NR 601 Week 7
What is culture? - answer culture refers to an ever-changing set of shared symbols,
beliefs, and customs that shapes individual and/or group behavior.
What is cultural competency? - answera set of congruent behaviors, attitudes, and
policies that come together in a system, organization, or among professionals that
enables effective work in cross-cultural situations.
One major critique of cultural competency is - answerlow likelihood that sufficient
cultural understanding can be obtained. Given that culture is an everchanging process,
categoric approaches to cultural competence training can potentially result in
unintended stereotyping and bias.
Wanda is a nurse practitioner in a community nursing home (NH) in Cleveland, Ohio,
where she has worked as the "house provider" for the past 3 years. She is 59 years old,
Caucasian, and has worked in a variety of care settings and practices over the past 20
years. Christopher is an LPN who works at the same facility. He is a 37-year-old Black
man and is thinking about going back to school to get his Bachelor of Science in
Nursing. The clients they serve at this NH are primarily low-income (Medicaid) and
people of different races. The mandatory, annual workshop on Cultural Competency
Training was held last week. Wanda dutifully attends the workshop and endorses the
importance of learning about all types of people and different backgrounds. She proudly
displays her workshop certificate on the bulletin board over her desk. Christopher is a
little more restless about the content and feels it is a bit oversimplified. - answerThe
following week, he does the admission intake for a new resident who is Afro-Caribbean
(Haitian) and realizes that he is having a hard time understanding the woman and her
family, both in language and "other ways." He is not sure why it makes him
uncomfortable and he is determined to spend more time with her and the family to ask
more questions and demonstrate his curiosity about her life in Haiti and how that
impacts her views on day-to-day living and approach to healthcare. This dialogue
expands on a daily basis, as Christopher does not allow his lack of familiarity with
Haitian culture to be a barrier to a caring relationship.
1. What are the differences between cultural competence and cultural humility?
2. How did the reactions to the workshop differ between Wanda and Christopher?
3. How should professional development "messages" be formatted to allow for greater
success when translated to the bedside?
Cultural humility in patient care - answerEstablishing a Therapeutic Relationship
Allows Providers to Comfortably Adhere to Person-Centered Care
Ensures That Flexibility in Care Is Maintained
Healthcare Provider Shortages (or Malalignment)
Promote Diversity and Inclusion in Training and Hiring
,Person-centered care" involves considering a person's desires, family situations, social
circumstances, and values. To achieve this level of awareness, clinicians must seek
and maintain a level of cultural awareness and sensitivity. - answerThe dominant US
cultural definition of personhood in terms of independence and achievement leads to
excess disability and suffering among people with conditions like dementia.
Dementia and personhood - answerWhen personhood is defined as the ability to relate
to others appropriately, dementia is less of a threat to the patient's personhood.
Interactions With Coworkers - answerPromotes Collective Growth of Healthcare Team
(Avoids Dominance of Certain Cultural Identities)
Nettie Mae is 78 years old and widowed. She is Black and raised her family on a farm in
Virginia and now lives with her grandson and his wife and their three small children. Her
own children live nearby and join for meals on a weekly basis. The family knows that
she is forgetful, and they do not like to leave her at home. She started a small fire in the
kitchen last year, and her family no longer lets her cook. In a joking but firm way, they
took her car keys away and did not allow her to drive. - answerOver the next 3 years,
she became increasingly dependent on family for self-care and was less able to have a
conversation. However, she remained a vital part of the family and was assisted to
church and all family outings. The stories of days gone by that she had told for decades
are now told on her behalf by family members. Her daughter reports a back strain
associated with providing the heavy care that is now required by Ms. Nettie Mae. You
raise the consideration of assisted living or nursing home. The family politely and
repeatedly declines the need for any such assistance.
1. If you had a parent or grandparent who needed assistance at the level of Ms. Nettie
Mae, what criteria would you use to determine whether you could maintain her in your
home? To what extent do you believe that these criteria differ across different cultures?
2. How does the definition of "personhood" impact how the family responds to her
change in care needs and family integration?
Many cultures rely on a family-centered approach (collectivism) as a principle for major
decision making, which opposes the autonomic/individual approaches of Western
medicine. - answerIn collective decision making, family members often receive
information about the diagnosis and prognosis of the patient, and make treatment
choices without consulting the patient. To manage these situations, the clinician should
consult with the patient regarding how he or she would like to make treatment decisions
and determine the extent to which the patient/family members would like to be involved
in the treatment decision. This requires a skillful and artful approach.
Further, cultures that have experienced historical disenfranchisement or discrimination
from the healthcare system may be reluctant to trust clinicians. - answerThis distrust
may be enhanced if the clinician is of a different race and/or ethnic background. To
address this potential concern, the clinician can encourage the patient or family member
, to inform them if they have quality-of-care concerns and reinforce to the patient/family
that decision-making processes will be a collective effort. Developing rapport with
patients and their family members to let them know that you are interested in their
cultural heritage will help facilitate more open communication when discussing end-of-
life treatments.
