CPNRE® Comprehensive Review Series: Part 12






Moving ahead with the serialization of part of the first chapter of the CPNRE® Comprehensive Review eBook, we’re picking up from the last post about culture and cultural sensitivity. Today’s post explains how to approach challenging question scenarios about culture and choices on the CPNRE®. You can find earlier posts here: part 1, part 2, part 3, part 4, part 5, part 6, part 7, part 8, part 9, part 10 and part 11


Nurse-client interactions: Culture 

Given the significance of cultural influences on health, it’s important for us to talk about how to approach the concept of culture and choices on the CPNRE®.

Question scenarios about culture will most likely test your understanding of what you’re supposed to do when clients make choices about their care that you might not agree with or believe in. For example, a question might involve a client who refuses a particular treatment plan, or a client who makes a spiritual or religious request you don’t practice yourself.

When you see questions involving clients who refuse certain treatments or care, or questions involving clients who make particular requests about their care, know that the correct answer will be to advocate.

When it comes to advocating, choices and culture, there are 3 steps we need to take:

Step 1. When a client refuses a particular treatment or requests something different about their care, our 1st priority is to validate our understanding of their choice by collecting more information.

In other words, we need to assess a client’s thoughts, feelings, preferences and concerns in order to better understand what they need. This is a priority because we cannot begin to offer help to clients unless we have an understanding of what they think, feel, believe and value.

Collecting more information is the first priority whenever clients refuse aspects of their care, or make requests about their care that could be harmful.

For example, if a client tells us they:

  • Want to smoke in their room
  • Don’t want a male nurse to care for them
  • Don’t want to take their medication
  • Don’t want to walk
  • Don’t want opioid analgesics
  • Don’t want to be repositioned
  • Don’t want to eat the meal they’ve been given

we have to prioritize an assessment in order to understand the reasons behind their choices. In my experiences as a nurse, I’ve found this step to be essential. Without understanding the reasons underlying someone’s choices and preferences, we cannot offer them the help they want and need

Let’s say a client preparing for surgery tells us, “I don’t want opioids after surgery”. We could respond by offering reassurance or information like, “Opioids are effective pain-relieving medications post-operatively” or “Opioids are not addictive when used in appropriate situations”. Or, we could start by asking, “What are your concerns about opioids?”. Unless we ask, we won’t know what clients need to hear. A client who doesn’t want to take opioids may be concerned about side effects, or they may be worried about taking them if they’ve had a reaction in the past.

On the CPNRE®, prioritizing assessment is most important whenever a client makes a request or refusal for care that could result in harm.

Remember, client choices often reflect their cultural values or beliefs, and while they may be helpful in some circumstances, when it comes to health and wellness, some values and beliefs can be harmful. In order for clients to make informed decisions about their health, we need to first understand what they know, what they believe and what they don’t know.

Step 2. After collecting more information to understand the reasons underlying clients’ requests or refusals about their care, the 2nd priority is for us to provide clients with relevant information so they can make an informed decision.

Once we understand the reasons underlying a client’s choice, then we’re able to provide them with information so they can make informed decisions about their health and their care.

It’s tempting to want to offer advice or information whenever someone makes a refusal about their care, or when someone makes a new or unusual request. But we know that prematurely offering information leads us down the slippery slope of making assumptions of what people need, instead of finding out what they actually need

Step 3. After we understand the reasons behind a client’s choice and provide them with relevant information, the 3rd priority is for us to discuss the client’s refusal for treatment or request with relevant health care team member(s).

Health care has become so complex and specialized that it’s quite normal for clients to have several different health care providers involved in their care. Through my experiences and from research, I’ve learned that it’s most appropriate to involve other health care providers when:

  • We’ve collected information in order to understand the reasons why a client’s refusing care or requesting changes in their care
  • We’ve provided a client with relevant information to help them make an informed choice
  • The client’s problem is best addressed by another health care provider

When a client’s problem, or the solutions to their problem falls outside our scope of practice or expertise, that’s when it’s time to reach out for help.


Exam tactic 

On the CPNRE®, questions about culture and client-choice may involve clients:

  1. Refusing a particular treatment or intervention (i.e. refusing to take narcotic analgesia, refusing to eat, or refusing to participate in physiotherapy)
  2. Making a request (i.e. to wear particular clothing, to eat a particular kind of food, to have a spiritual ceremony)

When you see a question scenario that sounds like these scenarios above, it’s important for you to choose the answer that best represents one these 3 steps of advocating in sequential order, from 1-2-3.

As you get ready to write your exam, keep in mind that although the culture of nursing values empathy, autonomy, empowerment, honesty and respect for choices, not every culture or client will share these values. As nurses, we don’t necessarily have to agree with clients’ choices or practices, but we are obligated to respect the choices they do make. Clients have the right to make informed choices and decisions about their health, and as long as they don’t cause harm to other people, and they’re are aware of the potential consequences and risks, the choice is theirs to make.