African American population demographics and characteristics

Applying the Nursing Process to The

Delivery Of Culturally-Competent Care

for african-americans

This paper explores the on-going health care needs of African-Americans as they relate to the delivery of competent nursing care. As a diverse group, African-Americans currently face some serious medical conditions based on lifestyle, genetics and a lack of access to high-quality health care. Thus, this paper will address several areas, such as psychological, environmental and psychosocial factors related to communications, the influence of cultural beliefs and barriers, and some possible ethical dilemmas. In addition, this paper explores how the Giger-Davidhizer Transcultural Assessment Model could be implemented as a way of analyzing the health care needs of African-Americans and for developing a health care plan, thereby increasing the lifespans and quality of living for all African-Americans.

INTRODUCTION:

According to Rachel E. Spector, writing in "Health and Illness in the Black Population," African-Americans are currently the largest emerging majority in America, making up more than 12% of the overall U.S. population. Demographically, more than 50% of African-Americans live in the Deep South, with the remainder living in practically every state. The largest numbers can be found in major cities like New York, Detroit, Memphis, Houston and Chicago. As a socio-economic group, almost 25% of African-Americans currently live in poverty, mostly in large urban areas. Also, almost 55% are under the age of eighteen with a mean age of less than 33 years (Cultural Diversity in Health and Illness, 2008, 260).

Not surprisingly, there is now a growing number of blacks coming into the United States as African immigrants and as of 2000, more than 880,000 Africans have arrived from countries like Nigeria, Somalia and the Sudan. Therefore, with these facts in mind, the health care needs of a growing number of black Americans, both naturally born in the U.S. And as naturalized citizens, are now influenced by a wide variety of traditional beliefs and practices brought from Africa related to ancient rituals, folklore, healing practices and spiritual personal health, all of which have only increased the difficulty in providing medically-proven techniques set against a number of cultural barriers based on superstition and the alleged spiritual power of long-dead ancestors (Spector, 2008, 261).

BACKGROUND INFORMATION:

Despite the fact that most African-Americans are now fully integrated into American culture via Westernized ideals, principles and behaviors, there still remains a large group that communicates with each other and within a family environment through deep-seated cultural identities-based mostly upon language and speech patterns left over from pre-slavery times. Of course, almost all African-Americans speak English, with the exception of individuals recently arrived from Africa who still speak their native languages and dialects which in a health care/nursing environment can cause problems related to communication between the patient and the caregiver. Veronica Duncan notes that this problem is especially prevalent with black males who possess "a culturally-induced vulnerability" which causes them to be very wary of opening themselves to outsiders (2005, 134). In one of her studies on this phenomenon, Duncan

discovered that African-American men are not comfortable with disclosing their inner feelings and desires to strangers; in fact, some of them find this to be downright unacceptable which can led to verbal and physical aggression (2005, 154). Duncan also discovered that some black males and a small number of females are often not open to compromise (2005, 157). Thus, it is clear that these culturally-influenced traits may make it difficult to provide adequate health care to some African-Americans, especially when they refuse to reveal exactly what is troubling them as it relates to an illness or disease.

Influence of Beliefs:

As to the influence of health-related beliefs and practices, African-Americans do not seem to be much different from other ethnic groups that originated outside of America and became part of it in the late 17th and early 18th centuries. As Spector relates, African beliefs concerning life and the nature of being a human person are based solely on ancient tribal customs and superstitions. For example, when a person is healthy, this means that the person is in harmony with the natural world; in contrast, illness is a state of disharmony. Thus, health is not just physical in nature but is a conglomerate of the mind, the body and the spirit (2008, 264).

Since illness is seen as a disharmonious state, Africans (and many modern-day African-Americans) attribute it to the presence of demons and malevolent spirits which must be removed if health is to be attained and maintained. In order to accomplish this, Africans traditionally employ voodoo or some other type of superstition-based remedy under the guidance of a healer, almost always a woman, who possesses wide-ranging knowledge on the use of herbs and other naturally-occurring plants to treat various afflictions of the body and the mind (Spector, 2008,

264). Of course, these and other beliefs and practices may cause a number of problems for caregivers, physicians and nurses, due to some African-Americans remaining steadfast and loyal to the ancient practices of their African heritage.

