12 Cultural Considerations and the Art and Science of Patient-Centered Caring

Cultural Considerations

Humans are social beings who form patterns of thinking, relating, and behavior which are considered “normal.” These patterns can vary widely between different groups of people, however. Think about the difference in thinking, relating, and behaving between teenagers and older adults or persons from developed countries and isolated indigenous populations. These patterns form cultures which include attitudes, beliefs, values, behaviors, roles, and self-definitions (Caplan, 2017). These factors affect the way that nurses care for and are expected to care for persons in each culture.

Definitions and scope

Culture is a complex concept that affects all areas of life including child-rearing, gender and family roles, communication patterns, self-definition, dietary habits, health beliefs, attire, religious practices, values, and care of elderly and vulnerable persons (Caplan, 2017). Culture develops within groups over time and shapes beliefs about health, illness, and healthcare delivery. Therefore, it is an important part of patient-centered care. Each patient and nurse have a set of health beliefs that are learned over time and these personal ideas affect every nurse-patient encounter. Healthcare workers often focus on disease prevention and treatment – the malfunctioning of one or more body systems. Patients, on the other hand, focus on how the disease affects them – the illness mindset (Potter, Perry, Stockert, and Hall, 2017). Nurses are taught to think about human responses to health and disease and understand how each patient experiences and responds to the illness. Nurses then use knowledge of culture to inform clinical decisions so that patient preferences are included. When nurses understand cultural similarities and differences, therapeutic communication can be enhanced so that health outcomes are improved.

In describing diversity, a core value of nursing education, the National League for Nursing (NLN) states that “Nursing takes place in a rich climate, one that embodies the belief that nursing is for all, and that each person’s worth and dignity is to be respected and valued” (NLN, p. 12, 2010). Nurse educators are urged to help students move “beyond tolerance to embracing and celebrating the richness of each individual” (NLN, p. 12, 2010). When nurses embrace cultural diversity, healthcare organizations can be transformed into systems that provide culturally competent healthcare.

Attributes, criteria, and context in healthcare

Culture is a ‘way of life’ that is learned and passed from one generation to the next through communication and imitation (Lenart, 2017). Enculturation is the process where individuals learn expectations about group beliefs, values, and behaviors (norms) from others within the group. For example, young children are taught expected behaviors by families, teachers, and caregivers within a culture and what to believe and value. Acculturation is the learning of new group norms while keeping some norms from the original group. Teenagers often adapt to peer group behaviors while adhering to some family beliefs and values. Nursing students move through this process during school before entering the professional nursing work culture. Some people experience several changes in beliefs, values, and behaviors over a lifetime, while others strive to maintain cultural heritage. Assimilation is the process of giving up former cultural identity and norms for another group’s preferences while biculturalism is the ability to maintain both patterns and identities. To feel safe and thrive in a new culture, persons who migrate from one culture to another must learn how to assimilate or find ways to live as a bicultural person.

Culture can change and adapt

Culture can change due to environmental or internal factors. For example, natural disasters can cause migration and the blending of different cultures. Each culture must learn to respect and adapt to the other if both are to live in harmony. Acculturation, assimilation, and biculturalism occur over time, changing both cultures as individuals adapt to the blending of beliefs, values, and behaviors. Internal factors can also create change due to new technology or knowledge. For example, new sanitation practices can dramatically reduce the number of deaths from infection, and electricity can support education, transportation, and communication within a culture. When motor vehicles replaced horses, people began moving across large distances quickly. This new ability dramatically changed American culture as people from different subcultures interacted with each other and shared produce, goods, ideas, attitudes, values, beliefs, and behaviors.

Shared beliefs, values, and behaviors

Most individuals within a culture learn social norms – the shared beliefs, values, and behaviors of the group – and live according to those views. Children begin enculturation from the moment they are born and learn to adapt to the expectations of their caregivers. However, not everyone wants to or is able to “fit in” completely. Sometimes people struggle with adherence to cultural expectations which causes stress for the individual and possibly for the group. Since culture is learned, each person makes decisions about what is learned or not learned. Beliefs, values, and behaviors that fall outside cultural expectations can cause a person to be ostracized or coerced by members of their group. Nurses must be alert to individual cultural differences to provide patient-centered care.

Cultural considerations for nurse-patient encounters

In today’s healthcare setting, nurses care for diverse populations which include persons from many different ethnicities, cultures, belief systems, and socio-economic and educational levels (Caplan, 2017). Most groups of people develop stereotypes about other groups; however, nurses must rise above stereotypes to provide accurate, compassionate, and safe care. Nurses are human and have innate biases so it would be unreasonable for nurses to think they have no biases or that they can rid themselves of all stereotypical thinking (Stabler-Haas, 2012). The goal is to be aware of bias and work around personal views to build therapeutic relationships and prevent harm. Every nurse must ask with every patient encounter, “How is my background affecting the way I care for this person?”

