Cultural competence: An essential journey for perinatal nurses Mary Lou Moore, PhD, RN, FAAN Merry-K. Moos, MPH, RN, FNP, FAAN Lynn Clark Callister, PhD,

Cultural competence:An essential journey for perinatal nurses

Mary Lou Moore, PhD, RN, FAANMerry-K. Moos, MPH, RN, FNP, FAANLynn Clark Callister, PhD, RN, FAAN

© 2010 March of Dimes Foundation

The need for cultural competencein the 21st century• High rates of immigration in the late-19th

and throughout the 20th centuries contributes to cultural diversity in the United States.

• Differences, including language, ethnicity and religion, exist within population groups.

• Nurses cannot make assumptions about an individual based on the person’s race or ethnicity.


The need for cultural competencein the 21st century (continued)

• Race is defined in biological terms, based on characteristics such as skin color and hair.

• Ethnicity refers to a group of people who share certain cultural characteristics. For example, the terms Hispanic and Latino refer to ethnicity.

• Immigrants choose to migrate to a country and can bring money and belongings.

• Refugees commonly are fleeing from their country of origin, often with little or no preparation.


Percent of U.S. population by race and ethnicityRace and ethnicity 2000

Census2008

estimate

White 75.1 79.7

Black or African-American 12.3 12.8

American Indian/Alaska Native 0.9 10.1

Asian 3.6 4.4

Native Hawaiian and Other Pacific Islander

0.1 0.2

Hispanic/Latino 12.5 15.4

Two or more races 2.4 1.7

U.S. Census Bureau, 2000, 2009a


Racial classifications in the 2000 U.S. Census• White• Black or African-American• American Indian/Alaska Native• Asian• Native Hawaiian and other Pacific

Islander• Some other race• Two or more races

U.S. Census Bureau, 2009b


• Health disparities are differences that occur in the incidence or prevalence of disease, or in morbidity or mortality. The term also refers to differences in the way patients are treated.

• Disparities occur in race, ethnicity, gender, age, economic status, religion and sexual preference.

• Among the greatest reproductive disparities in the United States are preterm birth, infant mortality and maternal mortality.

Health disparities


Preterm birth and LBW by race and ethnicity, 2006

Race/Ethnicity Preterm birth LBW

Non-Hispanic white 11.8 percent 7.2 percent

Non-Hispanic black 18.1 percent 13.6 percent

Hispanic 12.2 percent 7.0 percent

Asian/Pacific Islander

10.9 percent 8.1 percent

American Indian/Alaska Native

14.2 percent 7.5 percent

Kaiser Family Foundation, 2009; Martin et al., 2009


Disparities in infant & maternal mortality, United States, 2006

Non-Hispanic

white

Non-Hispanic

black

Hispanic Total

Infant mortality*

5.56 16.06 5.52 6.69

Maternal mortality**

9.50 32.70 10.20 13.30

* Infant mortality is deaths in the first year of life per 1,000 births.**Maternal mortality is deaths up to 42 days after the end of pregnancy per 100,000 pregnancies. Maternal mortality measures deaths related to or aggravated by pregnancy or pregnancy management. It does not include deaths after 42 days of birth or those related to external causes.

MacDorman & Mathews, 2009


• Failure of nurses and other providers to understand the importance of beliefs about health and illness

• Unwillingness to coordinate care with traditional healers, when appropriate

• Lack of minority staff members• Inadequate interpreter services

Cultural health disparities


Strategies for decreasing disparities in health care• Ensuring equality in access to care• Using educational approaches that serve the

needs of diverse populations• Ensuring cultural competence among health

care institutions and professionals• Using evidence-based care• Maintaining diversity within the health care

team• Conducting research to better understand

the needs of patients from various cultural groups


• Health literacy is person’s ability to obtain and use health information. It is an important predictor of health outcomes (DeWalt et al., 2004).

• Pregnancy may be the first time a woman with low or marginal health literacy skills encounters the health care system.

• Barriers to health literacyo Languageo Cultural traditions and beliefs

Health literacy


• Culture is a distinctive way of life that characterizes a particular community of people.