Rosario is a 79-year-old Mexican-American woman with multiple medical problems,
including severe ischemic cardiomyopathy, diabetic neuropathy, peripheral vascular
disease, and moderate Alzheimer-type dementia. She had a below-the-knee-
amputation 4 years ago. Her renal function is declining and has recently approached the
level of considering dialysis. A few days after Thanksgiving, she is hospitalized for an
exacerbation of heart failure (likely because of dietary indiscretion). She becomes
delirious in the hospital, which is distressing to the patient and family. The inpatient
team arranges a family meeting to discuss treatment preferences and is surprised that
the family is still wanting to be "full code." - answerThe conversation revolves around
their mom still being a person, someone they love, and cannot abandon. Because you
are her primary care geriatrics clinician, you arrange a follow-up meeting with the family.
Several of your office team also attend. It is clear from that meeting that this is not a
matter of misunderstanding the prognosis. Instead, it is a matter of living all life that is
left to live and the obligation to provide all care that is possible, regardless of the
likelihood of success.
1. Describe the sense of "personhood" that is attached to Rosario by her family.
2. How is this impacting their reaction to her health changes and perceived needs for
proper care?
3. In future care of other patients with dementia or poor overall prognosis, how should
the office staff respond to care decisions that do not make sense to them?
Advice for Primary Care Clinicians - answerPrioritize diversity and cultural awareness.
Given the many benefits to patient care, as well as other positive effects in the
workplace, it is highly recommended that clinicians develop cultural awareness and
humility. Evidence supports that these efforts positively impact patient, family, and staff
communication and care relationship.
Educate yourself on cultural issues and diversity on the local, national, international
level as it pertains to healthcare in your community (especially among older adults and
end-of-life issues). Clinicians should recognize how cultural awareness will impact the
care they provide and should therefore seek to educate themselves through various
methods, including mainstream media. The American Geriatrics Society has published
a very helpful handbook, entitled Doorway Thoughts (reflections at the doorway before
engaging the patient). This book offers many good examples about how different
cultural subgroups have subtle variability along the lines of different racial/ethnic groups.
1. Which of the following is true about cultural humility?
a. It is typically accomplished through professional development courses.
b. It can only be achieved by underrepresented minority groups.
c. It places emphasis on power imbalances and promotes interpersonal sensitivity
through partnerships with and learning from patients.
What is culture? - answer culture refers to an ever-changing set of shared symbols,
beliefs, and customs that shapes individual and/or group behavior.
What is cultural competency? - answera set of congruent behaviors, attitudes, and
policies that come together in a system, organization, or among professionals that
enables effective work in cross-cultural situations.
One major critique of cultural competency is - answerlow likelihood that sufficient
cultural understanding can be obtained. Given that culture is an everchanging process,
categoric approaches to cultural competence training can potentially result in
unintended stereotyping and bias.
Wanda is a nurse practitioner in a community nursing home (NH) in Cleveland, Ohio,
where she has worked as the "house provider" for the past 3 years. She is 59 years old,
Caucasian, and has worked in a variety of care settings and practices over the past 20
years. Christopher is an LPN who works at the same facility. He is a 37-year-old Black
man and is thinking about going back to school to get his Bachelor of Science in
Nursing. The clients they serve at this NH are primarily low-income (Medicaid) and
people of different races. The mandatory, annual workshop on Cultural Competency
Training was held last week. Wanda dutifully attends the workshop and endorses the
importance of learning about all types of people and different backgrounds. She proudly
displays her workshop certificate on the bulletin board over her desk. Christopher is a
little more restless about the content and feels it is a bit oversimplified. - answerThe
following week, he does the admission intake for a new resident who is Afro-Caribbean
(Haitian) and realizes that he is having a hard time understanding the woman and her
family, both in language and "other ways." He is not sure why it makes him
uncomfortable and he is determined to spend more time with her and the family to ask
more questions and demonstrate his curiosity about her life in Haiti and how that
impacts her views on day-to-day living and approach to healthcare. This dialogue
expands on a daily basis, as Christopher does not allow his lack of familiarity with
Haitian culture to be a barrier to a caring relationship.
1. What are the differences between cultural competence and cultural humility?
2. How did the reactions to the workshop differ between Wanda and Christopher?
3. How should professional development "messages" be formatted to allow for greater
success when translated to the bedside?
Cultural humility in patient care - answerEstablishing a Therapeutic Relationship
Allows Providers to Comfortably Adhere to Person-Centered Care
Ensures That Flexibility in Care Is Maintained
Healthcare Provider Shortages (or Malalignment)
Promote Diversity and Inclusion in Training and Hiring
,Person-centered care" involves considering a person's desires, family situations, social
circumstances, and values. To achieve this level of awareness, clinicians must seek
and maintain a level of cultural awareness and sensitivity. - answerThe dominant US
cultural definition of personhood in terms of independence and achievement leads to
excess disability and suffering among people with conditions like dementia.
