Part 1 Use the article below, chapters 6-8 in your textbook, and the movie (“Miss Evers’ Boys”) to help guide your answers. Most of these questions do not have a right or wrong answer. Was this study

Part 1 Use the article below, chapters 6-8 in your textbook, and the movie (“Miss Evers’ Boys”) to help guide your answers. Most of these questions do not have a right or wrong answer. Was this study
Ch 6 Box 6-1 Key Ethical Terms Ethics is a branch of philosophy that includes both a body of knowledge about the moral life and a process of reflection for determining what persons ought to do or be regarding this life. Bioethics is a branch of ethics that applies the knowledge and processes of ethics to the examination of ethical problems in health care. Moral distress is an uncomfortable state of self in which one is unable to act ethically. Morality is shared and generational societal norms about what constitutes right or wrong conduct. Values are beliefs about the worth or importance of what is right or esteemed. Ethical dilemma is a puzzling moral problem in which a person, group, or community can envision morally justified reasons for both taking and not taking a certain course of action. Codes of ethics are moral standards that delineate a profession’s values, goals, and obligations. Utilitarianism is an ethical theory based on the weighing of morally significant outcomes or consequences regarding the overall maximizing of good and minimizing of harm for the greatest number of people. Deontology is an ethical theory that bases moral obligation on duty and claims that actions are obligatory irrespective of the good or harmful consequences that they produce. Because humans are rational, they have absolute value. Therefore, persons should always be treated as ends in themselves and never as mere means. Principlism is an approach to problem solving in bioethics that uses the principles of respect for autonomy, beneficence, nonmaleficence, and justice as the basis for organization and analysis of ethical issues and dilemmas. Advocacy is the act of pleading for or supporting a course of action on behalf of a person, group, or community. Ethical Decision Making Ethical decision making is that component of ethics that focuses on the process of how ethical decisions are made. The process is the thinking that occurs when health care professionals must make decisions about ethical issues and ethical 124dilemmas. Ethical issues are moral challenges facing a person or a profession. In nursing, one such challenge is how to prepare an adequate and competent workforce for the future. In contrast, ethical dilemmas are human dilemmas and puzzling moral problems in which a person, group, or community can envision morally justified reasons for both taking and not taking a certain course of action. One example of an ethical dilemma is how to allocate resources to two equally needy populations when the resources are sufficient to serve only one of the populations. Ethical theories, principles, and decision-making frameworks help us think through these issues and dilemmas. In describing what ethics is, Bernheim and colleagues concentrate on normative ethics and say that in general terms, “normative ethics involves identifying and justifying moral norms regarding right and wrong, good and bad, and determining the meaning, range and strength of those moral norms for purposes of guiding human action” (2015, p. 4) Ethical decision-making frameworks use problem-solving processes. They provide guides for making sound ethical decisions that can be morally justified. Many such frameworks exist in the health care literature, and some are presented in this chapter. A caveat, however, is in order. Weston (2006, p. 22) notes that the first requirement of ethics is to think appreciatively and carefully about moral matters. We should not simply obey rules or authorities without thinking for ourselves; thinking for ourselves is both a moral responsibility and a hard-won right. Keeping the preceding caveat in mind, the following generic ethical decision-making framework is presented: 1. Identify the ethical issues and dilemmas. 2. Place them within a meaningful context. 3. Obtain all relevant facts. 4. Reformulate ethical issues and dilemmas, if needed. 5. Consider appropriate approaches to actions or options (such as utilitarianism, deontology, principlism, virtue ethics, caring and the ethic of care, feminist ethics). 6. Make a decision and take action. 7. Evaluate the decision and the action. The steps of a generic ethics framework are often nonlinear, and, with the exception of step 5, they do not change substantially. The rationale for each of the seven steps is presented in Table 6-1. The six approaches to actions or options in the ethical decision-making framework (step 5) are outlined throughout the chapter in the How To Boxes. TABLE 6-1 Rationale for Steps of Ethical Decision-Making Framework Step Rationale 1. Identify the ethical issues and dilemmas Persons cannot make sound ethical decisions if they cannot identify ethical issues and dilemmas 2. Place them within a meaningful context The historical, legal, sociological, cultural, psychological, economic, political, communal, environmental, and demographic contexts affect the way ethical issues and dilemmas are