• Culture encompasses beliefs about health and illness, including prevention of illness and care of persons who are ill.

Definitions of culture


Dimensions of culture: Decision-makingChildbearing decisions may be made by:•The woman •The woman and her partner•The woman’s extended family, including several generations•Males or male elders•Spiritual leaders


Dimensions of culture:Concept of time• Much of the world has a relaxed attitude

toward time. Women and families may not understand the need for specific time commitments, especially for prenatal care appointments.

• Cultures may be past-, present- or future-oriented. The dominant U.S. culture is future-oriented, which means people act today with expectations for future rewards. Cultures not future-oriented may not see the need for preventive care.


Dimensions of culture: Naming• Nothing is more personal than a person’s

name.• Societies follow different patterns of

naming that may cause nurses difficulty in record-keeping and completing birth certificates.


Dimensions of culture: CommunicationCommunication characteristics of the dominant culture in the United States•Well-developed verbal skills•Willingness to disclose personal information•Direct eye contact•Relatively large personal space•Moderate use of gestures•Expressive faces with smiles representing positive or encouraging emotions


Dimensions of culture: Religion

Religion Percent of U.S. adult population

Protestant 51.3

Catholic 23.9

Jewish 1.7

Buddhist 0.7

Muslim 0.6

Hindu 0.4

Pew Forum on Religion and Public Life, 2008


Dimensions of culture: World view• World view is the understanding of how

human life fits into the bigger picture. It allows people to make sense of what seems unknowable, including evil, disease and death (Farnes, Callister, Beckstrand & Carlton, in press).

• Disease etiology is the part of a person’s world view that explains illness. It may include ancestral displeasure, body imbalance (yin/yang or cold/hot), breach of taboo, evil eye, fright, germ theory, object intrusion, soul loss and spirit obsession.


Dimensions of culture: Modesty and gender• Modesty (exposure of the human body):

Some cultures accept public nudity under specific circumstances. In others, women must cover almost all of their bodies.

• Gender roles: For many societies, the norms for interaction between men and women are much more restrictive than they are in the United States.


Key concepts in working toward cultural competence• Ethnocentrism: When people think their

beliefs and practices are superior to the beliefs and practices of other groups

• Cultural relativism: The concept that a person’s beliefs and behaviors should be understood in the context of their culture

• Acculturation: The process for adopting the practices of another group

• Stereotyping: An oversimplification that reduces the possibility of knowing people as individuals


Key concepts in working toward cultural competence (continued)

• Emic perspective: An individual describing her own culture

• Etic perspective: An individual describing another culture

• Health practiceso Functional traditions can enhance health. o Neutral traditions neither harm or help

health.o Nonfunctional traditions are potentially

harmful.


Preconception careThe main goals of preconception care are to provide health promotion, screening and interventions to women of reproductive age to reduce risk factors that could affect a future pregnancy.


Preconception care:Issues across cultures• Ideal age for a woman to first become a

mother• Preferred number of offspring• Preferred interval between pregnancies• Appropriateness of preconception testing

for genetic and other disease risks• Use and suitability of contraception• Appropriateness of induced abortion• Desired gender of children• Appropriateness of fertility treatments


Preconception care: Genetic counselingCompetent preconception care includes assessment of genetic risks so that parents can make informed decisions about reproductive options, including: •Prenatal diagnosis after conception•Artificial insemination or oocyte donation•Preimplantation diagnosis •Attempting conception and pregnancy, regardless of potential outcomeMoos, in revision


Prenatal care• In many cultures, prenatal care is not

rooted in interactions with health care providers. Instead, family members and the community as a whole provide special attention and care for the pregnant woman.

• The United States spends more for prenatal care than any other nation (Strong,

2000); yet in 2005, the nation ranked 30th in infant mortality compared to the rest of the world (NCHS, 2008a).


• Most prenatal care occurs in an examining room. The woman is required to adapt to clinic processes and the authority of the provider and other staff.

