Chapter 5: Cultural Issues in Mental Health Care

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement, not replace the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

We need to talk about the N word.

Wow.

Okay, you are starting us off on high alert today.

I am, but I'm not talking about that word.

I'm talking about the word you see stamped, you know, in big red ink on patient charts.

The word whispered at the nurse's station during shift change,

non -compliant.

Ah, okay, that word, the difficult patient.

Exactly, the patient who won't take their meds, the patient who, you know, stares at the wall during group therapy, the patient who, frankly, makes our jobs 10 times harder.

And we're trained to look at that patient and see, well,

defiance.

We do, we see a problem be solved.

Or maybe we think it's a person who just doesn't wanna get better.

Right.

It's sort of the path of least resistance for a clinician, isn't it?

You label it, you chart it, you move on.

And it protects our ego, in a way.

If they're non -compliant, it means we didn't fail.

They did.

But what if we're just completely wrong?

What if that label is actually masking a massive clinical failure on our part?

That is what we are unpacking today.

We have the research here on the desk, specifically chapter five of Psychiatric Nursing, the seventh edition, and the chapter is titled Cultural Issues by Barbara Jones Warren.

And the premise here, it's uncomfortable.

It suggests that non -compliance is often just a fancy word for we didn't understand who we were talking to.

That's a heavy accusation.

But, I mean, looking at the source material, Warren isn't pulling any punches.

This isn't one of those chapters about being nice or celebrating diversity in that corporate HR kind of way.

This is about safety.

It's about biology.

And it's about the fact that if you treat a patient using only your own cultural operating system, you might actually be hurting them.

And that's the mission for this deep dive.

We're gonna strip down this chapter.

We need to understand why a hex might be as clinically relevant as a virus, why your liver enzymes might care about your ethnicity, and why being on time is actually a cultural bias that could ruin your therapeutic relationship.

And we should probably warn you, the listener, we are gonna get into the weeds here.

We're talking ethnopharmacology.

We're talking about four very specific worldviews that dictate human behavior.

And we are going to look at some assessment tools that, I mean, honestly, I wish I had known about 10 years ago.

Oh, me too.

Yeah.

Definitely.

So let's start at the very foundational level.

The text throws around this word culture.

And I think most of us hear that, and we think food, festivals, maybe what kind of clothes you wear.

Yeah, the tourism definition of culture.

It's all surface level, it's safe.

It's safe, exactly.

But the definition in the text is, it feels much more invasive.

Invasive is a good word for it, yeah.

The text defines culture as both the internal and external manifestations of learned and shared values.

But here's the kicker.

It describes culture as the lens through which we interpret life.

The lens.

Think about it.

You don't see a lens, you see through it.

If you're wearing blue sunglasses, everything just looks blue.

You don't stop and think, oh, the sky appears blue because of my glasses.

You just think, the sky is blue.

Culture is exactly the same.

It's the invisible software running in the background of your brain that tells you what's normal and what's weird.

So when I walk into a patient's room, I'm not just walking in as the nurse.

I'm walking in wearing my own specific cultural glasses, carrying all my cultural baggage, and operating on my own cultural software.

That's it.

And the patient, they have a totally different operating system.

So if you're running Windows, and they're running Linux, and you try to install a program, say a medication regimen without some kind of emulator.

You get a fatal error.

You get a crash.

And in nursing, we call that crash non -compliance.

Okay, so the text brings up this concept here called cultural competence.

And I feel like this is a buzzword that gets so abused.

You know, you sit through a one hour seminar, you sign a sheet and suddenly you're competent.

The check the box approach?

Yeah.

The text specifically refutes that.

It cites researchers like Campina Bacote to make the point that cultural competence is a process, not a destination.

You are never done.

You don't get a badge for it.

It's this constant state of becoming aware.

But why does this matter biologically?

Because I can hear the skeptics right now.

They're thinking, okay, sure, feelings matter, but I'm here to treat a chemical imbalance in the brain.

And that's where the data hits hard.

The text cites Anthony and Warren to show a direct measurable link between culturally competent care and patient recovery rates.

It's not just about feelings.

If you misunderstand a patient's culture, you might misinterpret a normal behavior as a symptom of their illness.

But you can be an example of that, like a real world example.

Sure, okay, think about eye contact.