formulated and justified 3. Obtain all relevant facts Facts affect the way ethical issues and dilemmas are formulated and justified 4. Reformulate ethical issues and dilemmas if needed The initial ethical issues and dilemmas may need to be modified or changed on the basis of context and facts 5. Consider appropriate approaches to actions or options The nature of the ethical issues and dilemmas determines the specific ethical approaches used 6. Make decisions and take action Professional persons cannot avoid choice and action in applied ethics 7. Evaluate decisions and action Evaluation determines whether or not the ethical decision-making framework used resulted in morally justified actions related to the ethical issues and dilemmas Two factors affect this ethical decision-making framework: (1) the growing multiculturalism of the American society, and (2) moral distress. First, nurses often deal with ethical issues and dilemmas related to the diverse and at times conflicting values that result from ethnicity. From a moral perspective, what should the nurse do when facing ethnicity conflicts? Callahan (2000) offers useful insights into these conflicts. He describes four situations in which ethnic diversity can be judged in relationship to cultural standards: 1. Situations that place persons at direct risk of harm, whether psychological or physical 2. Situations in which ethnic cultural standards conflict with professional standards 3. Situations in which the greater community’s values are jeopardized by specific ethnic values 4. Situations in which specific ethnic community customs are annoying but not problematic for the greater community Callahan (2000, p. 43) discusses how to judge diversity in the four situations. In situation 1, he says that “we in America imposed some standards on ourselves for important moral reasons; and there is no good reason to exempt [ethnic] subgroups from those standards.” For situations 2 and 3, he suggests a thoughtful tolerance but also some degree of moral persuasion (not coercion) for ethnic groups to alter values so that they are more in keeping with what is normative in the American culture. However, Callahan says that “in the absence of grievous harm, there is no clear moral mandate to interfere with those values” (p. 43). Finally, regarding situation 4, he believes in moral tolerance of nonthreatening ethnic traditions, because there is no moral mandate to do otherwise. Second, because decision making is central to the practice of nursing, and many decisions are difficult to make, it is useful to consider experience of ethical or moral distress. Moral or ethical distress occurs when a person is unable to act in a way that he or she thinks is right. You do not feel that you are able to act in a manner consistent with your own values, cultural expectations, and religious beliefs. When this conflict occurs, it can lead to a personal sense of failure in the kind of care you give and to subsequent performance issues and may lead to work and/or career dissatisfaction. However, there are ways to handle moral distress, as by (1) identifying the type(s) of situations that lead to distress; (2) communicating that concern to 125your manager and examining ways to work toward addressing the stressor; or (3) seeking support from colleagues. It is often useful to talk with colleagues. You may learn that they have similar concerns or that they have found ways to interrupt the stressful situation(s) (Carlock and Spader, 2007). Understanding both multiculturalism and moral distress aids in making ethical decisions. Two cases are presented in later sections of the chapter. Examine each using the ethical decision-making processes outlined in the How To Boxes and the codes of ethics provided in the chapter. These cases provide an excellent opportunity to discuss with classmates your personal beliefs about the application of ethical processes and to assess your own thoughts, feelings, and possible actions. The cases deal with what the nurse’s response should be when (1) the question arises about whether a parent can adequately care for a young child or the child should be removed from the mother, and (2) a client is not able or willing to take personal responsibility and does not want the nurse to report the situation. The Evidence-Based Practice box provides a summary of a research study that examined conflicting ethical concerns. Evidence-Based Practice Park (2013) developed and evaluated a case-based computer program to teach nursing students to effectively make ethical decisions. She used seven ethical cases chosen from 18 possible cases that were developed by practicing nurses and a six-step Integrated Ethical Decision-Making Model developed by the author. Interviews with the practicing nurses concerned ethical cases they had encountered as well as practical moral issues they had experienced. A total of 251 undergraduate students from three nursing schools used the program in their nursing ethics course. The program used in this study was based on Principles of Biomedical Ethics introduced by Beauchamp and Childress (2008). These principles are discussed in the chapter and they include autonomy, nonmaleficence, beneficence, justice, fidelity, veracity, and confidentiality. A goal of the program was for the students