Barrier Factors:

Some of the barrier factors that are closely linked to these and other superstitious beliefs and practices from a nursing standpoint include unintentional insults related to not understanding the cultural background of a particular patient; a feeling that as a patient, he/she is nothing more than material or a source of experimentation, even when seeking medical assistance and care in a hospital setting or a private clinic; utilizing home-based medicinal remedies handed down through the generations which in effect may cause more harm than good; and lastly, some African-American patients may view their caregivers/nurses as inadequate for providing their health care needs, meaning that they see traditional healers as more knowledgeable and capable, due to being from the same cultural/African background (Spector, 2008, 275-276).

Ethical Dilemma:

As to a prominent ethical dilemma related to the delivery of adequate health care for African-Americans, there is a growing population of blacks in today's America who practice Islam, one of the three major world religions and based on what is known as the Five Pillars of Islam and the teachings of the prophet Muhammad. Within the strict Muslim lifestyle, a practicing Muslim is forbidden to eat or consume anything containing pork; thus, if a black

American Muslim requires insulin as a result of having diabetes, the caregiver/nurse must be made aware of this situation and have the foresight to administer insulin that is not pork-based nor made from the pancreas of a pig which Muslims consider as unclean (Spector, 2008, 272).

ANALYSIS OF THE CULTURE:

THE GIGER-DAVIDHIZER TRANSCULTURAL ASSESSMENT MODEL:

Often referred to as the "Great Melting Pot," the United States is currently composed of a combination of various cultures and ethnicities, many of which possess their own distinctive beliefs and practices handed down through the generations. As a result, today's American health care systems must understand and appreciate these beliefs and practices when it comes to providing health care to these often divergent cultures. One important consequence related to failing to understand these beliefs and practices is that certain ethnic/cultural groups, especially African-Americans, may not receive proper health care. Thus, in order to address this seemingly growing problem, we will examine what is known as the Giger-Davidhizer Transcultural Assessment Model which utilizes six specific criteria that allows nurses and physicians to provide proper transcultural assessment and care. As will become apparent, the importance of this model for professional nurses is that it allows them to understand the differences related to health issues in divergent cultures and how to apply specific knowledge and information for optimized health care.

The first criteria of the Giger-Davidhizar assessment model is communication which covers both verbal and physical body language. For example, if a nurse is unable to effectively communicate with a patient, particularly if the patient is of a different ethnic group, then it would be almost impossible to understand exactly what the patient requires related to an illness or its symptoms. One way of overcoming this problem, outside of learning to speak the native tongue of such a patient, is to understand how different cultures communicate with each other without using language. In this respect, it could be something as simple as physical touching or a type of gesture that tells the patient that the nurse or physician understands his/her ailment and the possible pain associated with it, or it could be eye contact. However, a nurse must be extremely careful when applying any type of touching or gesture, due to the fact that people from certain cultures outside of the U.S. may be offended. Thus, every practicing nurse must clearly understand these and other types of communicative expressions in order to effectively assist patients from different cultural backgrounds (Transcultural Nursing, 2004, pg. #?)

The second criteria is space as it relates to personal physical space. For instance, within some cultures, the physical space between two people is very important, meaning that people from certain cultures find it uncomfortable to be placed in a position of close physical contact with another person. As Giger and Davidhizer point out, some individuals are highly sensitive to particular forms of intimate care between a nurse/physician and themselves (2004, 596-597). Therefore, a nurse must be fully aware of these sensitivities when providing care to a patient, especially when the patient is a member of cultural group from outside the U.S.

The third criteria is social organization. For example, most African-American families tend to be based on a matriarchal system with either the mother or another female member of the family serving as its leader. This matriarch may also serve as the source for advice on certain

family matters; of course, the patriarch of the family (i.e., the father figure) also plays a role in family decision-making. Thus, most African-American families are composed of a support network made up of mothers, fathers and other close relatives, something which often creates tension and dissent. In this respect, a nurse must be aware of this matriarchal system and its network in such a way as to gain the trust of family members when it comes to health care (Transcultural Nursing, 2004, pg. #'s?)