In let's say mainstream American culture or even just hospital culture, direct eye contact shows you're engaged, right?

It shows you're listening, you're being honest.

Absolutely, if a patient won't look at me, I'm charting guarded or internally preoccupied or avoidant.

Right, but in many cultures, and the text breaks this down later with specific groups, avoiding eye contact is a sign of respect for authority,

deep respect.

So you have a patient who is actively trying to show you respect and you are charting that they are paranoid or disengaged.

That is a diagnostic error.

You might end up treating a symptom that doesn't even exist.

That's terrifying.

It should be.

So let's move into the first major section of the chapter, barriers to culturally competent care.

The text uses a metaphor here that I really wanna dig into.

It calls the nurse the gatekeeper.

It's a powerful image, isn't it?

The gatekeeper.

It implies so much power, it implies that we hold the keys to the entire system.

Because in many ways we do.

The nurse is usually the first point of contact.

You do the intake, you decide who sees the doctor and when, you decide if a complaint is urgent or if it's just drug -seeking behavior, you control the flow of information and access.

And the text argues that that gate stays locked if there's miscommunication.

But not just language.

I think when people hear miscommunication, they immediately think, oh, I need a translator.

And of course, language barriers are huge, that's a given.

But the text focuses on something deeper, what it calls the blind spot.

The blind spot.

It's the clash of values.

The text describes a scenario where the nurse simply doesn't see the value in the patient's belief system, it's invisible to them.

Like, if a patient wants to use an herbal remedy from their grandmother.

Right, a nurse trained in the scientific model, which is all of us, might look at that herbal remedy and immediately think that's superstition, it's garbage, put that away and take this pill.

I have absolutely done that.

I've definitely thought, we don't have time for your magic tea, we have a blood pressure to manage here.

And that's the blind spot.

In that moment, you've just devalued their entire understanding of how their body works, you've dismissed their reality.

And the second you do that, the gate slams shut, the patient shuts down.

They might nod, they might say, okay, but they are not going to follow your plan.

And this goes right back to the adherence issue.

The text makes a really bold claim here.

It says, adherence increases when cultural needs are met.

It's logical, isn't it?

I mean, if I feel like you understand me, like you actually get me, I'm gonna trust you.

If I trust you, I'll try your solution.

If you roll your eyes at my beliefs, I'm gonna throw your prescription in the trash the second I leave the building.

There's a critical thinking question posed in this section of the chapter that I think every nursing student should have to answer in an essay.

It asks,

how do you handle a patient refusing a care plan due to a cultural conflict?

That is the million dollar question,

because safety is always our number one priority.

Right.

And if the hospital protocol says safety and the patient's culture says risk,

we are trained, we are drilled to choose safety every single time.

But the text suggests we have to redefine how we get to safety.

The answer isn't force, it's not coercion.

The answer is negotiation.

Negotiation.

That feels weird in a hospital setting.

We're used to orders, you know, doctor's orders, nurse's orders.

I know,

negotiating sounds like we are compromising standards of care.

But think of it this way, the best medical plan, the gold standard plan that the patient won't do is utterly worthless.

It has zero efficacy.

Right.

A good medical plan that the patient will do because it aligns with their life is infinitely better.

So if a patient refuses a medication at 9 a .m.

because it interferes with a morning prayer ritual.

The rigid nurse, the gatekeeper nurse says, 9 a .m.

is med pastime, you have to take it now.

The patient refuses.

The nurse charts non -compliant, end of story.

But the culturally competent nurse says, Okay, I understand.

Is it possible to take it at 9 .30 after your prayer, or maybe at 8 .45 before?

You negotiate.

You align the evidence -based practice with the patient's lived reality.

You don't just steamroll them with a schedule.

It seems so simple when you say it out loud, but in the heat of a busy shift, that requires a lot of mental flexibility.

It requires humility.

It requires you to admit that your hospital schedule isn't actually the center of the universe.

Which brings us to the root of these conflicts.

It's not just about schedules or pills.

It's about a fundamental disagreement on what sickness actually is.

This is the next section in the chapter on the cultural etiology of illness.

And etiology is just a fancy word for the cause.

Where did the sickness come from?

We take this for granted.

If I have the flu, it's because a virus infected my cells.

End of story.

It's simple.

That is the scientific view, and that is the bucket most of us listening to this are sitting in.

We believe in pathogens.