to learn to make an ethical decision justifiable in a real setting by applying ethical knowledge and critical thinking. The six steps of the Integrated Ethical Decision-Making Model were as follows: (1) the identification of an ethical program; (2) the collection of additional information to identify the problem and develop solutions; (3) the development of alternatives for analysis and comparison; (4) the section of the best alternatives and justification; (5) the development of diverse, practical ways to implement ethical decisions and actions; and (6) the evaluation of the effects and development of strategies to prevent a similar occurrence of the problem. The study demonstrated that a case-based computer approach could successfully replicate real-world ethical case vignettes in a structured decision-making process. The users said the program was helpful to them in ethical decision making. From Ulrich C, O’Donnell P, Taylor C, et al: Ethical climate, ethics stress, and the job satisfaction of nurse and social workers in the United States, Soc Sci Med 65(8):1708–1719, 2007. Ethics Definition, Theories, Principles Ethics is concerned with a body of knowledge that addresses questions such as the following: How should I behave? What actions should I perform? What kind of person should I be? What are my obligations to myself and to fellow humans? There are general obligations that humans have as members of society. Among these general obligations are not to harm others, to respect others, to tell the truth, and to keep promises. Sometimes, however, a situation dictates that a person tell a lie or break a promise because the consequences of telling the truth or keeping the promise may bring about more harm than good. For example, as a nurse you have promised a family that you will visit them at a certain time, but your schedule has gone awry because of unexpected circumstances. One of the other families you visit is in a state of crisis—their adolescent child is suicidal—and your nursing intervention is needed. Most nurses would agree that this is not a good time to keep the original promise. You are morally justified in breaking your promise because you fear that more harm than good would be done if the promise were kept. How To Apply the Utilitarian Ethics Decision Process 1. Determine moral rules that are important to society and that are derived from the principle of utility.* 2. Identify the communities or populations that are affected or most affected by the moral rules. 3. Analyze viable alternatives for each proposed action based on the moral rules. 4. Determine the consequences or outcomes of each viable alternative on the communities or populations most affected by the decision. 5. Select the actions on the basis of the rules that produce the greatest amount of good or the least amount of harm for the communities or populations that are affected by the actions. (Remember that the utilitarian ethics decision process is one of the approaches in step 5 of the generic ethical decision-making framework.) *Moral rules of action that produce the greatest good for the greatest number of communities or populations affected by or most affected by the rules. This example of promise breaking illustrates several things about ethical thinking. First, ethical judgments are concerned with values. The goal of an ethical judgment is to choose that action or state of affairs that is good or is right in the circumstances. Second, ethical judgments generally do not have the certainty of scientific judgments. For example, nurses diagnose an ethical situation on the basis of the best available information and then choose the course of action that seems to provide the best ethical resolution to the situation. In some situations, the decision is based on outcomes or consequences. That approach to ethical decision making is called consequentialism. It maintains that the right action is the one that produces the greatest amount of good or the least amount of harm in a given situation. Utilitarianism is a well-known consequentialist theory that appeals exclusively to outcomes or consequences in determining which choice to make. In other situations, nurses touch on options open to fundamental beliefs. In such circumstances, these nurses may conclude that the action is right or wrong in itself, regardless of the amount of good that might come from it. This is the position 126known as deontology. It is based on the premise that persons should always be treated as ends in themselves and never as mere means to the ends of others. Deontological theory is often called nonconsequentialist. It is a “theory of duty holding that some features of actions other than or in addition to con­sequences make actions right or wrong” (Beauchamp and Childress, 2013, p. 361). How To Apply the Deontological Ethics Decision Process 1. Determine the moral rules (e.g., tell the truth) that serve as standards by which individuals can perform their moral obligations. 2. Examine personal motives for proposed actions to ensure that they are based on good intentions in accord with moral rules. 3. Determine whether the proposed actions can be generalized so that all persons in similar situations are treated similarly. 