The fourth criteria is time, especially in relation to providing directions as to when to take medications. For example, when a nurse tells a patient to take his/her medication three times a day or perhaps once in the morning, some individuals may wrongly interpret these directions, thus creating life or death situations. This can also be applied to telling a patient when to change the dressing on a wound frequently. Therefore, a nurse must realize how a patient understands these and other directions and must be able to provide directions in a competent manner in line with a patient's cultural background (Transcultural Nursing, 2004, pg. #'s?)

The fifth criteria is environmental control which deals with a patient's cultural beliefs concerning physical illness and prevention practices. According to some studies, Hispanics are more likely than Caucasians to complain that physical pain has "ruined their lives" and the Chinese appear to consider asking for help as a sign of a lack of self-respect. In addition, some individuals view a request for pain medication as being disrespectful of a nurse's time. In this case, a nurse must always ask a patient if he/she requires medication; otherwise, the patient may do without, thus creating serious complications and/or physical pain (Transcultural Nursing,

2004, pg. #'s?)

The last criteria is biological variation which includes the susceptibility to disease, nutrition and genetics, all of which may have a significant impact on a patient's sensitivity to pain. Many studies have concluded that sensitivity to pain varies between individuals and cultures, a fact which all nurses must take into account when providing treatment or procedures which involve a certain amount of pain (Glanze, 2002, 467). Also, some cultures consider admitting to pain as being self-deprecating. Therefore, as with all of the criteria found in the Giger-Davidhizer model, a nurse must be aware of a patient's tolerance and acceptance of pain, particularly if the patient is a member of a cultural group from outside of the U.S.

Developing a Plan of Care:

The application of this model to the health care needs of African-Americans could be accomplished by focusing on three of the criteria -- social organization, environmental control and biological variation. With the first criteria, the role of the matriarchal mother or authority figure could be expanded as the primary source of advice for young African-American males and females, due to this figure being held in high esteem. For instance, this figure could possibly influence younger blacks to adhere to a diet that helps prevent in most cases obesity, heart disease, diabetes and certain types of cancer, due to statistics that demonstrate that black males tend to smoke at younger ages ("Health and Health Care," 2009, Internet). Of course, the matriarchal figure would have to be informed by her physician or caregiver about the true dangers of obesity and smoking and be convinced to follow proven medical procedures instead of relying upon traditional African remedies.

The second criteria of environmental control which in this case deals with a patient's traditional cultural beliefs related to physical/mental illnesses and prevention, could be overcome by educating not only the patient but also his/her family members about the unscientific basis of many African healing practices and "voodoo" remedies. Some of the diseases which could be avoided and which often result in premature death in African-Americans include hypertension, coronary heart disease, stroke, kidney failure, diabetes and certain types of cancer, most notably lung, breast, colon and prostate cancer (in men). Certainly, these often fatal diseases with high morbidity rates in African-Americans have been shown to be closely linked to a lack of education and the inability to access professional health care providers and clinics ("Health and Health Care," 2009, Internet).

With the third criteria, biological variation plays a major role in the lives of African-Americans as a result of possessing specific genetic flaws and/or predispositions, especially with sickle-cell anemia, a genetically-inherited disease of the red blood cells which was originally thought to have been an adaptation to fight malaria (Spector, 2008, 272). Since this disease tends to run in families, nurses and other caregivers could advise their black patients to undergo genetic testing in order to determine their risk of acquiring sickle-cell anemia. However, for many African-Americans, this may not be possible, due to the often prohibitive cost of the test and genetic counseling.

Interdisciplinary Approaches:

Since the African-American population in the U.S. is one of the most affected groups when it comes to accessing and utilizing health care delivery systems, it would be advisable that the current American health care industry adopt a number of interdisciplinary approaches for culturally-sensitive care delivery. As Karen Williams and Veronica W. Johnson points out, patients and all health care providers must adopt "patient-empowered skills, learn to be more culturally sensitive" and support efforts to create health policies and agendas in order to improve the health status of African-Americans (2008, Internet). For example, state governments and local community organizations should support health conferences aimed at black Americans, along with creating some type of health institute for the medical needs of African-Americans living in each state.