Ethnocentrism. Individuals within a culture sometimes believe that their culture is better than other cultures. This bias can lead to misunderstandings between cultures, social injustice, and even wars. In nursing, these views can prevent therapeutic communication, alienate patients and families, and result in poor quality healthcare (Lenart, 2017). Nurses are not immune to thinking that one patient deserves better care than another. The professional responsibility is to recognize personal ethnocentrism and then strive to provide nursing care with equal regard for all humans. For example, a nurse does not like caring for homeless people and feels disgusted when bathing them or dressing wounds. She values hard work and being able to “tough it out when the going gets rough.” She thinks these patients have been lazy and are “looking for a handout” so she provides minimal care and focuses most of her work hours on patients “who deserve my attention.”

Stereotyping. Nurses must recognize that individuals within a culture can have varied views about commonly accepted norms (Lenart, 2017). Some persons adhere to most or all cultural expectations while others violate beliefs, values, and expected behaviors on a regular basis. Nurses who think that all persons from a culture think, feel, and act the same could make mistakes in care and cause unnecessary discomfort or harm. For example, a nurse who is striving to be culturally sensitive removes a food item from the meal tray stating, “I know you will not be wanting that!” could be mistaken and cause embarrassment if this patient wanted

to eat the food. The best way for nurses to know how to support a patient’s beliefs, values, and behaviors is to ask (Kleinman, Eisenberg, and Good, 1978). The next section describes an evidence-based tool to guide a culturally sensitive assessment.

The patient’s view. One mark of an expert professional registered nurse is the ability to care for any person with dignity, respect, and attention to the patient’s view of health and illness. However, nurses sometimes care for patients and families they do not like or understand. Something about the beliefs, values, and behaviors disturbs the nurse. Professional nurses will keep this dislike and discomfort to themselves and care for each person with respect and dignity (Stabler-Haas, 2012). Many times, a mentor or colleague can offer advice or information that helps the nurse provide safe, compassionate, and quality care. Additionally, the nurse can get to know the person through therapeutic conversations.

A set of evidence-based questions was developed by researchers to guide clinician-patient interactions when caring for persons of various cultures (Kleinman, Eisenberg, and Good, 1978). These questions elicit the patient’s beliefs and values regarding health and illness and explain the meaning behind health behaviors. Nurses learn from patients and find common ground that leads to healthy behaviors such as taking medication on time, eating a healthier diet, or beginning an exercise routine. The questions can be adjusted based on patient characteristics but should reflect the nurse’s genuine interest regarding the patient’s view of health and illness (Kleinman, Eisenberg, and Good, p. 256, 1978).

1. What do you think has caused your problem?
2. Why do you think it started when it did?
3. What do you think your sickness does to you? How does it work?
4. How severe is your sickness? Will it have a short or long course?
5. What kind of treatment do you think you should receive?
6. What are the most important results you hope to receive from this treatment?
7. What are the chief problems your sickness has caused for you?
8. What do you fear most about your sickness?

These questions can help the nurse establish a trusting relationship. Through the conversation, the nurse learns about the patient’s hopes and goals for health – or the lack of hope. Sometimes a patient lacks hope or has a false hope due to misinformation or a cultural belief or value. The nurse can partner with the patient and family to improve health outcomes through culturally sensitive health education. Nurses work with the patient, family, and clinical team and often serve as an interpreter between lay-person understanding and western-medicine jargon. “This process of negotiation may well be the single most important step in engaging the patient’s trust, preventing major discrepancies in the evaluation of therapeutic outcome, promoting compliance, and reducing patient dissatisfaction” (Kleinman, Eisenberg, and Good, p. 257, 1978).

Cultural Competencies

Cultural competence is the ability to understand and appreciate other cultures and learn how to partner with individuals to ensure safe, quality nursing care and patient-centered goals (Lenart, 2017). Nurses use cultural knowledge to adapt skills that provide comfort while meeting individual patient needs. For example, one patient might want a family member to assist with bathing, while another patient might consider it a violation of privacy. Nurses learn what works through asking direct questions of each patient and family, observing for nonverbal communication, asking for the meaning of behaviors, and reading about and interacting with other cultures (Lenart, 2017). Nurses also learn about cultural lifestyles so that patient education is offered in a meaningful way. For example, patients with unusual dietary habits would need different medication scheduling instructions if drugs interact with food. Persons who work the night shift would also need adjustments in the dosing and scheduling of medications and other treatments.

Cultural competence includes four components: Cultural desire, self-awareness, knowledge, and skill (Caplan, 2017).

Cultural desire. Expert nurses develop a genuine interest in other cultures and a desire to learn about others so that quality patient-centered care can be delivered. This interest must come before cultural competence progresses. The willingness to listen to and learn from the patient’s point of view leads to greater trust in the nurse-patient relationship and helps the nurse develop patience, compassion, and empathy.