• If a woman or her support persons leave any prenatal visit feeling disrespected, unwelcome or marginalized, they may avoid future visits or disregard the information they received.

Prenatal care (continued)


Reasons women disengage from or do not attend prenatal care• Difficulty accepting the pregnancy• Depression• Discomfort with the specifics of prenatal

care, such as waiting times and payment requirements

• Perceived judgments by staff• Inability to keep appointments because

of work or transportation issues• Belief that the care lacks meaning• Lack of social support


• CenteringPregnancy® is a program that provides prenatal care in a group setting. It purposefully empowers women to become active participants in their own assessments and education.

• Taking care out of the examining room can eliminate barriers between health care providers and patients.

• Home visitation is an important feature of many enhanced models of prenatal care.

Prenatal care approaches


• Weight• Exercise• Postpartum

contraception• Domestic violence• Protection against

STIs

• Nutrition• Breastfeeding• Avoiding harmful

substances• Use of seatbelts• Screening and

diagnostic tests and test results

Prenatal education topics


• The nurse’s role in prenatal testing is to facilitate informed choices by the woman and her family.

• Culture mediates reasons for seeking testing, interpretation of results and decision-making.

• Women and couples may find prenatal testing confusing, emotionally charged and uncertain.

• Test results can create negative consequences for women.

Prenatal testing


• Food has symbolic and health connotations.

• Nutritional counseling can be challenging when culturally determined practices, such as fasting, conflict with principles of good and safe prenatal nutrition.

Prenatal nutrition


Intrapartum care: Birthing environmentThe atmosphere and policies of bio-technological birthing units may present cultural challenges for women (Lauderdale, 2008).

•They may be anxious and fearful as they are forced to conform to a medical center’s policies and procedures. •They may feel their privacy is being invaded. •They may find it hard to be far from the support of extended family members. •They may face language barriers.


Intrapartum care: Support persons during labor and birth• Expectations about who accompanies or

supports a laboring woman vary across cultures. Nurses must know the traditions of the cultural groups they serve and the specific preferences of each woman.

• In many cultures childbirth is exclusively a woman’s experience. The baby’s father is not present.


Intrapartum care: Cultural responses to pain• A woman’s sense of personal control over

pain management influences the quality of the birth experience (Carlton, Callister & Stoneman, 2005).

• Perceptions of childbirth pain, pain behaviors and pain-management preferences are culturally bound (Callister, 2006b). o Some view pain as a normal part of

childbirth and coping with pain as a maternal achievement.

o Some view pain as suffering that requires aggressive pharmacological management.


Intrapartum care: Cultural responses to pain (continued)

• Some women may:o Prefer to be active during laboro Use herbs, acupressure, massage,

meditation, hydrotherapy, birthing balls and position changes to reduce pain

o Prefer to squat to give birth• Nurses should facilitate the use of safe,

nonpharmacological methods of pain management and respecting women’s preferences for pain management.


• Nurses should assess how each woman or couple prefers to make important health care decisions, including cesarean birth, before a crisis arises. Ideally this occurs in prenatal care.

• Even when this assessment is available, the labor and birth nurse revisits preferences and reviews situational limitations with the woman and her support persons early in labor.

Intrapartum care: Cesarean birth and birth emergencies


Postpartum care: Restoring balance to the body• The dominant U.S. culture encourages women

to leave the hospital quickly, resume their normal diet and participate in activities as they can.

• Other cultures prohibit eating certain foods and engaging in most activities for several weeks after giving birth.

• Much of the world believes that health is achieved by balancing hot and cold. Many believe that giving birth depletes the woman’s body of the hot element, which puts her in a cold state.


Postpartum care: Activities and relationships• Postpartum practices provide social

support, help the woman adapt to the maternal role, allow for care of the newborn, and promote the woman’s physical recovery.

• Some cultures believe that postpartum women are delicate or vulnerable.

• Who cares for a woman after she leaves the hospital often is culturally prescribed.


Postpartum care: Postpartum depression (PPD)• PPD occurs in most cultures throughout the

world, with similar levels of prevalence (10 percent to 15 percent) (Beck, 2008).

