Culturally Congruent Care in the NlCU

Transcription

1 Eileen J. Colon, RN, MSN Culturally Congruent Care in the NlCU Exploring the Needs of a Mexican Family and Their Infant Son 60 A W H O N N Lifelines Volume 5, Issue 5

2 aring for clients and families from different cultures has C become a daily Occurrence for nurses. The ability to provide for the client s health needs may be hindered or enhanced by the nurses sensitivity and understanding of the cultural expectations of the client and his or her family. Consider the following case study involving a young Mexican family and their preterm infant son. A 35-week gestational age, male neonate was admitted to NICU for expiratory grunting and nasal flaring. His prenatal history was insignificant. The labor history, however, was significant, for the mother had experienced rupture of membranes more than 36 hours prior to the birth and had registered a maternal temperature of 101 degrees Fahrenheit at delivery. During labor, the mother received no antibiotics. At birth, the infant weighed four pounds and eight ounces, he had an axillary temperature of F, and he had a foul odor. He was placed in a radiant warmer with a pulse oximeteq ECG leads and a skin temperature sensor. His initial treatment included a blood culture, followed by three days of antibiotics. Because his oxygen saturation remained above 95 percent, an oxygen hood was unnecessary. His grunting and flaring began to subside and his temperature dropped to 100 F. Several hours later, the infant s temperature remained at 100 F and his grunting had subsided. His mother, father and paternal grandmother came to the NICU to see him. The infant s mother and father spoke limited English, and his grandmother spoke no English at all. The grandmother became visibly upset when she saw the infant and spoke animatedly to the mother and father, who attempted to ask questions about the infant and then spoke to the grandmother in Spanish. Fortunately, the nurse was able to communicate with this family in Spanish, but if that had not been possible, an appropriate translator would have been required. In conversation with this family, the nurse was able to discover that any care decisions were to be addressed to the baby s father who, after consulting with his mother, would make final decisions concerning the infant s care. Appropriate medical and nursing care that was acceptable to this family included using the appropriate communication I channel (Becker & Grunwald, 2000; Locasin, 2000; Schlott & Henley, 2000; Zoucha, 2000). The infant s care was explained to and discussed with the paternal grandmother who would manage the infant s care. However, the father ultimately made all care decisions. To have addressed the grandmother directly concerning care decisions, or to direct teaching of infant care to the father, even if he had better communication skills in English, might have caused culture conflicts and stress and resulted in the famiiy s unwillingness to provide the needed care (Leininger, 1991; Wenger, 1993). Reaching Across Cultures Providing access to a patient for family members, encouraging spiritual or religious practices, cultural foods, family participation, cultural treatments and discovering the communication channels within the culture are nursing measures of accommodation. It was obvious that to provide nursing care that would be acceptable and satisfying for this family, it was important to discover their understanding and expectations of the situation (Becker & Grunwald, 2000; Locasin, 2000; Schlott & Henley, 2000; Zoucha, 2000). Their views of the infant s health status and the care required to achieve optimal health, as well as the communication channels within this particular group, needed to first be understood for the nursing care to be effective and culturally congruent. Language is a very important vehicle for the discovery of culturally defined patterns, and in this particular case it was important that the nurse spoke and understood Spanish. Nurses need to understand how to provide culturally congruent care. Leininger (1991) proposed that culture care theory might guide nurses in varied situations to provide clients with treatment that is culturally specific and congruent with their beliefs, thereby enhancing client and family satisfaction and response. There are two basic tenets in Leininger s theory (1991): caring is the essence and focus of nursing definitions of caring need to be culturally and contextually identified for significance within a given situation Leininger uses a model of a sunrise to illustrate the interrelated components of the theory, assisting caregivers to explore the client s worldview social structure Octobermovember 2007 AWHONN Lifelines 61