Self-awareness. Nurses learn to be self-aware regarding cultural competence and examine their own cultural beliefs, values, and behaviors. Professional nurses realize their personal views are learned assumptions and could be considered unusual or unhelpful to persons from other cultures. For example, a nurse who values traditional marriage might consider homosexual relationships to be immoral. Another nurse might feel anger toward a person who receives free healthcare paid for by tax dollars. Some nurses dislike caring for patients with obesity or addiction due to health beliefs and values regarding self-care expectations. Each nurse must investigate personal views so that respectful nursing care can be provided to every patient and family member. Some questions to ask oneself are:

• “Does the poor hygiene and odor-filled room cause me to avoid caring for this patient?”
• “Does this person’s anger and irritability make me recoil in fear?
• “Does my belief system cause me to think less of this ethnicity, attire, or faith?”

Knowledge and cultural encounters. Nurses learn about other cultures through formal education and by asking patients and families about their cultural beliefs, values, and behaviors. The nurse-patient relationship can be strengthened through the nurses’ genuine curiosity that is focused on bringing comfort, dignity, and respect. When nurses ask patients and families how to support cultural practices, especially as these relate to healthcare, patient outcomes can be improved. This information is added to the patient care plan so that other nurses can know what is important to the individual and family.

Nurses can also increase cultural knowledge by visiting ethnic grocery stores, community events, and religious services. To learn more about other cultures, a nurse can observe the way individuals use time, communication, healthcare systems, and customary beliefs and practices (Lenart, 2017). Some cultures are future-oriented, while others are past or present-focused. Some value being on time for appointments whereas others think of time as fluid. Communication preferences can be direct or indirect and eye contact can be considered polite or rude. Silence has several meanings and can bring comfort or distress. Personal space when interacting can be comfortable at very close ranges (less than 18 inches) or considered intrusive if less than two feet away. Touch can be viewed as helpful and comforting or intrusive and impolite. The healthcare system might seem efficient, healing, and helpful or rude, confusing, and inaccessible. Cultural beliefs and practices related to health, illness, and healing can augment or prevent adequate care. Family roles and responsibilities can differ across cultures. These factors can cause misunderstandings between patients, families, and nurses which leads to poor health outcomes. It is the nurse’s responsibility to observe, learn about, and provide culturally competent care for each individual.

Skill. Nurses acquire culturally sensitive skills through formal education, practice, and evaluation of what works/what does not work. To hasten competence, nurses perform cultural assessments of patients, families, and community members using the cultural assessment questions listed above (Caplan, 2017; Kleinman, Eisenberg, and Good, p. 257, 1978). Over time, expert nurses consider factors that influence cultural perspectives within each nurse-patient encounter: age, gender, ethnicity, socioeconomic status, communication patterns, nationality, subculture affects, and beliefs about religion, the meaning of life, health, illness, and mortality (Caplan, 2017). Nurses who strive for cultural competence listen carefully to patients and continually re-assess themselves for bias, stereotyping, and other assumptions. They have a genuine desire to learn what works best – from their patients and families.

Exemplars

These scenarios describe how expert nurses mentor novice nurses through cultural competency. The nursing profession values quality care for all persons within diverse populations and good mentors will help new nurses to build the required skills (NLN, 2010).

Nonverbal communication and family roles

Nancy, a new nurse on the medical/surgical unit was assigned to a 35-year-old male Latino patient with acute alcohol withdrawal and liver failure. The patient spoke Spanish and understood only a few English words, and he had been angry and uncooperative during the last shift. His 10-year-old daughter often translated for him when the medical interpreter was unavailable, and she was in the room during shift hand-off rounds. Nancy had learned in school that caregiver stress can be severe for children who interpret health information for their parents. Her concern for the child was compounded by anger against the father for having an addiction to alcohol. Her cultural beliefs viewed alcoholism as a sin and behavior that can be controlled through prayer and abstinence. She expressed her dislike for the patient and asked the charge nurse to reassign this patient. The charge nurse was an expert nurse with good mentoring skills who pulled Nancy aside.

“Nancy let’s talk about your health beliefs for a moment. They are interfering with your ability to provide professional nursing care to one of our patients.” Through expert mentoring and evidence-based nursing knowledge about addiction, the charge nurse helped Nancy see that her own learned culture had prevented an ability to provide compassionate care. The science of addiction-care has advanced rapidly through neuroscience and technology and explains why healthy behaviors can be hijacked in substance-use disorders. Nancy realized she was caring for a person with a substance use disorder and remembered that nurses should care for ‘addicts’ with the same quality and compassion as other diseases. She agreed to keep the assignment and use the eight cultural assessment questions to better understand this patient. She would also be able to learn how best to care for his daughter since there was no medical interpreter available that day. After asking permission from the daughter and patient to allow the daughter to interpret, Nancy began asking cultural assessment questions.

Nancy: What do you think has caused your problem?