4. Select the action that treats persons as ends in themselves and never as mere means to the ends of others. (Remember that the deontological ethics decision process is one of the approaches in step 5 of the generic ethical decision-making framework.) Members of the health professions have specific obligations that exist because of the practices and goals of the profession. These health care obligations have been interpreted in terms of a set of principles in bioethics. The primary principles are respect for autonomy, nonmaleficence, beneficence, and distributive justice as shown in Box 6-2. These principles are “general guidelines for the formulation of more specific rules” (Beauchamp and Childress, 2013, p. 13). This approach has been called principlism, and is clearly discussed in the seventh edition of Principles of Biomedical Ethics by Beauchamp and Childress (2013). This approach to ethical decision making in health care arose in response to life-and-death decision making in acute care settings, where the question to be resolved tended to concern a single localized issue such as the withdrawing or withholding of treatment (Holstein, 2001). In these circumstances, preserving and respecting a client’s autonomy became the dominant issue. According to Beauchamp and Childress (2013), these four clusters of moral principles are central to the field of biomedical ethics. Principles are more general guides than are rules. Principlism is a “theory about how principles link to and guide practice” (Beauchamp and Childress, 2013, p. 25). Box 6-2 Ethical Principles Respect for autonomy: Based on human dignity and respect for individuals, autonomy requires that individuals be permitted to choose those actions and goals that fulfill their life plans unless those choices result in harm to another. Nonmaleficence: Nonmaleficence requires that we do no harm. It may be impossible to avoid harm entirely, but this principle requires that health care professionals act according to the standards of due care, always seeking to produce the least amount of harm possible. Beneficence: This principle is complementary to nonmaleficence and requires that we do good. We are limited by time, place, and talents in the amount of good we can do. We have general obligations to perform those actions that maintain or enhance the dignity of other persons whenever those actions do not place an undue burden on health care providers. Distributive justice: Distributive justice requires that there be a fair distribution of the benefits and burdens in society based on the needs and contributions of its members. This principle requires that, consistent with the dignity and worth of its members and within the limits imposed by its resources, a society must determine a minimal level of goods and services to be available to its members.* *In public health nursing client may be a person, group, or community. Modified from Bateman N: Advocacy Skills for Health and Social Care Professionals. Philadelphia, PA, 2000, Jessica Kingsley, p 63. Despite its success as a basis for analysis in bioethics, principlism has come under attack (e.g., Callahan, 2000, 2003; Walker, 2009), and there are grounds for the criticism. First, the principles are said to be too abstract and narrow to serve as guides for action. Second, the principles themselves can conflict in a given situation, and there is no independent basis for resolving the conflict. Third, some persons claim that effective ethical problem solving must be rooted in concrete, individual experiences. Fourth, ethical judgments are alleged to depend more on the judgment of sensitive persons than on the application of abstract principles. The How To Box below can serve as a guide for how to use the principlism ethics decision process. How To Apply the Principlism Ethics Decision Process 1. Determine the ethical principles (respect for autonomy, nonmaleficence, beneficence, justice) that are relevant to an ethical issue or dilemma. 2. Analyze the relevant principles within a meaningful context of accurate facts and other pertinent circumstances. 3. Act on the principle that provides, within the meaningful context, the strongest guide to action that can be morally justified by the tenets foundational to the principle. (Remember that the principlism ethics decision process is one of the approaches in step 5 of the general ethical decision-making framework.) The dominance of the principle of respect for autonomy has been challenged by critics concerned about decision making in non–acute care settings, where the ethical decision is more likely to be about, for example, long-term care or access to health care for persons of diverse cultures (Callahan and Jennings, 2002; Walker, 2009). Thus, whereas autonomy may be stressed in acute care settings, an overemphasis on autonomy may inhibit ethical decisions in public health. In public health, beneficence and distributive justice are frequently a greater issue than autonomy. For this reason, it is useful to look at other models for ethical decision making, including models that expand the focus of nursing beyond the individual nurse-client relationship to the social environment and systems that impact health care (Bekemeier and Butterfield, 2005). Utilitarianism and deontology were developed from the Age of Enlightenment’s focus on universals, rationality, and