3 environmental situation and affecting factors kinship religious beliefs economic, political and educational situation and affecting factors care pattern and practices professional and folk practice experiences With this discovered information, nurses and patients together can design care decisions that are sensitive to and consistent with the patient s perceptions of caring. Three dominant modalities can be used to guide care decisions and actions (Leininger, 1991): culture care maintenance culture care negotiation culture care restructuring Culture care maintenance includes those actions that reinforce a behavior that has been seen as beneficial and satisfying to a patient. Reinforcing adequate nutrition, exercise and leisure activities that have been a part of a patient s lifestyle are considered maintenance care. The grandmother had brought a bat to place on the child s head to protect his spirit and she was encouraged to place it on him and reassured that he would continue to wear it. In the culture care negotiation mode, nurses accommodate behaviors that have significant caring meaning for a particular patient. For example, providing access to a patient for family members, encouraging spiritual or religious practices, cultural foods, family participation, cultural treatments and discovering the communication channels within the culture are nursing measures of accommodation. In the culture care restructuring mode, a patient and her care provider may examine new ways of doing daily activities that are designed to support or promote lifestyle changes required by a patient s health status. These changes should be acceptable and satisfying to the patient. At times only one mode of action may be needed while some situations may require the use of two or all three. These modes are expected to assist the nurse and client to creatively design culturally acceptable and beneficial nursing care. Eileen J. Colon, RN, MSN, is a staff nurse at Women s Hospital in Greensboro, NC. Back to the NlCU With this young Spanish-speaking family, the NCU staff was able to use Leininger s concepts of cultural accommodatior and maintenance to design, accommodate, negotiate and facilitate care that was beneficial to the infant and satisfying to the family. Exploring what would have been done for the infant at home helped nurses discover some areas of concern for this family. Recognizing the normal practices of this family s culture in infant care, the nurses were able to accommodate to meet their needs (Krajewski-Jaime, 1991; Schlott & Henley, 2000). As this family was encouraged to participate in the care, with special attention paid to the grandmother and her leading role in the infant management for this family, the grandmother s initial resistance and hostility began to disappear (Galanti, 1997; Krajewski-Jaime, 1991; Zoucha, 2000). For example, the grandmother was concerned that the baby was not being kept wrapped in blankets for warmth. The nurses explained that they needed to observe the infant s skin and activity as well as his vital sips. Having her feel the child and the heat within the warmer bed alleviated some of her anxiety concerning his temperature. Having him lay undiapered was acceptable because the concept of machismo allows male children to have their genitalia exposed and discussed. However, had this been a female infant, it would have been extremely important to cover her genitalia from public display. The family wished to follow the practice of rubbing the child with oil. This concerned the nursing staff because the various ECG leads and temperature sensors need to adhere to the skin. It was suggested that the grandmother limit the rubbing of oil to the baby s head and extremities. After exploring these limitations with the grandmother, and encouraging her to ADDITIONAL READING Andrews, J. D. (1995). Cultural, ethnic, religious reference manual for health care providers. Winston Salem, NC: JAMARDA Resources Axtell, R. E. ( Gestures: The do s and taboos of body language around the world. New York: Wiley Galanti, G. A. (1997). Caring forpatients from different cultures. Philadelphia: University of Philadelphia Press Geissler, E. M. (1994). Pocket guide to cultural assessment St. Louis: Mosby Lassiter, S. M. (1995). Multicultural clients: A professional handbook for health care providers and social workers. Westport, CT: Greenwood Press Spector, R. (1996). Cultural diversify in health and illness. Stamford, CT: Appleton & Lange 62 AWHONN Lifelines Volume 5, Issue 5

4 participate in her grandchild s care, she enthusiastically began her ritualistic anointing. The pulse oximerer was moved to the alternate extremity after the oil had been applied to continue to monitor oxygen saturation levels. The grandmother had brought a hat to place on the child s head to protect his spirit, and she was encouraged to place it on him and reassured that he would continue to wear it. She also tied a loose red yarn around his ankle to give him strength. The family had brought a small religious medal to pin to the child s clothing, which presented a challenge. Compromise was found in pinning it to the bedding; prominent signs posted on the bed, chart and care plan explained about the medal, yarn and hat for continuity of care. The family was assured that as soon as the child was dressed, the medal would be pinned to his clothing. Acknowledging these culture care maintenance activities and involving them into the care of this infant expressed the respect and confidence necessary for the caring essence of nursing to be perceived by the family (Galanti, 1997; Krajewski-Jaime, 1991; McGrath, 2000; Schlott & Henley, 2000; Zoucha, 2000). None of these activities interfered with the technical aspect of the care of the infant, and they alleviated anxiety and ten- None of these activities interfered with the technical aspect of the care of the infant, and they alleviated anxiety and tension among the family members. sion among the family members (Becker & Grunwald, 2000; McCrath, 2000). The family was informed that any religious person they chose could visit the infant, as well as any other designated family members (Krajewski-Jaime, 1991; Locasin, 2000; Schlott & Henley, 2000). Any people with special cultural roles in relation to the infant were also welcome if designated by the parents. The open visiting hours, the phone number to call for information about their infant and the names of persons who could speak some Spanish were given to them written in Spanish and English. Culture Care Restructing The father indicated that the infant was to be formula-fed in the hospital and that the mother would be breastfeeding when the child was discharged home. When it was suggested that the mother come to the nursery to breastfeed several times a day until he was discharged home, the father became very emphatic that the infant was to be formula-fed until discharge. Exploring further, the father revealed his belief that colostrum was too strong and of insufficient quantity to be of worth for the newborn. Formula would provide sufficient quantity for smaller infants until the mother s milk came in the second to fourth day. Issues regarding privacy and modesty being a hindering factor to breastfeeding in the nursery for this family were explored, and the staff offered a small private nursing room at the corner of the nursery to try to promote breastfeeding. Even after further discussion and attempts at education, the father remained adamant with his decision. Avoiding criticism or confrontation regarding this decision allowed the father to save face and kept the lines of communication open concerning infant care and discharge teaching. The family remained receptive to caregivers treatment and teaching (Leininger, 1991; Wenger, 1993; Zoucha, 2000). The nurses discussed with the grandmother the use of a breast pump by the mother to stimulate milk production because the infant would not be sucking for several days. The grandmother was receptive to the suggestion of a breast pump as an alternative to the manual pumping that was normal cultural practice for her and the child s mother. She was able to explain and demonstrate the use and cleaning of the hand pump after demonstration and explanation by a nurse. Working with the grandmother provided an opportunity to use all three modalities in making and implementing care decisions. Recognizing the grandmother s importance in the family structure and presenting an alternative method to a cultural practice was effective care negotiation and restructuring. By encouraging and supporting the practice of breastfeeding, the October/November 2001 AWHONN Lifelines 63