Daughter/patient: [She squirms; his head lowers as if ashamed] My daddy drinks too much because he is worried about not having a job or enough money to feed our family. He worries we will have to go back to our country where bad men want to kill him.

Nancy: Why do you think it started when it did?

Daughter/patient: [She looks up as if remembering better days; he sheds a few quiet tears] It started when we had to move from California to here and there was no work. We lived in a car for two years and were hungry a lot of the time. My mother left us to go back to our country and my Daddy became very sad. There are three of us children and we are too young to work.

Nancy: What do you think your sickness does to you? How does it work?

Daughter/patient: [She questions him back and forth as if trying to get an accurate answer; he fidgets and looks away often] The alcohol makes the pain go away but it is making my Daddy’s belly bigger. His belly was getting big because he was a house painter and paint is a poison. He can no longer work for very long. He can’t stand on the ladders anymore.

Nancy: How severe is your sickness? Will it have a short or long course?

Daughter/patient: [She asks politely but appears shocked by his irritability] I don’t know. He is angry with this question and doesn’t want to answer. He looks very sick now and his skin and eyes turn yellow. Is he going to die? I cannot take care of my brother and sister.

[The nurse gathers more information about the children, where they are living and their current physical, mental, educational, and spiritual needs].

Nancy: What kind of treatment do you think you should receive?

Daughter/patient: [She begins to sob and puts her head in her hands but recovers bravely; he looks directly at the nurse with an intense gaze that suggests an urgent request for help] My daddy says to just let him die and to hand us over to the American government. He says he can no longer work and is useless to us. [sobbing and soothing her father’s forehead] He says he is worthless, cannot pay the rent, and that we should let him go. I want my daddy to get better.

Nancy: [omits this question] What are the most important results you hope to receive from this treatment?

Nancy: What are the chief problems your sickness has caused for you?

Daughter/patient: [She sits up straight, wipes her own and her father’s tears; he shifts determinedly in bed and looks directly at the nurse] He says that his liver was damaged by the paint and that there is nothing that can be done. He can no longer work and will not get better. He says he failed to feed us or get us a better life in this country. He wants us to live here and go to school.

Nancy: What do you fear most about your sickness?

Daughter/patient: [She squirms again with a worried facial expression and looks at the nurse pleadingly; he maintains a determined body posture] He says that he is going to die and wants us to live here and go to school. He wants to talk with a person who can help him hand us over to the authorities. I don’t want to live with anyone else!

Nancy held back tears during parts of the interview and used her professionalism to appear neutral and caring even though she was emotionally distraught. She monitored the daughter’s nonverbal communication carefully and was ready to stop the interview if needed. She also asked periodically if it was “OK” to continue. Both the patient and daughter wanted to keep talking. Through this interaction, Nancy’s view of the patient was transformed, and she knew that she needed to make immediate referrals for social services and possibly psychiatry. The children needed immediate care and if the patient was suicidal, Nancy would need to implement precautions. She worked with her charge nurse to provide quality care for the patient, make referrals to help him with healthcare decisions, and secured adequate services for the children. Nancy later told a co-worker that this patient and his young daughter had helped her learn a valuable lesson in cultural competence.

Cultural taboos and health beliefs

Jeff was an RN on an oncology unit where blood transfusions were often administered for a variety of reasons. He was assigned to a 16-year-old male patient named Steven who was close to death due to severe long-standing anemia. This teen was newly emancipated from a

family who believed that blood transfusions were “of the devil” and that he would be condemned to hell for eternity if the transfusion took place. Steven had gone to court to obtain emancipation so that he could make his own healthcare decisions independent of his faith community’s health beliefs and taboos. Even though he was near death, he wanted to try the transfusion.

When Jeff entered the room, he was shocked by the patient’s cachexia and pallor(extremely thin and pale). This adolescent should have been developing muscles, facial hair, and a deeper voice, but he was about 77 pounds and appeared to be 10 years old. He was so weak that he needed assistance to sit up in bed and tired easily when he ate or talked for more than five minutes. Jeff knew that he would need to be efficient with all nursing care and interactions to prevent fatigue. He felt angry that a young person had been so neglected and wondered how parents could believe that preventing simple healthcare would be sinful. Jeff kept his intense emotions to himself and decided to give the best possible nursing care even though it might be too late.

After the morning assessment and comfort measures, Jeff returned with the blood and transfusion equipment. He explained that he would stay in the room during the first 15 minutes of the 1-2-hour infusion to monitor vital signs. Steven agreed and settled in for the procedure. During this time, Jeff used the eight cultural assessment questions to learn more about his patient’s life experience and the courageous choice he had made to violate his cultural norms. For most of his life, Steven had believed that God would heal him if he was worthy and prayed hard enough. The suffering had meaning because he was purging sin from his body and would be rewarded with a place in heaven for eternity. But during his last hospitalization, a nurse from the same culture told her story of hope and healing. She had a different illness but was also not allowed access to western medical care due to beliefs that the treatment would be sinful and a disgrace to her parents. An aunt who no longer subscribed to their beliefs convinced her to try the treatment. She went to live with her aunt and was ostracized by her family and friends, but the treatment worked. Through several interactions with nurses, she realized that nursing was her calling and way to honor God’s healing and answer to prayers.