isolated individuals. Each theory maintains that there is a universal first 127principle—the principle of utility for utilitarianism and the categorical imperative for deontology—that serves as a rational norm for our behavior and allows us to calculate the rightness or wrongness of each individual action. Both utilitarianism and deontology also follow the lead of classic liberalism in asserting that the individual is the special center of moral concern (Steinbock et al, 2008). Giving priority to individual rights and needs means that these should not be sacrificed for the interests of society (Steinbock et al, 2008). The focus on individual rights leads to complications in the interpretation of distributive or social justice. Public health ethics rests on a set of general moral considerations. Bernheim and colleagues (2015, p. 21) identify nine moral considerations in public health: (1) producing benefits; (2) avoiding, preventing, and removing harms; (3) producing the maximal balance of benefits over harms and other costs (often called utility); (4) distributing benefits and burdens fairly (distributive justice); (5) respecting autonomous choices and actions, including liberty of actions; (6) protecting privacy and confidentiality; (7) keeping promises and commitments; (8) disclosing information as well as speaking honestly and truthfully (often grouped under transparency); and (9) building trust. These nine moral considerations in public health nursing are easy to apply. Distributive justice, or social justice, refers to the allocation of benefits and burdens to members of society. Benefits refer to basic needs, including material and social goods, liberties, rights, and entitlements. Wealth, education, and public services are benefits. Burdens include such things as taxes, military service, and the locations of incinerators and power plants. Justice requires that the distribution of benefits and burdens in a society be fair or equal. There is wide agreement that the distribution should be based on what one needs and deserves, but there is considerable disagreement as to what these terms mean. Three primary theories of distributive justice that are defended today include egalitarian, libertarian, and liberal democratic theories. Egalitarianism is the view that everyone is entitled to equal rights and equal treatment in society. Ideally, each person has an equal share of the goods of society, and it is the role of government to ensure that this happens. The government has the authority to redistribute wealth if necessary to ensure equal treatment. Thus, egalitarians are supportive of welfare rights—that is, the right to receive certain social goods necessary to satisfy basic needs, including adequate food, housing, education, and police and fire protection. The weaknesses of egalitarianism are both practical and theoretical. It would be practically impossible to ensure the equal distribution of goods and services in any moderately complex society. Assuming that such a distribution could be accomplished, it would require a coercive authority to maintain it (Coursin, 2009; Hellsten, 1998). Further, egalitarianism is unable to provide any incentive for each of us to do our best, because there is no promise of our merit being rewarded. The libertarian view of justice holds that the right to private property is the most important right. Libertarians recognize only liberty rights—the right to be left alone to accomplish our goals. Hellsten (1998, p. 822) notes, “The central feature of the libertarian view on distributive justice is that it is totally individualist. It rejects any idea that societies, states, or collectives of any form can be the bearers of rights or can owe duties.” Libertarians see a limited role for government, namely, the protection of property rights of individual citizens through providing police and fire protection. While they also concede the need for jointly shared, publicly owned facilities such as roads, they reject the idea of welfare rights and view taxes to support the needs of others as coercive taking of their property. Given the libertarian rejection of the priority of the state, however, it is not clear where the right to property originates (Hellsten, 1998). The work of John Rawls (2001) represents the liberal democratic theory. Rawls attempts to develop a theory that values both liberty and equality. He acknowledges that inequities are inevitable in society, but he tries to justify them by establishing a system in which everyone benefits, especially the least advantaged. This is an attempt to address the inequalities that result from birth, natural endowments, and historic circumstances. Imagining what he calls a “veil of ignorance” to keep us unaware of our actual advantages and disadvantages, Rawls would have us choose the basic principles of justice (p. 15). Once impartiality is guaranteed, Rawls (2001, p. 42) maintains that all rational people will choose a system of justice containing the following two basic principles: Each person has the same indefeasible claim to a fully adequate scheme of equal basic liberties, which scheme is compatible with the same scheme of liberties for all; and social and economic inequalities are to satisfy two conditions: first, they are to be attached to offices and