Nursing Implications for Six Cultural Phenomena, Case Study Example

1 Back ground

61 years old Hispanic female came to emergency room with complaints of chest pressure and shortness of breath. Along with her was her 38 year old son. She is from Puerto Rico. She has lived in United States for 39 years. She has a 38 year old son and large support system with 3 sisters and their family. She lives alone but all three sisters lives in same block. Her son is very affectionate and they speak in Spanish and English. She is having Diabetes and hypertension and is taking medicine for both. Maria found difficulty to catch breath and was having pain in her chest. She was brought to hospital and her son, her three sisters and their husbands along with many other relatives are there in the hospital. They are praying and talking and all family members are wearing a cross across their neck.

2 Assessment

Being a Hispanic lady of 61 years, it is necessary for the nurse to perform cultural and psychological assessment along with physical assessment. Identifying the culture of patient will help to promote healing as it will help to understand cultural strength of communities and family of patient. Interaction patterns will help to identify interconnection of group members (Dr. Marianne, 2010).

2.1 Communication

Nurse on entering the room can give a warm and friendly customary greeting in the form of a shake hand or a nod of the head. To start with and to identify and examine communication nurse can ask the name of the patient and her place of birth, length of time in United States etc (Gloria, 2012). Nurse can also ask about her race and cultural definition with a simple question like what is your race? Such casual questions will help to understand voice quality of patient, pronunciation and enunciation, use of silence and use of non verbal methods of communication. As Maria is from Puerto Rico she will prefer to be addressed by her first name and this fact is to be kept in while. Maria is quiet and often seeks help from her son to answer questions. She is little reserved and hence it is necessary to become friendlier with her. For this the best method is to keep direct eye contact.

It is necessary to note her pitch while talking as Puerto Ricans usually talk in louder voice. It is also necessary to note her use of silence, use of non verbal communication methods etc. Puerto Ricans use hand gestures and movements in their casual conversations (Fliszar, 2003). It is necessary to observe hand movement, eye movement, gestures, expressions and hand movement of Maria.

Latinos appreciate personal discussions and personal relation with service provider (Dahl, 2004). Nurse can also ask about her family, personal life and work before medical interview and this will keep the patient at ease. To give respect nurse can address the patient as Mrs. Maria. As Maria is very close to her son it is also good to talk to him while talking with Maria. Nurse can ask his name, profession, family etc in casual. This will also help to develop some intimacy with patient. Nurse can also visit the patient when she gets time and develop a personal relation with her. While visiting the patient a warm shake hand will increase intimacy. Follow up questions like how you feel now? Or is there anything I can do? Can be asked (Priscilla, 2011).

2.2 Space

It is to be noticed that Maria was comfortable with the conversation that was going on with her. Nurse can talk to her in English for she can speak and understand English. She has been in United States for 39 years. She was sitting with her son. He was holding her hands and was rubbing her back. Maria was feeling comfortable and was not moving even though space invaded. Distance in conversation is to be kept very less as Latinos prefer closeness, to remain as close as possible physically (Foster, 2004). If nurse keeps distance she might feel it as a sign of uninterested or detached. It is to be noticed that all family members are sitting closer to each other. Nurse can touch her hands during conversation and observe her reaction to it, whether she is accepting touch with difficulty or with out difficulty. Nurse can sit at a smaller distance of about 3 feet and ask whether she is comfortable wit the distance. She can be asked about her degree of comfort with closeness while talking. Whether she is comfortable with the objects or furniture in the room and make changes if possible. What is to be done is to make her feel comfortable and this will increase the intimacy. If a patient feels some intimacy towards those whoa re treating them, it will make treatment easier for there will be more positive response. Latinos are highly attuned to non verbal message and hence space is a very important factor while dealing with them. This is to be taken care of while dealing with a Latino patient (Gloria, 2012).

2.3 Social Orientation

It is necessary to assess her normal health (www.culturediversity.org, 2012) and in this case Maria’s health is fair. It is also necessary to understand her background and nurse can ask her about this in a casual way. Latinos prefer to peak personal and hence Maris herself will answer these questions (Fliszar, 2003). It will also develop some intimacy with person providing nursing service to her.

Maria is from an urban setting in Puerto Rico and has been living in United States for 39 years and her husband died 38 years back in an accident soon after she came to United States. She got only one son, married with two children and is living away from her. Her parents are living and they are in Puerto Rico. She is Spanish by origin and can speak both Spanish and English. Major support for her is her family members, three sisters and their family living in same block as hers. Nurse can ask her casual questions like who has come with her other than her son, or who called ambulance for her, whom did she inform when she felt the pain etc. all this will help to identify her relation with other family members.