This interaction with a nurse from the same culture helped Steven realize that cultural beliefs and values are based on learned assumptions about the world and human existence. He then talked with a boy whose parents had left the same faith community to secure medical treatment for their son. His friend was well and thriving in a new school even though it took a lot of adjustment. The boy’s parents agreed to let Steven live with them, and he obtained court-ordered emancipation from his parents.

Jeff learned quite a bit about Steven’s calm, gentle, and non-violent culture. He had seen the odd attire on occasion but did not have any desire to learn about these very different people. After spending time with this patient, however, Jeff realized that the many healthy values and practices the community taught would be a good starting place for Steven’s return to health. If the transfusion worked, there would be many more treatments, and Steven would need additional health education to begin a long road to recovery.

The Art and Science of Patient-Centered Caring

“Caring is at the heart of a nurse’s ability to work with all patients in a respectful and therapeutic way” (Potter, Perry, Stockert and Hall, p. 80, 2017). Caring is a “significant and necessary dimension of nursing practice” (NLN, p. 11, 2010). Nurses care for patients, families, communities, each other, and the systems in which they work. Nurses also strive to provide care that encompasses the whole person in ways that reflect patient preferences (NLN, 2010). Every patient uniquely experiences illness with a personal story that gives meaning to the illness (Benner and Wrubel, 1989). When nurses care about these stories and the person who holds them, the nurse-patient encounter is deeper and more connected. Nurse researchers have studied the science of caring and the ways in which nurses help patients navigate the experience of illness and health (Benner and Wrubel, 1989; Watson, J, 2008). During interviews with expert nurses, a common theme emerged: “Nurses provide care for people in the midst of health, pain, loss, fear, disfigurement, death, grieving, challenge, growth, birth, and transition on an intimate front-line basis” and that “expert nurses call this the privileged place of nursing” (Benner and Wrubel, p. xi, 1989). This section introduces the art and science of patient-centered nursing care.

Definitions and scope

Nurses define caring in several ways. The National League for Nursing (NLN) defines caring as the promotion of “health, healing, and hope in response to the human condition” (NLN, p. 11, 2010). Benner and Wrubel state that caring “is a basic way of being in the world” (p. xi, 1989) and “means that persons, events, projects, and things matter to people” (p. 1, 1989). These nurse researchers found that “caring is central to human experience, to curing, and to healing” and that expert nurses care for the lived experience of health and illness, not just the disease process (Benner and Wrubel, p. xi, 1989). They also make a distinction between the role of other healthcare workers and nurses. Most disciplines in healthcare focus on the prevention, remediation, management, and rehabilitation from disease or injury. However, nurses help patients through the whole experience of illness and recovery.

Illness includes the physical, mental, emotional, and spiritual loss and dysfunction associated with disease or injury. Every patient has a story about the meaning of illness – the personal impact of disease or injury, and expert nurses listen to and care about that story. Jean Watson (p. 5, 2008) describes this process as the “caring occasion” or “caring moment.” She defines caring moments as unique points in time where the nurse and patient relate deeply to each other. The nurse pauses to “see” the patient fully and is open to the wisdom of learning about another’s way of being in the world (Watson, p. 5, 2008). Caring transforms the nurse and fuels the work of nursing.

NLN (2010) core values also include holism and a patient-centered mindset which inform caring that leads to human flourishing and high-quality nursing care. Holism is the ability to view the patient as a complex human being with multiple dynamic parts that must be considered as a whole when planning and delivering care for each individual across the illness-wellness continuum (NLN, 2010). In nursing, each human is viewed as a unique blend of body, mind, and spirit that include cultural beliefs, values, and behaviors, physical and psychosocial characteristics, varied experiences, and myriad other factors and qualities.

No nurse can fully know another person, so partnerships with patients and families are vital to the provision of quality care. A patient-centered mindset recognizes that patients and families have needs and desires that require respectful attention from nurses. This core value “is an orientation to care that incorporates and reflects the uniqueness of an individual patient’s background, personal preferences, culture, values, traditions, and family” (NLN, p. 14, 20010). Nurses who provide patient-centered care promote human flourishing through the inclusion of patient and family preferences at each level of healthcare. When a patient’s daughter feels heard, nurses can observe the more relaxed body language and might hear, “Thanks so much for listening. I worry about my mother. She doesn’t always tell people what she needs and is afraid of becoming a burden. She was always taking care of us.” Now the nurse has additional information about this patient and knows to look for signs of distress more attentively.