We believe in neurochemistry, DNA, structural abnormalities.

It's a very mechanical view.

The body is a machine and the machine is broken.

But the text outlines two other massive belief systems that our patients might be operating under.

The natural and the unnatural.

And these are wildly different from the scientific view.

Let's look at the natural view first.

This is common in many indigenous cultures, some Asian cultures, and even in holistic health circles in the West.

The core belief here is balance.

Equilibrium.

Everything is connected.

The body, the spirit, the earth, the concepts of cold and heat.

Illness isn't an attack from an outside germ.

It's a sign that you are out of sync.

You've lost your harmony with the environment.

So if I try to treat a natural view patient by just carpet bombing the germ with an antibiotic.

You're missing the point for them.

They don't just want the germ dead.

They want the balance restored.

They might believe they need a purification ritual just as much as they need that antibiotic.

If you give them the pill but you deny the ritual, they don't feel healed.

They feel like you only did half the job.

Okay.

And then there's the unnatural view.

Yeah.

And this is where I think Western nurses really, really struggle.

This is where we start rolling our eyes.

This is the realm of the supernatural.

And the text is very specific here.

We are talking about magic, witchcraft, ghosts, and hexes.

Bells.

Yes.

The belief that an outside force, a spirit, or a person using spiritual power has actively and intentionally caused this illness to happen to you.

I had a patient once who was convinced, I mean absolutely convinced,

that her severe stomach pain was because her neighbor had put a curse on her.

We did every scan.

CT, MRI, ultrasound.

We found nothing.

And what did you tell her?

I told her the scans were clean and that she was physically healthy.

And did she believe you?

Did her pain go away?

Not for a second.

She left angry.

She said we didn't know what we were doing.

And because you were answering a scientific question, which was, is there a tumor?

When she was asking an unnatural question, which was, is the curse still there?

To her, your CT scan is irrelevant.

A CT scan can't see a curse.

So what was I supposed to do?

I mean, was I supposed to call an exorcist to the GI lab?

Well, maybe not you personally.

But the first step is to acknowledge the reality of her distress.

You don't have to believe in the hex, but you absolutely have to believe that she is suffering because of her belief in the hex.

If you dismiss it as delusional right out of the gate, you lose her.

It feels like a tightrope walk.

It is.

But that's why this chapter focuses so heavily on worldviews.

If we can understand the underlying logic behind the behavior, we stop seeing it as crazy and we start seeing it as just a different set of rules.

The text breaks this down into four distinct worldviews in these huge tables.

Tables five one through five four.

These tables are the absolute meat and potatoes of this chapter.

They really explain the why behind all the friction we see on the floor.

They do.

And I wanna go through them one by one because I guarantee every listener will recognize themselves in one and probably their most difficult patient in another.

Okay, let's start with the default for healthcare.

The analytic worldview.

This is labeled in the text as European American, but honestly, you could just call it hospital culture.

Even if you aren't European American yourself, if you work in a hospital for long enough, you are trained into this worldview.

So what are the core values here?

Detail, individuality, material possessions, but the big one, the one that rules everything, time.

In the analytic worldview, time is a commodity.

It can be wasted, it can be saved, it can be spent.

We value being on time, we value efficiency.

We wanna start the meeting at nine o 'clock sharp and end it at 9 .15.

Time is money,

that whole idea.

Exactly, and the logic is described as dichotomous.

That's just a fancy way of saying we separate things into boxes, mind versus body, work versus home, the problem is here, you fix the broken part and you move on.

So an analytic patient loves a schedule.

They love a plan.

They love a pamphlet, they love a chart with data.

They wanna know the side effects in a bulleted list.

They want to get down to business immediately.

Okay, so that's me.

That's most of us in healthcare.

Now, contrast that with the relational worldview.

This is associated with African, African American, Hispanic and Arabic cultures.

And the shift here is seismic.

I mean, it's a completely different planet.

The core value isn't time or efficiency,

it's relationship.

Meaning what, exactly?

Meaning the human interaction is the point.

Spirituality is often the context for everything and the logic isn't separation, it's union.

Everything is interrelated, mind, body, spirit, family, community,

it's all one thing.

So if I walk into a relational patient's room with my analytic clipboard and I say, okay, pain scale one to 10, let's go.

I have three other patients waiting.