positions open to all under conditions of fair equality of opportunity; and second, they are to be to the greatest benefit of the least advantaged members of society (the difference principle). As the veil of ignorance and the justice principles indicate, Rawls and other justice theorists all assume the Enlightenment concept of isolated, atomic selves in competition for scarce resources. The significance of justice, then, becomes the assurance of fairness to individuals. Violating the dictates of distributive justice is an offense to the dignity of the collective preferences of autonomous, rational moral agents. The interests of the community may be in conflict with the interests of individuals; yet, confined to the Enlightenment ideal, the needs of society are not directly addressed, nor is society given any priority. This Enlightenment assumption has been challenged by a number of ethical theories loosely grouped together under the heading communitarianism. The dominant themes of communitarianism are that individual rights need to be balanced with social responsibilities; individuals do not live in isolation but are shaped by the values and culture of their communities (Wringe, 2006). Among the theories with a communitarian focus are virtue ethics, caring and the ethic of care, and feminist ethics. Virtue Ethics Virtue ethics is one of the oldest ethical theories; it belongs to a tradition dating back to the ancient Greek philosophers Plato and Aristotle. It is not concerned with actions, as utilitarianism 128and deontology are, but instead asks: What kind of person should I be? The goal of virtue ethics is to enable persons to flourish as human beings. According to Aristotle, virtues are acquired, excellent traits of character that dispose humans to act in accord with their natural good. During the seventeenth and eighteenth centuries, the Greek concept of the good as a principle of explanation went out of favor. In public health nursing the virtue of care, or caring, is central to professional ethics. “The ethics of care emphasizes traits valued in intimate personal relationships such as sympathy, compassion, fidelity and love” (Beauchamp and Childress, 2013, p. 35). Caring refers to the “emotional commitment to, and willingness to act on behalf of, persons with whom one has a significant relationship” (Beauchamp and Childress, 2013, p. 35). Beauchamp and Childress (2013) examine five focal virtues for health professionals. They are (1) compassion, which focuses on the pain, suffering, disability, and misery of another person; (2) discernment, which involves the ability to use sensitive insight, astute judgment, and understanding to make good decisions; (3) trustworthiness, which is essential in health care when clients put themselves in the hands of others; (4) integrity, with a differentiation between moral integrity and professional integrity; and (5) conscientiousness, which is the character trait of acting to achieve what one believes to be the right thing to do given the circumstances. The appeal to virtues results in a significantly different approach to moral decision making in health care (Olson, 2008). In contrast to moral justification via theories or principles, the emphasis is on practical reasoning applied to character development. How To Apply the Virtue Ethics Decision Process 1. Identify communities that are relevant to the ethical dilemmas or issues. 2. Identify moral considerations that arise from a communal perspective and apply the consideration to specific communities. 3. Identify and apply virtues that facilitate a communal perspective. 4. Modify moral considerations as needed to apply to the specific ethical dilemmas or issues. 5. Seek ethical community support to enhance character development. 6. Evaluate and modify the individual or community character traits that impede communal living. (Remember that the virtue ethics decision process is one of the approaches in step 5 of the generic ethical decision-making framework.) Modified from Volbrecht RM: Nursing Ethics: Communities in Dialogue. Upper Saddle River, NJ, 2002, Prentice Hall, p 138. Caring and the Ethic of Care Caring in nursing, the ethic of care, and feminist ethics are all interrelated and, historically, all converged between the mid-1980s and early 1990s. Seminal work in caring in nursing was done by nurse-scholars (e.g., Leininger, 1984; Watson, 2007), who wrote about caring as the essence of or the moral ideal of nursing. This conceptualization occurred as a response to the technological advances in health care science and to the desire of nurses to differentiate nursing practice from medical practice. The discussion of the centrality of caring to nursing is reflected in Eriksson’s (2002) work on a caring science theory, which she sees as ethical in its essence. Proponents of caring support its premises; its detractors believe that nursing is not the only essentially caring profession and that caring, when placed within a broader societal context, represents the use of a disempowering concept to identify the essence of nursing. However, most nurses, including those who work in the community, would agree that there is a relationship between caring and ethics or morality. How To Apply the Care Ethics Decision Process 1. Recognize that caring is a moral imperative. 