Concepts that affect these values are context-environment and relationship-centered care (NLN, 2010). Context-environment refers to all factors that are external to the nurse-patient relationship and which influence the ‘who, what, where, when, how, and why’ the interaction happens. Work culture, training, and adequacy of staffing, safety, and ethical climate, regulatory requirements, leadership characteristics, organizational mission and goals, and availability of resources are just a few of the influencing factors (NLN, 2010). The social and physical system in which nurses and patients interact can support or interrupt therapeutic encounters, and this is why nurses strive to create healthy and healing environments. One nurse noticed that the constant alarm on the vital signs monitor was irritating to the patient and family who needed rest. He wanted to mute the sound but knew that this patient could deteriorate quickly so the alarm was an important part of high-quality care. The nurse obtained earplugs and helped the patient and family insert them properly. This simple act of caring – adjusting the environment to promote healing – was so helpful, that the family sent a letter of gratitude to the nursing vice president. This nurse eventually received a nurse-of-the-year award due to his consistent attention to many small “caring moments.”

Relationship-centered care is central to the provision of caring, holistic, and patient-centered nursing care (NLN, 20010). The word relationship indicates that patients are valued as persons who are more than the illness which brought them to a nurse-patient encounter. Therefore, nurses learn how to build trusting and therapeutic relationships with patients, families, and communities. These relationships show that nurses value “diversity, integrity, humility, mutual trust, self-determination, empathy, civility, the capacity for grace, and empowerment” (NLN, p. 27, 2010). One expert nurse was very good with admission assessments and used this time to get to know patients at a deeper level. She did not use any extra time, but it was the way she asked the questions – as if the assessment interview was a conversation with a friend or partner. During one admission with an irritable, rough-talking coal miner, this nurse adjusted the process based on his needs, not her own routine. He was struggling to breathe and did not want to answer any questions, but she needed certain information before beginning care. She said softly with compassion, “It looks as though your breathing is hard right now. We will keep this short and get medication started right away so you can breathe better. Before I bring the medicine, I need to know three things to make sure you get exactly what your body needs. Will you help me so I can help you?” The man’s face softened, and he gave the nurse the required information. During this very brief encounter, the nurse was also observing his physical, mental, and emotional status to gather required assessment information. The patient then reached out to pat her hand and said thank you as she left to retrieve his medication. This interaction could have gone several ways, but this nurse chose to create a caring atmosphere where the patient could feel safe and heard so that healing could begin.

Care of the patient. The patient – often described as a patient – is the center of nursing practice (Potter, Perry, Stockert, and Hall, p. 1, 2017). Patients include individuals, families, and communities of all ages, ethnicities, genders, and cultures. The art of caring for the health needs of all people and populations includes caring skills, standards of practice, and commitment to the therapeutic relationship.

Care of the caregiver. The nurse also cares for family members, friends, and other persons who support the patient at home. The caregiver might be a spouse, adult child, parent, grandparent, neighbor, or other loved one and this experience can be quite stressful. Many patients receive care by persons who have minimal or no healthcare experience and the expectations can be overwhelming. Caregivers can experience stress due to changes in roles, finances, social activities, occupational concerns, personal health issues, and fear of harming the patient.

Therefore, nurses attend to caregivers holistically (mind, body, spirit) and encourage healthy lifestyle practices, stress management techniques, usual social interactions, and attention to meaning in life (Sherman, Anzardo, Lima, and Padron, 2017). Sometimes caregivers require more attention than the patient to ensure optimal health outcomes. For example, an anxious spouse is learning to perform skilled nursing procedures so the patient can be discharged to home. The spouse requires patience, compassion, and education in stress management techniques as well as the procedure. Much time is spent building confidence and reducing fear until the technique is properly completed. Meanwhile, the patient is relaxed and using humor to lighten the situation.

Role changes can be substantial when an adult child must now bathe a parent, or a spouse must feed a life-partner. Financial stress can occur due to loss of income or healthcare costs. Loss of social activities can cause grief and anger due to scheduling difficulties. Sometimes caregivers ignore their own health needs. Occupational stress due to constant interruptions and work absence can result in decreased work hours or loss of employment.

Nurses are attentive to signs and symptoms of caregiver stress and intervene with education and resources when needed. Common signs include:

• Feeling angry or frustrated
• Feeling overwhelmed
• Feeling alone, isolated, or deserted by others
• Sleeping too much or too little
• Gaining or losing a lot of weight
• Feeling tired most of the time
• Losing interest in activities you used to enjoy
• Becoming easily irritated or angered
• Feeling worried or sad often
• Having headaches or body aches often

Source: US Department of Health & Human Services, Office on Women’s Health at https://www.womenshealth.gov/a-z-topics/caregiver-stress

Nurses also provide information on community resources such as respite care, sitters, home care services, and adult day care centers. When needed, nurses make referrals to counselors, clergy, and case managers to assist with difficult decisions and placement concerns.