You are being incredibly rude.

You are violating their core value.

To them, you haven't established a human connection yet.

You haven't earned the right to ask those questions.

You're treating them like a task on a to -do list.

But to me, they're a task on my list.

I have 15 other meds to pass.

And that is the friction.

That's the clash right there.

You think you are being efficient.

They think you are being uncaring and cold.

And once they decide you don't care about them as a person, they stop listening to you as a nurse.

So what does the text suggest?

It suggests you have to chat first.

You have to be a human being before you can be a nurse.

Ask about their family.

Comment on the picture on their bedside table.

Spend two minutes building a rapport.

That costs time.

Time I don't always have.

But it's an investment.

Think of it that way.

If you invest that two minutes up front building the relationship, you get the adherence.

You get the trust.

If you save that two minutes in rush, you get a non -compliant patient who ends up taking an hour of your time later because they're angry or they refuse care.

That's a really good way to frame it.

It's an investment, not a cost.

And the text also says they often want family involved in decisions, right?

Yes, very much so.

Decisions are often made as a group, as a family unit.

In the analytic view, we are obsessed with patient privacy and autonomy.

We want the patient to decide for themselves.

But in the relational view,

cutting the family out of the decision is like cutting off a limb.

It's unthinkable.

OK, let's look at the third one from the tables, the community worldview.

This is linked to Asian and Polynesian cultures.

This one is different again.

Here, the needs of the group, the community, supersede the needs of the individual.

It's all about maintaining balance and harmony between the member and the community.

The text mentions politeness and reticence here as the key nursing implication.

This is a huge, huge trap for analytic nurses.

In many community worldviews, questioning authority is seen as deeply disrespectful.

You are the nurse.

You are the expert.

You are the authority.

So if you give them instructions and then ask, do you understand, they will almost always say yes.

Even if they don't have a clue what I just said.

Especially if they don't have a clue.

They are nodding and saying yes to show you respect, not to show you comprehension.

They are nodding to maintain the harmony of the interaction.

They don't want to cause a problem or make you feel like you didn't explain it well.

So a yes and a nod is basically a false positive for understanding.

It can be.

You walk out of the room thinking, great, perfect patient education session and they're left thinking, I have no idea what to do but I didn't want to embarrass the nurse by asking.

So how do you check for understanding then?

You can't just ask, do you understand?

You have to use the teachback method.

You have to say, to make sure I explain this correctly, can you show me how you will take this medicine?

Or tell me in your own words what you need to do when you get home.

You need them to demonstrate or verbalize it back because they won't verbally contradict you.

That's a major clinical pearl right there.

Yeah.

Okay, the fourth and final one from the tables.

The ecologic worldview.

This is associated with Native American and indigenous cultures.

This worldview is deeply rooted in the interconnectedness of all things, especially the earth and the universe.

The logic is that the great spirit is in everyone and everything.

And the communication style is, well, it's quiet.

Quiet.

Very quiet.

Learning happens through quiet observation, through contemplation.

There's a value placed on minimal verbal clutter.

I'm imagining the cheerleader nurse, you know the type.

Super high energy, loud voice, walks in clapping, good morning, how are we feeling today?

That nurse is a sensory assault for an ecologic patient.

It's overwhelming, it's jarring, it's seen as disrespectful.

The text is very clear that a quiet, calm, restful approach is best.

If you rush, if you talk too much, you are actively pushing them away.

It's just amazing when you lay them all out like that, isn't it?

The exact same behavior, being high energy and efficient, makes the analytic patient happy, it annoys the relational patient, it confuses the community patient, and it offends the ecologic patient.

And that is precisely why cultural competence can't be a checklist.

You have to learn how to read the room, you have to figure out which operating system is running before you try to install your program.

So we've covered these worldviews.

Now let's move to something that can really trip up a psychiatric nurse specifically.

We are talking about culture -bound mental health issues.

This is fascinating territory.

These are recurring patterns of behavior that create really disturbing experiences for the person, but they are specific to certain cultures.

And the important note here is that the DSM -5, the Bible of psychiatry, now actually includes a cultural formulation tool to help clinicians with this.

These aren't just folktales anymore, they are recognized clinical phenomena that we need to know about.

So let's look at the specific examples the text gives.

It mentions Native American patients describing depression in a particular way.

Yes, they might not use the word depressed.