Among Latinos it is the eldest member who takes decision (Agency., 2008). So it is necessary to know who the decision maker is and it is also important to respect preferences of family in clinical encounters. Maria takes most of her decisions on her own and her son also plays a very important role and has input in such decisions. Nurse can ask her about her educational level. Whether she was working, what are her hobbies, does she read books, etc. Maria doesn’t have high school education, training or college education. So it is important to know whether she will understand treatment procedures. She often looks towards her son for answering questions or to get approval from him before answering questions. So it will be better to ask whether treatment related matters are to be discussed with him. It can be seen that several family members have gathered in visiting room and it indicates that she is closely related to family members. So nurse can also ask whether, there is any one from medical profession and can describe treatment matters with him. This is because patients are likely to bring family members to appointments. So it is necessary to know to whom medical results are to be given and who is included in treatment plan.

It is also necessary to know the religion and belief of a person. Maria is a catholic and it can be seen that family members are wearing a cross around their necks and there are many rosaries. Some relatives of Maria are praying and some are talking. It is important to understand the belief of a patient for most Hispanics believe that health is a gift from god and it should not be taken for granted (Harwood, 2006). To prevent illness they offer prayers to god and illness prevention is an accepted practice. They usually keep relics at home and wear religious medals. Hispanics visit church usually and offer candles and medals. Most homes have shrines with picture of Saints and statues. Prayers are cited at home and candles are lit during prayers (Harwood, 2006). To know about religious beliefs nurse can ask about political view of Maria or how her political view influences her attitude towards illness. She can also be asked whether she believes in Supreme Being or how she is worshiping Supreme Being. All these will help in continuing treatment and hence plays a major role in initial assessment.

2.4 Time

Orientation of time also plays a major role in assessment. It is necessary to understand whether Maria is present, past or future oriented person (Barbara & AmericanHolisticNurses’Association, 1997). Maria is with present time orientation as she has not missed any appointments or has no issues with non compliance. Nurse can ask her about her daily wear time piece. This will help to know whether she is clock oriented or social oriented. Nurse can further ask her acceptable time of arrival if she is given an appointment at a certain time like 2pm.

Her physiochemical reaction to time is also to be noted. For this nurse can ask for her hours of sleep. Does she sleep for 8 hours at night, is that consistent and continues or does she wakes up in between. Does she understand the importance of timely medication and treatments? What measures she adopts for health like preventive measures. It can be seen that she never had a mammogram and she has not received flu this season (Giger & Davidhizar, 1995).

Hispanic Americans do not believe that a calendar is necessary to organize their occupations. They usually do not care about getting late for social occasions in comparison to non Hispanic Americans. But when there is an appointment or when they are to arrive for work, it is usual to see that they reach the place early and they do put some effort for that (wps.prenhall.com, 2012).  Further Hispanics are also not much concerned about an opportunity they missed. This is because they believe that another opportunity awaits them. They focus on big picture only while working on a project and they are not ashamed to reveal that they do not care about details. It can be seen that about half of American Hispanics are not bothered about planning. This means that they are not calendar oriented people. They believe that things never turn out the way they are supposed to. Most adult Hispanics especially of first generation and Spanish dominant are of this opinion and same is with Maria also (Berrios, 2003).

Nurses are concerned about this factor because it is necessary to know whether patients are likely to appear for appointments on time, take medicine on time and to know whether they are reluctant to take medicine. Follow up care is yet another concern. Hispanics have a present time orientation and they focus more on activity than clock time. Thus nurse will have to emphasize importance of clock time while taking medicine. It is also necessary to make sure that they attend every appointment as it is also critical. For this nurse can ask to meet the person who is likely to come with patient for appointments and make them understand the importance of clock time (Dahl, 2004). As family is the central focus in this culture it will be better to emphasize to them than the patient. Family members are to be informed of follow up care, future appointments and medicine timings.

2.5 Environmental control

It is necessary to understand values, health practices and the definition they give for illness and health. Most Hispanics believe that illness is the will of god and hence they will offer prayers to god for curing the same. Elders are the one to take decision and they are given prestigious status in family. This is because they are experienced. Family members always rely on elders for taking decision or to seek an advice. A person who is sick will always seek the advice of elders and will also turn to them for comfort and support. In usual cases elders usually recommend home remedies that are very simple (Katie, 2007).