Attributes, criteria, and context in healthcare

Caring is both an art and a science where best practice includes skills, knowledge, and a careful, empathetic approach to care. The ANA standards of nursing practice state that registered nurses communicate effectively in all areas of practice which includes therapeutic communication (2010). To learn empathy and therapeutic communication, students can ask themselves what they might want from the nurse in a similar situation. Nurses develop caring skills that give meaning to the work and comfort to the patient who often relinquishes all independence, pride, and needs to the nurse (Engel, p, 23, 2006).

Caring skills. Presence, touch, and listening are three key elements for creating a caring moment (Potter, Perry, Stockert, and Hall, 2017). Presence is a genuine person-to-person interaction that demonstrates sensitivity, perception of the whole person, intimacy, vulnerability, and the ability to adapt to each moment. Presence is the art of “being there” while attending to the patient’s needs. This trusting relationship relieves suffering, provides comfort, and lets the patient know that the nurse is available. Nurses who provide presence allow patients to put feelings into words, which calms anxiety and fear and helps the patient gain a better understanding of themselves. The nurse uses attending behaviors to create openness and mutual understanding (eye contact, caring body language). As one patient wrote, “‘I’m here.’ Those two little words are a warm embrace of protection for your patient…[and] offer more hope and security than anything else you can say or do” (Engel, p. 23-24, 2006).

Nurses use touch to communicate caring, provide comfort, and perform procedures. Touch communicates connectedness and can be a form of nonverbal communication. The way the nurse touches a shoulder, hand, or foot; moves a patient in bed; or performs a procedure can communicate profound caring. Protective touch is another type of caring that can prevent a fall or redirect a patient with confusion. Expert nurses are careful to apply touch that is culturally sensitive and appropriate for each person’s needs and preferences. Touch conveys many messages and can be received in many ways; therefore, nurses are mindful of the caring moment and adjust touch as needed. Engel (2006) reminds nurses that sudden jolts, touches, and breezes from busy nurses can feel like a violation. For some patients, touch feels disruptive, disturbing, unsettling, or upsetting, and can seem unruly and unnecessary. Patients are not simply bodies or diseases to be treated, so nurses ask before touching. Caring touch is careful and conveys a genuine understanding of the patient’s needs and perspective.

Listening attentively is a vital skill in nursing and a main ingredient in the therapeutic relationship. Active listening is a planned and deliberate act where the nurse silences his/her own thoughts to truly hear the patient’s meaning. From this artful listening, the nurse can know and respond to what is important to the patient. For example, a 22-year-old woman with cancer is more concerned about her children that her own health and feels the need to talk.

Nursing students change rapidly from a student with self-interest to a developing professional who is other-centered (Stabler-Haas, 2012). Students quickly learn that nurses go far beyond normal social interactions into deeply personal nurse-patient relationships. A major psychological adjustment occurs as students learn how to touch strangers physically, mentally, emotionally, and spiritually in fairly intimate ways. Patients need bathing and help with toileting. They also need someone to listen as they ponder deep personal troubles or make decisions about end of life concerns. Some of the interactions can be quite painful for the nurse and the patient, however, the nurse must remain therapeutically present.

Students and new graduates will probably not have the skills to meet all needs, and even experienced nurses gag at certain smells or sights and might have difficulty listening to patients talk about certain topics. But expert nurses know to leave the room for a moment, take a few deep breaths, center themselves and return to the room to complete patient care. Nurses must at least be honest with the patient and themselves about limits and abilities and advocate for the patient to receive needed care (Stabler-Haas, 2012).

Professional boundaries. The space between the nurse’s power and the patients’ vulnerability is influenced by the fact that the nurse knows much more about the patient than the patient knows about the nurse. Expert nurses respect this power imbalance and protect the patient’s privacy and their right to appropriate care. Professional boundary violations can occur when the nurse fails to keep personal needs in the background during patient-nurse interactions. Patients can be harmed by overstepping professional boundaries. For example, red flag behaviors included:  flirting, favoritism, gossiping about other staff, keeping secrets with, from, or for a patient, meeting a patient outside of work settings, and discussing the nurse’s personal issues with a patient. Nurses who become aware of boundary violations must report behaviors to supervisors.

The nurse-patient relationship can be thought of as a continuum between two poles: Under-involvement to over-involvement with the therapeutic relationship in the center. The National Council of State Boards of Nursing [NCSBN] published a brochure to help new graduates discern the difference between professional and social boundaries. Watch the video at https://www.ncsbn.org/464.htm.

“The difference between a caring relationship and an overinvolved relationship is sometimes difficult to discern. A nursing professional living and working in a small, rural or remote community will, out of necessity, have business and social relationships with patients. In these instances, it is extremely important for nurses to openly acknowledge their dual relationship with patients and to emphasize when they are performing in a professional capacity. The nurse must ensure the patient’s care needs are primary. When this is not possible, nurses should remove themselves from the situation or request assistance from a supervisor or colleague” (NCSBN, p. 7, 2018).