They're more likely to describe the feeling as heart pain or being heartbroken.

Now, if a nurse in an emergency room, hears a patient say, I'm having heart pain, what's the first thing they do?

They call for EKG stat.

They're thinking heart attack, they're getting the crash card, it's a code blue situation.

Yeah, right.

They go immediately down the cardiac pathway.

But for this patient, heart pain is the cultural idiom for deep, profound depression.

If you don't know that cultural code, you're treating the wrong organ.

You're giving them aspirin when what they might need is counseling or an antidepressant.

Wow, okay, what about the Hispanic examples the book gives, susto and malojo?

Susto translates loosely to soul loss or magical fright.

It's believed to happen after a traumatic or frightening experience where the soul is thought to have literally left the body.

And malojo is the evil eye, the belief that a curse or a malicious stare can cause illness.

And what do the symptoms look like?

The symptoms can look a lot like things we'd recognize, lethargy, loss of appetite, changes in sleep, crying, sadness.

Which sounds a lot like major depressive disorder or maybe generalized anxiety disorder in the Western DSM model.

It matches the symptom cluster, yes.

But the perceived cause and the treatment path are completely different.

The text notes that for these conditions, a healer or a root doctor is often the very first stop, not the hospital.

The goal isn't to get a prescription for Zoloft.

The goal is to perform a ritual to return the soul or to break the hex.

The book mentions a few others.

Running amok in Malaya or Laos, which is described as a sudden psychotic episode.

Ghost sickness in some Native American cultures.

And the belief in spells or hexes in certain African American or Appalachian cultures.

And there is a clinical example in the text about an Appalachian woman who is completely convinced her illness is due to a hex placed on her by another woman.

The critical question for the nurse is, do you try to convince her she is wrong?

My gut reaction, my analytic brain says yes.

It wants to say, that's not real.

But based on everything we've talked about, my gut says the right answer is no.

The nursing takeaway is, do not try to convince the patient they are wrong.

You must acknowledge the distress in their cultural context.

You don't have to believe in hexes yourself, but you have to believe that she believes in hexes and that that belief is causing her real legitimate suffering.

So it's about validating the distress without necessarily validating the supernatural cause.

Or at least not getting into a fight about it.

It's about not setting up an adversarial relationship.

The second you say hexes aren't real, what she hears is, you think I'm crazy or you think I'm stupid.

And in that moment, you've lost her completely.

That makes sense.

Yeah.

Okay, moving on to alternative therapies.

We know patients are using them, often alongside what we're doing.

What does the text highlight here?

It covers a whole range of therapies that are used to restore that sense of balance we talked about.

There are the physical techniques like acupuncture and acupressure, which work on stimulating the body's meridians.

But then we have things that are much more likely to be misinterpreted by healthcare staff.

Things like skin scraping, coining and cupping.

I've seen pictures of cupping with the big round bruises, but I've heard of coining.

Can you describe what that is?

It involves rubbing the skin briskly, often on the back or chest, with a coin or another hard object.

For cupping, heated glass cups are placed on the skin to create suction.

The goal, culturally, is to bring heat and stagnant energy or illness to the surface and release toxins or evil spirits.

But visually, the result looks pretty dramatic.

Visually, it leaves very distinct marks.

It causes linear bruising, patechiae and abrasions.

And this is a huge red flag for nurses who don't know what they're looking at.

Huge.

A nurse, especially in pediatrics or the emergency department, might immediately mistake these marks for signs of physical abuse.

And the text warns us in no uncertain terms, do not mistake this for abuse.

However, there is a clinical duty here.

You must monitor for skin integrity.

These are abrasions.

The skin is broken.

They can get infected.

So you respect the practice, but you treat the wound.

Exactly.

You don't call social services.

You get some bestatracin.

Okay, then there's moxibustion.

What's that?

That's the practice of burning moxa, which is a dried, cotton -like substance from the mugwort plant on or near the skin to generate heat and release illness.

Again, there's a potential for burns, but it's a deeply held belief in its efficacy for restoring balance.

And then there's the concept of hot and cold balance.

This one always confuses people because we immediately think of temperature.

Right, and it has nothing to do with the thermometer.

In many Hispanic and South American cultures, among others, hot and cold refer to the intrinsic property of the substance, a food, an herb, a medicine, and how it reacts in the body to restore equilibrium.