Hispanic family is usually traditional in character and it is the head of the family to take decisions in every matter. Man is the head and it is for him to take all major decisions. Hispanics have a strong sense of paternalism. Women are also given equal role and are considered as the maternal powerhouse of a home. Women are considered sacred and revered and are hence in usual case protected. This is not because she is not capable to handle herself or that she is not having any voice in family, but Hispanics believe that it is in her well being that the solidarity of family unit depends (Perez y Gonzalez, 2000).

Maria is very old and hence it is important to know whether she believes in home remedies. There are folk medicines used by Hispanics and recent emigrants practice folk medicine largely. Such medicines are usually combination of herbs or eating of hot or cold food for restoring any body imbalance. It is necessary that Maria take her medicines as prescribed and visit hospital during her appointments. It is also necessary to make sure that follow up care of Maria is properly done.

Some Hispanics even believe in spiritual healing and go for espiritistas or curanderos for any disease they are having (Carlson & Harwood, 2003). Hence it is necessary to ask patients whether they are pursuing any other treatment options other than conventional medicine prescribed for them. Some might be of the opinion that any physical issue can be healed from with in and it is called as internal locus of control. Some might believe in external locus of control like luck or fate. They believe that a disease is the result of fate and to cure it completely is luck. Such people might or might not believe in any supernatural forces or magic or prayer or witch craft (Dahl, 2004).

To understand this it is necessary for the nurse to ask Maria some questions in this regard. But it is not good to ask direct questions. Nurse can ask Maria about home remedies she knows and the use for those. Whether she has used them and are they working. Ask her about treatment methods that her parents or elders used to adopt while she was a child. How often she is having visitors at home or how often she visits others. How often she goes to church or offers her prayers. Do visitors often drop in to your house unexpectedly and is that acceptable for you. What do you mean by good health or bad health or what is illness according to you. Answers to these questions will help the nurse to get an understanding of her believes and practices and she will be able to guide the patient and his relatives accordingly (Dr. Marianne, 2010).

Latinos consider fat as health and fat people are considered as strong ones. This necessitates patient education. They are not of the opinion that several diseases like cardiovascular diseases, diabetes, cholesterol etc are likely to be caused by fat accumulation. Health beliefs of patient is to be elicited and it is also to be noted whether patient believes in mind body connection (Agency., 2008).

2.6 Biological variations

In order to understand biological variations nurse will have to conduct physical assessment in complete. This must include body structure as to whether Maria is of large, small or medium frame, her skin color, whether there are any unusual skin discolorations for her, what is her hair color and hair distribution, height, weight, any visible characteristics (physical) like chloasma, keloids etc. Her blood is to be tested in lab to note hemoglobin level, hematocrit etc. Sickle cell phenomenon is to be noted for Mediterranean and Black (Dr. Marianne, 2010). It is also to be noted whether she is having nay disease and whether any disease like diabetes is common in her family. Whether there is a possible genetic susceptibility for any disease, behavior of family when one of its members is ill, what is her response to anger, food habits of her and her family, whether she had cravings for any thing at any stage, what was her food habit during childhood and what is her traditional food? It is also necessary to know her religious beliefs and food they use during special occasions or celebration (Andres-Hyman, Ortiz, Anez, Paris, & Davidson, 2006).

3 Nursing assessment

Nursing assessment must include all the particulars observed by a nurse during her assessment. Whether client is culturally assimilated or whether she is observing her own cultural practices. Data collected is to be incorporated into nursing care plan. Patient need to be encouraged discussing on cultural differences. Communication methods are to be understood and effort must be made to accept it.  If patient is demanding space it is to be met with. If patient wishes to worship or honor Supreme Being it must be allowed and facility must be provided by identifying a spiritual person to contact. Nurse will have to determine the effect of spiritual practice on health, well being and life (like refusal of blood and blood derivatives by Jehovah’s Witnesses). It is for the nurse to identify the hobbies of a patient and this is to be noted especially when there is need for rehabilitation or convalescence of any term. Honor value and time orientations of patient and when it is necessary to adhere to time apprehension and anxiety must be dispelled.  Patient must be provided privacy according to health status and personal needs. Cultural health practices are to be noted like encouraging and identifying efficacious practices, identifying and discouraging practices that are dysfunctional and identifying whether there will be long term ill effect for practices that are neutral. Food preferences are to be noted and adjustment is to be made in diet according to health status and benefits of long term and as far as possible by dietary department. Dietary practice of patient is to be noted and those likely to have serious implications on his health are to be noted down.