2. Identify personally lived caring experiences as a basis for relating to self and others. 3. Assume responsibility and obligation to promote and enhance caring in relationships. (Remember that the care ethics decision process is one of the approaches in step 5 of the generic ethical decision-making framework.) Carol Gilligan (1982) and Nel Noddings (1984) are often associated with the ethic of care. Gilligan (1982) speaks of a personal journey wherein, by listening and talking to people, she began to notice two distinct voices about morality and two ways of describing the interpersonal relationships between self and others. Contrary to what has been written about Gilligan and the two distinct voices (i.e., male and female) related to moral judgment, here is what she actually wrote: “The different voice I describe is characterized not by gender [italics added] but theme. Its association with women is an empirical observation, and it is primarily through women’s voices that I trace its development. But this association is not absolute, and the contrasts between male and female voices are presented here to highlight a distinction between two modes of thought and to focus [on] a problem of interpretation rather than to represent a generalization about either sex” (Gilligan, 1982, p. 2). Her 1982 book is based on three qualitative studies about conceptions of morality and self and about experiences of conflict and choice. She discovered what she calls the “voice of care” through interviews with girls and women (Beauchamp and Childress, 2013). She identified two modes of moral thinking: an ethic of care and an ethic of rights and justice. Although she did not say that these two modes correlated with gender, she did maintain that men tended to be involved with the ethic of rights and justice whereas women were more likely to affirm an ethic of care centering on responsiveness in “an interconnected network of needs, care, and prevention of harm” (Beauchamp and Childress, 2013, p. 35). From these studies she formulated her basic premises about responsibility, care, and relationships. These premises, in Gilligan’s (1982) own voice, are as follows: • “Sensitivity to the needs of others and the assumption of responsibility for taking care lead women to attend to voices other than their own” (p. 16). 129 • “Women not only define themselves in a context of human relationships but also judge themselves in terms of their ability to care” (p. 17). • “The truths of relationship, however, return in the rediscovery of connection, in the realization that self and other are interdependent and that life, however valuable in itself, can only be sustained by care in relationships” (p. 127). Noddings’ (1984) personal journey started at a point different from that of Gilligan’s. Noddings noticed that ethics was described in the literature primarily on the basis of principles and logic. The goal for Noddings’ book, therefore, was to express a feminine view that could be accepted or rejected by women or men. The basic premises of Noddings (1984), in her own voice, are as follows: • “The essential elements of caring are located in the relation between the one caring and the cared-for” (p. 9). • “Caring requires me to respond with an act of commitment: I commit myself either to overt action on behalf of the cared-for or I commit myself to thinking about what I might do” (p. 81). • “We are not ‘justified’—we are obligated—to do what is required to maintain and enhance caring” (p. 95). • “Caring itself and the ethical ideal that strives to maintain and enhance it guide us in moral decisions and conduct” (p. 105). What both Gilligan and Noddings have in common has been called a feminine ethic, because they believe in the morality of responsibility in relationships that emphasize connection and caring. To them, caring is not a mere nicety but a moral imperative. Nevertheless, a long-term healthy debate has surrounded their premises. How To Apply the Feminist Ethics Decision Process 1. Identify the social, cultural, legal, political, economic, environmental, and professional contexts that contribute to the identified problem (e.g., underrepresentation of women in clinical trials). 2. Evaluate how the preceding contexts contribute to the oppression of women. 3. Consider how women’s lives are defined by their status in subordinate social groups. 4. Analyze how social practices marginalize women. 5. Plan ways to restructure those social practices that oppress women. 6. Implement the plan. 7. Evaluate the plan and restructure it as needed. (Remember that the feminist ethics decision process is one of the approaches in step 5 of the generic ethical decision-making framework.) Modified from Volbrecht RM: Nursing Ethics: Communities in Dialogue. Upper Saddle River, NJ, 2002, Prentice Hall, p 219. Feminist Ethics Although feminist ethics finally has entered nursing, for many years, nurses appeared reluctant to embrace feminism and its ethics (Silva, 2008). According to Rogers (2006), the tenets of feminist ethics are relevant to public health. Rogers notes that a feminist perspective leads us to think critically about connections among gender, disadvantage, and health, as well as the distribution of power in public health processes. Because these issues affect