So a disease might be classified as hot, like a fever, and it needs a cold medicine or a cold food to treat it.

Exactly, and here is the direct clinical application.

A patient might refuse a medicine you're giving them because they classify it as a hot medicine and they believe their condition is already hot.

Taking it would make them worse.

And the nurse just sees a patient refusing meds.

The uninformed nurse does.

But the culturally competent nurse knows this rule, and they can say, I understand this is a hot medicine.

What if we take it with a glass of cool water or fruit juice, which might be classified as cold?

And suddenly, by making that one simple adjustment, the patient agrees, the balance is maintained.

That is such a simple, elegant fix if you just know the rule.

It really is.

So much of cultural competence is about these simple fixes that unblock the gate.

Okay, now we are gonna pivot pretty hard.

We've been talking a lot about beliefs, feelings, and spirits,

but chapter five takes a hard right turn into hard science.

We are talking about ethnopharmacology.

This is the biology of culture.

It's the study of how a person's race and ethnicity affect how their body processes medications.

This moves us away from beliefs and into the world of genetics and physiology.

And this is where the blind spot isn't just cultural, it's physiological.

You can cause real physical harm if you don't know this stuff.

Absolutely, the text focuses on metabolism variations.

We hear these terms, fast and slow metabolizers.

Can you break that down in plain English for us?

Sure.

Think of your liver as a big processing plant for drugs.

The workers in that plant are your enzymes.

If you are a slow metabolizer, your workers are, well, slow.

They don't break the drug down fast enough.

So the drug starts piling up on the conveyor belt.

Exactly, it accumulates in your bloodstream to dangerously high levels.

This means the patient is at a very high risk for toxicity.

They might take a standard 10 milligram dose, but their body handles it like it's 20 milligram or 30 milligrams.

They get severe, sometimes dangerous side effects from a normal dose.

And fast metabolizers, what happens with them?

Their workers are too fast, they are overeager.

They break the drug down and flush it out of the body before it can even do its job.

This leads to therapeutic failure.

The patient takes the pill every day as directed, but nothing happens, they don't get better.

The text gives some very specific biological examples here, starting with alcohol sensitivity.

Yes, this is a classic example.

It notes that approximately 50 % of people of Asian descent and also many Native Americans have a deficiency of a specific liver enzyme called aldehyde dehydrogenase.

What does that enzyme normally do?

It's a cleanup enzyme.

When you drink alcohol, your body first turns it into a really nasty toxic chemical called acetaldehyde.

This enzyme is supposed to swoop in and immediately clean that toxin up before it can cause problems.

And if you don't have enough of the enzyme.

The toxin builds up instantly.

It's like having a poison dump directly into your system.

And what's the result of that?

What does the person feel?

Intense facial flushing, erasing heart rate tachycardia, and a burning sensation in the stomach.

It's physically painful and deeply uncomfortable.

It is not a pleasant buzz.

It's a toxic reaction.

Okay, so for psychiatric nursing,

the big players are the cytochrome P450 enzymes.

Specifically, the text points out 2D6 and 2C19.

Yes, those sound like droids from Star Wars, I know.

They really do.

But they are the absolute workhorses of drug metabolism in the liver.

And the text provides a crucial table, table 55, that shows the cross -ethnic variability in how these enzymes function.

This is data that every nurse who gives medications needs to know.

So give us the highlights from that table.

What's the bottom line?

Okay, let's look at the enzyme 2C19.

The text says that about 17 to 22 % of East Asians are poor metabolizers for this specific enzyme.

Now compare that to only three to 5 % of whites or blacks.

So that means almost one in five East Asian patients might not process drugs that use this enzyme pathway effectively.

They're at a much higher risk.

A much higher risk of toxicity.

So if you give a standard dose of a psychotropic drug that is metabolized by 2C19 and many of them are to an East Asian patient, there is a significantly higher chance that they will develop severe side effects.

And the so what here is absolutely vital for practice.

The so what is that if a patient from a high risk group complains of severe side effects, you do not dismiss it.

You don't say, well, 10 milligrams is a very low dose.

You shouldn't be feeling that.

Their genetics might be making that 10 milligram act like 50 milligram in their body.

If you ignore them, they will stop taking the medication and then they will relapse and you'll be back at square one.

This brings us perfectly to the final section.