Dementia and personhood - answerWhen personhood is defined as the ability to relate
to others appropriately, dementia is less of a threat to the patient's personhood.
Interactions With Coworkers - answerPromotes Collective Growth of Healthcare Team
(Avoids Dominance of Certain Cultural Identities)
Nettie Mae is 78 years old and widowed. She is Black and raised her family on a farm in
Virginia and now lives with her grandson and his wife and their three small children. Her
own children live nearby and join for meals on a weekly basis. The family knows that
she is forgetful, and they do not like to leave her at home. She started a small fire in the
kitchen last year, and her family no longer lets her cook. In a joking but firm way, they
took her car keys away and did not allow her to drive. - answerOver the next 3 years,
she became increasingly dependent on family for self-care and was less able to have a
conversation. However, she remained a vital part of the family and was assisted to
church and all family outings. The stories of days gone by that she had told for decades
are now told on her behalf by family members. Her daughter reports a back strain
associated with providing the heavy care that is now required by Ms. Nettie Mae. You
raise the consideration of assisted living or nursing home. The family politely and
repeatedly declines the need for any such assistance.
1. If you had a parent or grandparent who needed assistance at the level of Ms. Nettie
Mae, what criteria would you use to determine whether you could maintain her in your
home? To what extent do you believe that these criteria differ across different cultures?
2. How does the definition of "personhood" impact how the family responds to her
change in care needs and family integration?
Many cultures rely on a family-centered approach (collectivism) as a principle for major
decision making, which opposes the autonomic/individual approaches of Western
medicine. - answerIn collective decision making, family members often receive
information about the diagnosis and prognosis of the patient, and make treatment
choices without consulting the patient. To manage these situations, the clinician should
consult with the patient regarding how he or she would like to make treatment decisions
and determine the extent to which the patient/family members would like to be involved
in the treatment decision. This requires a skillful and artful approach.
Further, cultures that have experienced historical disenfranchisement or discrimination
from the healthcare system may be reluctant to trust clinicians. - answerThis distrust
may be enhanced if the clinician is of a different race and/or ethnic background. To
address this potential concern, the clinician can encourage the patient or family member
, to inform them if they have quality-of-care concerns and reinforce to the patient/family
that decision-making processes will be a collective effort. Developing rapport with
patients and their family members to let them know that you are interested in their
cultural heritage will help facilitate more open communication when discussing end-of-
life treatments.
Rosario is a 79-year-old Mexican-American woman with multiple medical problems,
including severe ischemic cardiomyopathy, diabetic neuropathy, peripheral vascular
disease, and moderate Alzheimer-type dementia. She had a below-the-knee-
amputation 4 years ago. Her renal function is declining and has recently approached the
level of considering dialysis. A few days after Thanksgiving, she is hospitalized for an
exacerbation of heart failure (likely because of dietary indiscretion). She becomes
delirious in the hospital, which is distressing to the patient and family. The inpatient
team arranges a family meeting to discuss treatment preferences and is surprised that
the family is still wanting to be "full code." - answerThe conversation revolves around
their mom still being a person, someone they love, and cannot abandon. Because you
are her primary care geriatrics clinician, you arrange a follow-up meeting with the family.
Several of your office team also attend. It is clear from that meeting that this is not a
matter of misunderstanding the prognosis. Instead, it is a matter of living all life that is
left to live and the obligation to provide all care that is possible, regardless of the
likelihood of success.
1. Describe the sense of "personhood" that is attached to Rosario by her family.
2. How is this impacting their reaction to her health changes and perceived needs for
proper care?
3. In future care of other patients with dementia or poor overall prognosis, how should
the office staff respond to care decisions that do not make sense to them?
Advice for Primary Care Clinicians - answerPrioritize diversity and cultural awareness.
Given the many benefits to patient care, as well as other positive effects in the
workplace, it is highly recommended that clinicians develop cultural awareness and
humility. Evidence supports that these efforts positively impact patient, family, and staff
communication and care relationship.
Educate yourself on cultural issues and diversity on the local, national, international
level as it pertains to healthcare in your community (especially among older adults and
end-of-life issues). Clinicians should recognize how cultural awareness will impact the
care they provide and should therefore seek to educate themselves through various
methods, including mainstream media. The American Geriatrics Society has published
a very helpful handbook, entitled Doorway Thoughts (reflections at the doorway before
engaging the patient). This book offers many good examples about how different
cultural subgroups have subtle variability along the lines of different racial/ethnic groups.
1. Which of the following is true about cultural humility?
a. It is typically accomplished through professional development courses.
b. It can only be achieved by underrepresented minority groups.
c. It places emphasis on power imbalances and promotes interpersonal sensitivity
through partnerships with and learning from patients.