To read the complete brochure, go to https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf.

Environmental factors. In modern healthcare settings, the art and science of caring can take a back seat to technical skills, procedures, and processes within busy work environments. However, several nurse theorists (as described in Chapter one) and many nurse experts emphasize the art and science of caring (Benner and Wrubel, 1989). Modern nurses often feel torn between the need for caring for patients and the technical aspects of their care. The many demands of busy healthcare settings leave less time at the bedside. Without one-to-one time with patients, nurses can lose touch with the patient’s perspective, needs, and story.

Florence Nightingale said that experienced nurses observe more than symptoms of disease when they attend to needs such as fresh air, light, warmth, variety, quiet, cleanliness, punctuality, and healthy food (Nightingale, p. 8, 1860). She taught that nurses do more than busily care for wounds and administer medications. She emphasized the art of nursing to include care of the whole person with attention to the small details that mean so much to patients. For example, she reminds nurses to sit facing patients to minimize strain during nurse-patient interactions and to include patients in every conversation that occurs in the room. “If you knew how unreasonably sick people suffer from reasonable causes of distress, you would take more pains about all these things” (Nightingale, p. 104, 1860).

Expert nurses with long careers still experience the tension between creating caring moments and the many other demands that distract the nurse’s attention. However, the intimacy that nurses share with patients and families is unsurpassed and “it is the very soul of nursing” (Stabler-Haas, p. 81, 2012).

Exemplars

These examples are fictional stories based on real nursing practice.

A simple caring moment

The elderly woman had fallen at the grocery store and broken her hip. The rush to the hospital was disorienting, but the strong, handsome young men were kind and careful not to hurt her too much. The emergency room nurse greeted her warmly although working fast to insert an IV and an embarrassing urinary catheter. No one had seen her private area in over 20 years, but the nurse kept her covered and did not let anyone else enter the room until the blankets were back in place. She was so grateful for these small kindnesses and settled in to wait for surgery. No family members were available, and the morphine was clouding her sharp mind. The nurse came back to ask how she was doing, and she started to cry. “Am I losing my mind? I do not know where I am, and I forgot who you are.” The nurse sat down, took her hand, and said, “I am here. You are safe. My name is Alice.” This simple act started a caring moment that soothed the patient and helped her to rest. The nurse stayed with her until she was transferred to the surgical team.

Nursing care for the patient with professional boundary issues

A young female patient was admitted to the hospital for exploratory surgery due to a tumor in her abdomen. She knew all the nurses on the unit because she worked there. Her co-workers were worried about her and confused about how to approach this nurse who was now their patient with a grapefruit-sized tumor. At first, none of them talked with her as they would have with another patient. They used nurse humor and other healthcare worker jargon to deflect their feelings. She felt isolated and alone and was quite frightened about what would happen to herself and her children if this mass was cancerous. She was biting her nails and talking rapidly and overeating.

Eventually, one of the nurses broke the silence, sat down at her bedside, and with a genuine concern began asking her how she was feeling. The nurse offered presence, touch, and listening that “broke the dam” of emotions and the patient began to cry. She was able to tell her story as a person in pain, rather than a seasoned co-worker. Her family history of cancer was a cause for concern, and it was nice to be able to let someone know how frightened she was. This nurse used professional boundaries in a way that moved past the social relationship the two nurses had shared. She offered professional nurse caring.

Care of the caregiver

A nurse was caring for a 28-year-old woman with a history of substance use (methamphetamine) and bipolar disorder. She was a single mother of a seven-year-old when the problems began. After an arrest for DUI, she was sentenced to 10 years’ probation. Her parents became the child’s guardian. The financial strain, deferred retirement plans, and lack of alone time caused great physical, emotional, and mental strain for the grandparents. The daughter continued to struggle with her substance use disorder and mental illness which led to numerous incarcerations. The child is often sad and angry and wants to change her last name.

During a routine pediatric office visit, the nurse noticed the grandmother’s weariness and pulled her aside to ask about caregiver stress issues. This small moment of caring was so touching that the grandmother began talking about all her concerns. The nurse offered education on community resources and self-care practices. She continued to listen as the grandmother vented. The kind attention to her story relieved some of the strain and she gave the nurse a hug saying, “Thank you so much for listening. I feel better.”

In this chapter, students learned about:

• cultural considerations in nursing
• the art and science of patient-centered caring

Key Terms

• Active listening
• Acculturation
• Assimilation
• Biculturalism
• Caring
• Caring moment
• Caregiver
• Caregiver stress
• Cultural desire
• Cultural knowledge
• Culture
• Enculturation
• Ethnocentrism
• Holism
• Patient centeredness
• Presence
• Professional boundaries
• Relationship-centered care
• Self-awareness
• Stereotypes
• Taboo
• Touch

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