to the lack of exposure to such encounters, the student was uncertain with regards to handling the situation. She was more familiar with her Western ways of grieving and took that as a benchmark for normalcy. This belief is fortified by other patients and their family on the ward who were mainly of Australian descent. When a person’s customs are threatened by other unfamiliar cultural practices, he or she can become defensive and dwell on their own ethnocentric values (Ruddock & Turner, 2007). Undeniably, the student nurse was affected by the incongruence in culture. She was initially puzzled but reported feeling annoyance as she saw visitors’ actions as disturbances rather than cultural practices.
Given the hierarchical nature of the health care setting, asymmetrical power is present throughout any level of relationships including organisational and individual (Ramsden, 2002). The professional culture as set out by the hospital privileges ritualised routine care, leaving little room for nurses to work in a culturally safe manner (Richardson & MacGibbon, 2010). The power imbalance further pervades at the individual level as nurses have an inherent role power over patients (Kuokkanen & Leino-Kilpi, 2000). This power often underpinned the nurses’ professional practices and interactions. In order for patients to receive effective healthcare, nurses have the responsibility to analyse and understand these power relationships. Power imbalances should be managed to avoid isolating patients and promote equitable nursing care. Even so, nurses will still make the conscious decision to exercise their power as a form of domination which occurred in Talib’s situation (Gallant, Beaulieu, & Carnevale, 2002).
Power relationships in the above case study involved both the institution and the nurses which interplayed with each other. The most obvious agent of control was the institution. In the name of patient safety and enforcement of order in the ward, hospitals will put in force policies and guidelines which are carried out by the employees. This inadvertently or advertently dictates the actions of nurses and impacts on their decision-making and nursing care (Kuokkanen & Leino-Kilpi, 2000). The cultural need of Talib and his community, however, presented a major challenge to upholding order and control within the ward. Consequently, the cultural practice was overruled in favour of preserving the ward environment. The nurses in the case study were authorised to regulate the behaviours of patients and their visitors. Talib and his community were subjected to the nurses’ power to enforce hospital guidelines and polices when the visitors were forced out of the ward by hospital security.
The decision to call in security was solely that of the nurses without any prior notice to Talib and his community. The author and her preceptor also brought up the idea of imposing restrictions on the influx of visitors to the medical practitioners. While the doctor’s order to restrict the number of visitors was made in consultation with Talib’s daughter, it was hardly the consensus of other family members. The agreement to the visitor restriction may be an attempt to avoid another confrontation with security by assimilating into the hospital culture while compromising on their cultural practice. In this manner, the African community was disempowered by both healthcare providers and institutions.
Culturally safe care has its basis in cultural awareness and cultural sensitivity (Phiri, Dietsch, & Bonner, 2010). The ability to be culturally sensitive is developed from openness towards cultural diversity and respect for these differences (Campinha-Bacote, 2003). Appreciating the underlying forces that drive certain cultural practices can also contribute to developing cultural sensitivity (Ramsden, 2002). Thus, for nurses to acquire the knowledge, skills and attitudes that are pertinent to the delivery of culturally safe care that is congruent with the patient’s needs, they have to recognise the patient’s cultural system and norms. Nurses will need to be aware of their own prejudices to circumvent stereotyping and categorising which can affect their approach towards the acceptance of culturally different end-of-life practices (Chenowethm, Jeon, Goff, & Burke, 2006).
The understanding of a culture should not be confined to rituals, customs and practices of a group alone. Learning about a single aspect of one culture does not provide insight into the complexity of people’s behaviours their cultural realities (Duffy, 2001). In reality, culture is complicated and difficult to define. In order to maintain cultural safety and accommodate for cultural differences without disregarding diversity and individual considerations, nurses have to move away from a checklist approach to provision of care (Peiris, Brown, & Cass, 2008). Individual variations exist within each ethnic group. Talib’s daughter decided to put the health of her father above that of her cultural practices and against the wishes of other family members. Therefore, nurses have to tailor their care accordingly while respecting the overall cultural-defined norms and allowing for those individual differences.
Provision of culturally competent care
Culturally competent care is supported by both communication and recognition of diversity within and between groups of culture (Nursing Council of New Zealand, 2011). In line with this concept, Andrews and Boyle proposed that nurses need to possess certain skills in order to deliver culturally competent care (Andrews & Boyle, 2008). Cultural self-assessment and addressing communication needs are two of the skills that are applicable to this case study. When caring for culturally diverse patients, nurses have a higher tendency to display inadequacy in their communication (Donnelly, 2000). Misconceptions regarding these patients can arise, leading to a lack of respect for those with cultural values different from one’s own. This was manifested by the student nurse who was in effect demonstrating ethnocentrism. She made a fallible judgment of viewing Talib’s cultural practices from the dominant cultural lens.
By believing that the only way to identify Talib’s healthcare needs was through the patient without considering his family and community was characteristic of an individualistic view. In addition, the student nurse’s ethnocentric view of Western bereavement culture as proper and rational, while the African culture was disruptive was indicative of a racist undertone. It was important to acknowledge the patient’s ownership and control over their cultural knowledge, customs and beliefs and recognise these as the reality (Karnilowicz, 2011). The student nurse should have communicated with Talib’s family members with regards to their needs as they are the main decision makers in Talib’s health care. In addition, the nurses took matters into their own hands by deciding to impose visitor restrictions and kicking the visitors out. A more culturally sensitive method is to discuss with Talib’s family as they may be able to negotiate and control their visitors in a way that is less degrading than expelling them from the ward.
Culture has a pronounced influence on how patients, their families and healthcare providers view end-of-life experiences. Understanding the cultural differences could enhance the cultural competence and culturally safe practices of nurses. This article has attempted to illuminate some of the cultural differences displayed by Africans living in Australia and how these may lead to diverged end of life needs in these communities. These differences have implications for how appropriate palliative care can be provided to them. Before attempting to accommodate to those differences, it is imperative that nurses possess cultural awareness through recognising their own cultural realities and prejudices.
Understanding the power relations played out in the hospital setting is a step towards enhancing the implementation of culturally safe care. Apart from the inherent dominance nurses have over patients, institutions also have bearing over how nurses exert these powers leading to suppression of certain cultural practices. It is necessary for systems and individuals to learn about the customary beliefs of the patient and avoid generalising patients who belong to the same culture as individual differences exist. By acknowledging the various cultures and their norms, it is anticipated that the provision of culturally
competent end-of-life care to these ethnic minority groups can be attained.
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