In the case of Maria, she is from Puerto Rico and has been in United States for 39 years. She speaks Spanish and English and there is no noticeable colloquialism. She understands English well and can understand all the information given to her. Her sisters and their husbands are all waiting to know about her in waiting room along with several other relatives. They are praying and most of them are wearing a cross around their neck and there are many rosaries. From all this assessment can be made that Maria is culturally assimilated. Maria need to be asked about their culture and difference it has from other cultures. This will help to enlighten the nurse and her cultural matters can be noted down. Maria is comfortable even though her son is sitting in close proximity to her rubbing her back and holding her hand. Hence there is no issue of space for Maria. As Hispanics prefer closeness it will be better to address her as Mrs. Maria and to keep distance not more than three feet. She can make her prayers for free as most of her relatives are praying and there are many rosaries. Maria is a quiet person and is little reserved. So there is a chance for her to need privacy.

She never had any mammogram and had no flu this season. She never takes any preventive measures. She never misses any appointment but Hispanics do not believe in clock time and calendar and hence she and her family are to be informed of importance of timely intake of medicine. This is to be done with regard to future appointments and care. She along with her son and some relatives who are likely to accompany her to appointments are to be informed of importance of medicine. This is because she is a Catholic and is likely to follow the belief that health is a gift from god and should not be taken for granted.

References

Agency., C. -C. (2008). The world factbook – Puerto Rico. Retrieved November 17, 2012, from www.cia.gov: https://www.cia.gov/library/publications/the-world-factbook/geos/rq.html

Andres-Hyman, R., Ortiz, J., Anez, L. M., Paris, M., & Davidson, L. (2006). Culture and clinical practice: Recommendations for working with Puerto Ricans and other Latinas(os) in the United States. Professional Psychology: Research and Practice , 694-701.

Barbara, M. D., & AmericanHolisticNurses’Association. (1997). Core Curriculum for Holistic Nursing. Sudbury: Jones & Bartlett Learning.

Berrios, C. (2003). Culturally competent mental health care for Puerto Rican children. Journal of Child and Adolescent Psychiatric Nursing, 112-122.

Carlson, V. J., & Harwood, R. L. (2003). Attachment, culture, and the caregiving system: The cultural patterning of everyday experiences among Anglo and Puerto Rican mother-infant pairs. Infant Mental Health Journal , 53-73.

Dahl, M. (2004). Cross-cultural competence: Working with Puerto Rican clients. Health Care Food & Nutrition Focus , 10-12.

Dr. Marianne, J. (2010). Teaching Cultural Competence in Nursing and Health Care, Second Edition. New York: Springer Publishing Company.

Fliszar, R. S. (2003). Culture care of Puerto Rican elderly in a community setting. Pennsylvania: Duquesne University.

Foster, J. (2004). Fatherhood and the meaning of children: An ethnographic study among Puerto Rican partners of adolescent mothers. Journal of Midwifery & Women’s Health , 118 – 125.

Giger, J. N., & Davidhizar, R. E. (1995). Transcultural Nursing Assessment and Intervention. Mosby: St. Louis.

Gloria, K.-M. (2012). Delivering Culturally Competent Nursing Care. New York: Springer Publishing Company.

Harwood, R. L. (2006). Explaining the concept of respect among Turkish and Puerto Rican migrant mothers. Bochum: US National Library of Medicine: National Institutes of Health.

Katie, W. (2007). Psychosocial Issues and Self-Care . American Journal of Nursing , 34-38.

Perez y Gonzalez, M. E. (2000). Puerto Ricans in the United States. Westport CT: Greenwood.

Priscilla, L. S. (2011). Transcultural Nursing Theory and Models:Application in Nursing Education, Practice, and Administration. New York: Springer Publishing Company.

wps.prenhall.com. (2012). Culturalcare Guide. Retrieved November 17, 2012, from wps.prenhall.com: http://wps.prenhall.com/chet_spector_cultural_7/94/24265/6211875.cw/index.html

www.culturediversity.org. (2012). Transcultural nursing; Basic concepts and case studies, Assessment measures. Retrieved November 17, 2012, from http://www.culturediversity.org: http://www.culturediversity.org/assesmnt.htm