The nurse's role in cultural assessment.

We've got all this theory.

How do we actually apply it on a Tuesday morning?

The key word the text uses is integration.

A cultural assessment should never be an interrogation.

You don't walk in with a clipboard and just fire off a list of questions.

Tell me your cultural beliefs now.

It has to be done smoothly and sensitively woven into the fabric of your general health assessment.

There is a worksheet mentioned, table five, six.

It breaks down the key domains to cover.

Let's maybe just run through them quickly so listeners know what they should be listening for and asking about.

First up is communication.

Obvious things like what language do they speak?

Do they need a professional interpreter?

But also subtler things.

How do they feel about eye contact or about being touched?

Okay, then orientation.

What does that mean?

That's about their background.

Where were they born?

How long have they lived in this country?

This helps you understand their level of acculturation, which can really vary.

Next is nutrition.

This is a great non -threatening way to start the conversation.

What foods do you eat when you're ill?

Are there foods you avoid for spiritual or health reasons?

People usually like talking about food.

This one is huge.

Who makes the decisions in your family?

Is it patriarchal?

Is it matriarchal?

Is it a group decision?

If you're spending an hour educating the patient, but it's really their grandmother who makes all the health decisions, you're educating the wrong person.

Health beliefs.

This is the golden question.

What do you think caused this illness?

Or why do you think you are sick right now?

The answer they give you will tell you immediately if they are operating from a natural, unnatural or scientific worldview.

It's a spirituality.

What's their religious preference?

Are there certain times they need for prayer or meditation?

Do they have any spiritual objects they need to keep with them?

And finally, biology.

This is where that ethnopharmacology comes in.

Are there any specific physical attributes or known enzyme differences that we need to suspect or be aware of based on their ethnic background?

And to wrap it all up, the text gives us three very specific nursing interventions from the theorists Leiner and McFarland.

These are like the tools in the toolbox once you've done your assessment.

Yes, these are the three action modes.

The first one is cultural preservation.

This is where you actively acknowledge and value the patient's helpful beliefs.

You accept them.

You support them.

So like letting a patient wear a religious amulet into a procedure if it's not in the way.

It doesn't hurt anything and it helps them feel safe and grounded.

So you preserve it.

The second one is cultural negotiation.

This is where you work within their belief system to find a compromise that allows for safe medical care.

That's the example of moving the medication time to not interfere with prayer.

Perfect example, you negotiate.

And the third one is cultural repatterning.

This is the hardest one.

This is what you do when a cultural practice is actually harmful.

Like the example of using a dirty needle for a folk remedy?

Right.

If a patient is using a folk remedy that involves say cutting the skin with a dirty blade to let the illness out, you can't preserve that.

It's dangerous.

But you don't just say, stop it, that's stupid.

You say something like, I understand the need to release the bad blood.

That is an important part of your healing.

But using this blade can cause a serious infection.

Let's look at a sterile way we can achieve this or another way to help you feel that release.

So you identify the harmful practice and help the patient change it while still respecting the underlying cultural need.

You're not deleting their belief.

You're repatterning it.

You keep the core of the culture intact, but you remove the immediate danger.

Well, we have covered a lot of ground today.

From the initial frustrations of that non -compliant label all the way down to the molecular level of liver enzymes.

It's a whole journey, isn't it?

We moved from understanding that culture is basically an operating system to recognizing those four worldviews, analytic, relational, community and ecologic and how they dictate every single communication.

We looked at how culture defines the very cause of illness.

We explored the culture -bound syndromes that can look like pathology, but are actually valid patterns of distress.

And we finished with the hard biological reality of ethnopharmacology.

And the main takeaway from all of this, what's the one thing you want people to remember?

The cultural competence isn't just being nice or being politically correct.

It is evidence -based practice.

It improves adherence, it improves safety and it promotes recovery.

If you actually want your patient to get better, you have to take the time to understand who they are.

And I wanna leave you, our listener, with a final thought, something to mull over.

The next time you see a patient who's been labeled non -compliant or the next time you feel that frustration rising because the patient just isn't listening to you,

will you pause and ask yourself, is this defiance or is this a difference in worldview that I haven't taken the time to understand?

That's the question that changes your entire practice.

Thank you for joining us for this deep dive.

A warm thank you from the last minute lecture team.

Take care, everyone.