When cultures collide: decision making in a multicultural environment. (1997)

The health care system mirrors the growing diversity of America's population. This changing face of the nation is particularly evident to nurses who care for increasing numbers of foreign-born individuals with varying cultural beliefs, values, and practices. Both clients and nurses approach health care situations from unique perspectives based on personal experiences. These perspectives color the way clients assess their health care needs, nurses interpret the clients' specific health/illness behavior, and the joint decision-making processes involved in helping clients seek health care. Nurses are, however, obligated to respect the clients' health beliefs and practices even when their own personal values and beliefs are different. In turn, they want the practice environment to be supportive of their decisions and actions. But how can nurses avoid a collision with the client's value system while meeting their professional obligation? More specifically, what is the responsibility of the nurse and the director when a white South African woman refuses care from an Afro-Caribbean nurse and insists that her care be provided exclusively by white nurses? This question arose at a college-managed nursing center at which nursing students and faculty provide care to homebound older clients in a collaborative effort with social workers. In managing this issue, students were challenged to critically analyze their own value systems as well as the value systems of their clients and devise strategies to provide culturally competent care. Cultural competence is a complex integration of cognitive, affective, and skill dimensions that motivate nurses to develop the knowledge, skill, and ability necessary to care for diverse clients, families, and communities (Frei, Hugentobler, Schurman, Duell & Alioth, 1994; Orlandi, 1992). It is an ongoing process that is developed in a variety of ways, but mainly through experiences with clients from different cultures (cultural encounters) and through receptivity to these experiences that would allow for change in behavior. Culturally competent nursing care takes into consideration the client's cultural needs (AAN Expert Panel, 1992), It is a higher level of performance than culturally sensitive care that was once associated with effective nursing care. To be culturally sensitive suggests that nurses may be aware of cultural differences, but may not have the skills or the commitment to change their behavior and effectively work with clients within the context of their culture. Report of Case One particular case among many encountered at the Nursing Center of the State University of New York Health Science Center, in Brooklyn, New York, can serve to illustrate the principles of cultural competency as they relate to nursing care. In May, 1994, a 90-year-old Orthodox Jewish South African woman, experiencing increasing memory loss, was referred to the Nursing Center. The client had recently been robbed by someone posing as a delivery person, but she could not remember the time or the items that were taken. On the initial visit, the woman, well coifed and dressed, a cameo brooch, at the neck of her dress, had an aristocratic demeanor. She was articulate and spoke with a British accent learned when I went to a boarding school in Pretoria. The following nursing diagnoses were made: (1) potential for injury due to uncompensated memory deficit, limited mobility, and decreased vision; (2) potential alteration in self-bathing and hygiene due to cognitive changes resulting in inability to provide self-care; (3) potential alteration in sensory perception due to uncompensated visual defects resulting in falls, inability to read; (4) alteration in bowel elimination: constipation due to inadequate intake of fluids and inadequate activity; and (5) urge incontinence resulting in potential urinary tract infection. While the identified diagnoses were pertinent, a more pressing issue soon surfaced that threatened the development of an effective nurse-client relationship: the client's inability to relate to the multicultural staff at the center. …