CPNRE® Comprehensive Review Series: Part 11





Today’s post in the serialization of the first chapter of the CPNRE® Comprehensive Review eBook takes a look at culture and the ways in which we can be sensitive to the cultural influences and choices our clients make. You can find the previous posts here: part 1, part 2, part 3, part 4, part 5, part 6, part 7, part 8, part 9 and part 10


Nurse-client interactions: Culture

The process of writing this book taught me so much about nursing. This couldn’t be any more true than when it comes to the topic of culture. When I first started learning more about culture and cultural sensitivity, initially I cringed. Here’s another wishy-washy topic, I thought. But of course, it didn’t take long for me to learn that most client behaviours and choices are inextricably connected to cultural values and beliefs.

For years I was frustrated whenever clients would continue to make unhealthy choices or decisions despite my attempts to provide health education.

  • Clients with uncontrolled diabetes wouldn’t take their medications as I instructed
  • Clients on Coumadin wouldn’t get their INR done when I asked them to
  • Clients with advanced COPD would continue to smoke despite knowing the risks
  • Clients with asthma would not use their inhalers despite my efforts to teach them why they’re important

It was as if my information always went in one ear and out the other.

For most of my career I believed that the best and only way we can help clients make better decisions about their health was through education. But after learning more about culture, I’ve realized that we cannot truly help clients achieve better health unless we acknowledge and respect their cultural values and practices. And, that we can only support clients to get to where they want to go by gently helping them to see when their values and beliefs and behaviours – their culture – isn’t serving them well.

The simplest definition of culture that I could find is that it’s “a learned way of thinking and behaving – for better or for worse – amongst a certain group of individuals”. From this definition, culture is considered a group of people who are connected to one another through shared characteristics, customs, values, behaviours, beliefs, traditions and language.

Although we may not think that culture is all that significant, it’s important to understand that it impacts everything we do, from:

  • What we eat
  • When we eat
  • How we dress
  • How we behave
  • How we spend our time
  • How we treat other people
  • How we parent
  • How we work, &
  • How we live

There are no areas of our life immune to cultural influences.

Here’s the thing: most of us are so influenced by our culture that we often don’t recognize that it exists. Without being aware of our own cultural influences, it’s hard to see how culture impacts the thoughts and behaviours of the clients we care for, especially when it comes to health.

As I think about my own cultural influences on health, I’ve learned about one belief in particular that isn’t all that helpful – and is actually harmful to me.

When I’m sick, I believe that I have to continue fulfilling my obligations at work and at home. I do this because this is how my family raised me. I was taught that you don’t get a free pass to relax when you’re sick. As I’ve grown older I’ve realized that this belief is not healthy. As a consequence, I have to work really hard to be kind to myself and take time to rest when I need to, because it’s not my first instinct. This might seem ridiculous to some of you who were brought up in a culture that values self-care. I certainly wasn’t.

When I think about positive influences of my culture on my health, I’ve learned that my belief in physical wellness is a good thing.

I was fortunate to grow up in a family that taught me about the importance of regular physical activity early in life. As a young girl I remember regularly going to aerobics classes at the YMCA with my mom, because ‘that’s just what we did’. As an adult I continue to live an active life. Physical activity has become so engrained in my life that it almost doesn’t feel like a choice, even though it is. Thankfully, it’s a choice and a value that keeps me well.

When we are aware of cultural ‘norms’ and expectations, it’s easier to acknowledge when our values, beliefs and practices are harmful to us.

This idea that culture influences how we think and act is important because in order for us to help clients achieve better health, we have to do two things:

  1. We have to understand and respect clients’ culture beliefs and practices (the choices they make) when they’re not harmful.
  2. We have to help clients learn about other ways of thinking and being in the world when their cultural beliefs and practices (the choices they make) are putting them at risk for harm.

If a client wants us to arrange a religious ceremony or respect their traditions and they aren’t putting other people at risk for harm, it’s our job to support their needs.

If a client wants to smoke in their hospital room, or refuses to receive medically necessary care, it’s our job to understand the reasons underlying their choices and help them understand the implications of their decisions.

One of the biggest reasons why clients often feel disrespected by us has nothing to do with our nursing skills or competence, and everything to do with our sensitivity towards their values, beliefs, and choices. We know from research that people are more likely to feel worthless, disconnected, disrespected and unaccepted when we pass judgment about their choices, when we force people to make different decisions, and when we use shame as motivation to help them change their behaviour. In her book ‘I thought it was just me’, Brene Brown says that “we cannot force people to make positive changes by putting them down, threatening them, humiliating them in front of other people or belittling them”.

So if we tell a client enough times:

  • You should exercise more because you’re gaining weight and it’s raising your blood sugars.”
  • “You should really take chemotherapy because without it you’ll die.
  • “You shouldn’t take homeopathic remedies.”
  • We can’t allow you to practice your religious beliefs.”

We’ll likely see a swift change in their behaviour, but it probably won’t be a lasting change, and it certainly won’t be a positive change. When we use shame or pass judgment about someone’s choices as a means to help them change, when we attack someone’s cultural beliefs and practices – it leads them to be silenced and secretive and feel unworthy of connection. The effects on health are disastrous.

Instead of telling clients what to do or forcing clients to make different decisions, it’s really important for us to seek an understanding of their values, goals, beliefs and preferences, and advocate for their needs to be met in a way that’s meaningful to them.

Here are a few lessons about culture:

  • Capable clients know what’s best for them
  • Capable clients have the right to make choices and decisions about their health (as long as their choices don’t hurt other people)
  • People in the same culture group have different values and beliefs
  • We have an obligation to commit to integrating clients’ cultural preferences into their care when there’s no risk of harm to other people
  • Culturally-sensitive care is client-centered care