• Culturally specific risk factors for PPD:• Placing a higher value on having male

rather than female children• Immigrant or refugee status• Inability to practice postpartum cultural

rituals• Lack of an effective social support network


Newborn care• Circumcision: Cultural traditions and religious

beliefs may be the basis of whether or not male infants are circumcised, and when.

• Feeding: Some cultures consider colostrum essential to establishing nutrition and maternal-infant bonding. Others think colostrum is dirty, old or unfit for a newborn.

• Names: As hospital stays become shorter, members of many cultures find it challenging to follow hospital naming conventions.


Care of preterm and high-risk newborns: Family-centered care• Family-centered care is an approach to

planning, providing and evaluating health care that is grounded in collaboration between families, nurses and other health care providers (Institute for Family-Centered Care, 2010).

• NICU staff provides ongoing opportunities for mothers, fathers and babies to be together and for parents to participate in care.

• Discharge teaching includes discussion of transportation home and follow-up appointments.


Fetal and neonatal death: Assessing the meaning of loss and grief• What are important cultural traditions and

rituals for coping with dying, handling the deceased’s body and honoring the deceased?

• What does the family believe happens after death?

• What are expected expressions of grief and acceptance of loss?

• What family roles exist in coping with death?


Cultural competenceCulturally competent nurses:• Acknowledge differences between people

as valuable and enriching• Seek to understand the perspectives of

those who are different from themselves and modify practices to accommodate those differences

• Advocate for organizational change • Continue to develop knowledge and skills

about those for whom they care


Cultural competence: Assessing the childbearing woman• How does the woman’s culture value

childbearing?• Is childbearing viewed as a normal

physiologic process, a wellness experience, a time of vulnerability and risk, or a state of illness?

• Is birth a private intimate experience or a societal event?

• How is childbirth pain managed? What maternal and paternal behavior is appropriate?


Cultural competence: Assessing the childbearing woman (continued)

• What support is given during pregnancy, childbirth and beyond? Who gives this support?

• What maternal precautions or restrictions are necessary during childbearing?

• What does the childbearing experience mean to the woman?

• How does the culture view newborns? What are the customs regarding infant care and relationships within nuclear and extended families?


Cultural competence: Nursing education Diversity in nursing can help achieve culturally competent care and reduce health disparities (ANA, 2002; Giddens, 2008; IOM, 2003). Racial distribution of RNs in the United States,

2008

Race Percent of all RNs

Non-Hispanic white 83.00

Asian/Pacific Islander 5.87

Non-Hispanic black 5.40

Hispanic/Latino 3.60

U.S. DHHS Health Resources and Services Administration, 2010


Cultural competence: Health care organizations• Title VI of the Civil Rights Act of 1964

mandates that no person shall be subject to discrimination because of race, color or national origin in any program receiving federal financial assistance (U.S. Department of Justice, 1964).

• In 1999, the U.S. DHHS Office of Minority Health published 14 National Standards for Culturally and Linguistically Appropriate Services (CLAS).


Special topics: Working with an interpreter• The best choice for an interpreter is a

trained medical interpreter. A friend or family member may not understand terms used by the health care provider. A woman may be discussing issues she wants to keep private.

• Many health care agencies rely on phone-based interpretation services; disadvantages include the inability to observe nonverbal communications.


Special topics: Female genital cutting (FGC)• FGC is the cutting of the female genitalia

for nonmedical reasons. • 100 million to 140 million women and

girls in the world have experienced FGC (WHO, 2001).

• The United Nations condemns FGC. It is illegal in the United States, Canada and most western European countries.


SummaryNurses must understand the role of culture and cultural competence throughout childbearing, from the preconception period and care of the newly born infant through the postpartum period. They must understand the importance of attitudes, knowledge and skills in the development of cultural competence for individual nurses and health care organizations.

Documents

Cultural competence: An essential journey for perinatal nurses Mary Lou Moore, PhD, RN, FAAN Merry-K. Moos, MPH, RN, FNP, FAAN Lynn Clark Callister, PhD,