5 staff also demonstrated culture care maintenance (Leininger, 1991; Locasin, 2000; Schlott & Henley, 2000). When the infant was discharged, the family expressed their appreciation of the care they and their infant received by giving abrazos (hugs) to the staff involved with their infant. They also sent pictures and brought the baby back after his discharge to share his growth and beauty with the staff. To be seen as extended family and included in the child s life as he grows is a high compliment from Hispanic families. Implications Although it was difficult for the staff not to work directly through the infant s mother, they were able to work effectively through the kinship hierarchy (culture care maintenance) to provide and maintain the family support system and integrate the family customs (culture care negotiation) in order to provide effective infant care. They were able to introduce the breast pump and principles of hygiene and nutrition through the interactions with the paternal grandmother (culture care restructuring) and exhibit respect for the family s cultural values and practices. Communication with patients and families who speak a language other than English can be difficult for all involved. Unfortunately, many health care facilities and providers use family members as translators. The most effective translator is usually not a family member due to the possibilities of cultural prohibitions upon sensitive communication issues and lines of authority (Caudle, 1993; Wenger, 1993). Even for a fluent non-family translator it s important to consistently and frequently verify that understanding is taking place by requesting feedback. The nursing staff working with this family was able to gain understanding because of effective communication and sensitivity to cultural practices. An important part of the development of trust within the Hispanic culture is social, nonfocused conversation. Social niceties are to be exchanged, conveying politeness and respect for the family members, before discussing the topic of interest (Caudle, 1993; Krajewski-Jaime, 2000). This social exchange may help the translator to determine some of the kinship communication patterns and identify the authority figure in order to facilitate culturally appropriate communication patterns (Caudle, 1993; Leininger, 1991; Galanti, 1997; Wenger, 1993; Zoucha, 2000). Appropriate communication facilitated this positive interaction. Beginning with the exploration of the social and kinship structure and by using the cultural language, the staff was able to discover and explore health care patterns and practices of this family. The needs of the infant were met, and the family structure and members roles were maintained. Nursing care was focused on the preservation and accommodation of family interaction. The staff was able to achieve beneficial care and family satisfaction by exhibiting confidence in and respect for the family s cultural values and patterns and by giving care that preserved kinship involvement. If the family had refused the monitoring or antibiotics, cultural conflicts would have surfaced. Greater negotiation might have been necessary if the infant had been much younger and tactile stimulation contraindicated or if artificial ventilation had been required. There will be situations where the cultural beliefs of a client will not be accepted or considered. Although Leininger s Culture Care Theory can be useful in an ever-more multicultural world, its application may be limited by facility policies and insensitive or uninformed caregivers. As patient advocates, nurses need to be actively involved in helping develop culturally sensitive and responsive policies to meet the needs of our multicultural world. + References Becker, R. T., & Grunwald, R. C. (2000). Contextual dynamics of ethical decision making in the NICU. ]ournal of Perinatal & Neonatal Nursing, 14(2), Caudle, P. (1993). Providing culturally sensitive health care to Hispanic clients. Nurse Practitioner, 2 8( 12), Galanti, G. (1997). Caring for patients from different cultures (2nd ed.). Philadelphia: University of Pennsylvania Press. Krajewski-Jaime, E. R. (1991). Folk-healing among Mexican- American families as a consideration in the delivery Qf child welfare and child health care services. Child Welfare, 70(2), Leininger, M. M. (1991). Culture care diversity & universality: The theory of nursing. New York: National League of Nursing Press. Locasin, R. C. (2000). Building bridges: Affirming culture in health and nursing. Holistic Nursing Practice, 25( 1) 1-4. McGrath, J. M. (2000). Developmentally supportive caregiving and technology in the NICU: Isolation or merger of intervention strategies? Journal of Perinatal & Neonatal Nursing, 14(3), Schlott, J., & Henley, A. (2000). Culture, religion and patient care. Nursing Management, 7( l), 13. Wenger, A. F. (1993). Teaching families from diverse cultural backgrounds. Neonatal Network, 12(1), Zoucha, R. (2000). The significance of culture in caring for Mexican Americans in a home health setting. Home Health Care Management & Practice, 12(6), GETTING ALLTHE FACTS Transcultural Nursing Society: ww.tcns.org Transcultural Nursing and Healthcare Association: Transcultural Nursing -A Selected Bibliography with Links to Foreign language health materials: brary/html/cuituredmed/bi bhranscuttural 64 AWHONN Lifelines Volume 5, Issue 5