health, feminist perspectives and approaches are important for nursing practice. What is meant by feminists and feminist ethics? Feminists are women and men who hold a worldview advocating economic, social, and political equality for women that is equivalent to that of men. Consequently, feminists reject the devaluing of women and their experiences through systematic oppression based on gender. In analyzing the common good, feminists pay careful attention to power relations that constitute a community, to the rules that regulate it, and to who pays and who benefits from membership in the community (Rogers, 2006). Feminists also can ascribe to the ethic of care. Feminist ethics encompasses the tenets that women’s thinking and moral experiences are important and should be taken into account in any fully developed moral theory, and that the oppression of women is morally wrong. Study of feminist ethics entails knowledge about and critique of classical ethical theories developed by men as well as ethical theories developed by women. Study of feminist ethics includes knowledge about the social, cultural, political, legal, economic, environmental, and professional contexts that insidiously and overtly oppress women as individuals, or within a family, group, community, or society. Feminists and persons who ascribe to feminist ethics are not passive; they demand social justice and political action, preferably at the societal level and through legislation. Ethics and the Core Functions of Population-Centered Nursing Practice The three core functions of public health nursing (i.e., assessment, policy development, and assurance) are discussed in Chapter 1. This discussion, however, did not stress the basic assumption that public health nursing is an ethical endeavor, with moral leadership at its core. Now the links of these three core functions to ethics are described. Assessment To review, “assessment refers to systematically collecting data on the population, monitoring the population’s health status, and making information available about the health of the community” (see Chapter 1). Three ethical tenets underlie this core function. The first relates to competency related to knowledge development, analysis, and dissemination. An ethical question related to competency is: Are the persons assigned to develop community knowledge adequately prepared to collect data on groups and populations? This question is important because the research, measurement, and analysis techniques used to gather information about groups and populations usually differ from the techniques used to assess individuals. Wrong research techniques can lead to wrong assessments, which in turn may hurt rather than help the intended group or population. A startling example of this is the case of Henrietta Lacks, whose cancerous cervical cells were taken without her or her family’s 130knowledge or permission and have now launched a medical revolution and a multimillion-dollar industry as the HeLa cells used in countless medical experiments (Skloot, 2010). The second ethical tenet relates to virtue ethics or moral character. An ethical question related to moral character is: Do the persons selected to develop, assess, and disseminate community knowledge possess integrity? Beauchamp and Childress (2013) define integrity as the holistic integration of moral character. The importance of this virtue is self-evident: without integrity, the core function of assessment is endangered. Persons with compromised integrity are easy prey for potential or real scientific misconduct. An example of a failure of integrity for nurses would be bias in collecting or reporting based on racism or homophobic grounds. The third ethical tenet relates to “do no harm.” An ethical question related to “do no harm” is: Is disseminating appropriate information about groups and populations morally necessary and sufficient? The answer to “morally necessary” is yes, but to “morally sufficient,” it is no. The fallacy with dissemination is that there is no built-in accountability that what is disseminated will be read or understood. If not read or understood, harm could come to groups and populations regarding their health status. Policy Development To review, “policy development refers to the need to provide leadership in developing policies that support the health of the population, including the use of the scientific knowledge base in making decisions about policy” (see Chapter 1). At least three ethical tenets underlie this core function. First, an important goal of both policy and ethics is to achieve the public good (Silva, 2002). Denhardt and Denhardt (2000), Rogers (2006), and Ruger (2008) among others say that the concept of “the public good” is rooted in citizenship. For example, Denhardt and Denhardt (2000) view citizenship, or what they call “democratic citizenship” (p. 552), as a stance in which citizens play a more substantial role in policy development. For this to occur, citizens must be willing to be both informed about policy, and to do what is in the best interests of the community. The approach is basically one in which the voice of the community is the foundation on which policy is developed, rather than the voice of community and public health administrators. The second ethical tenet purports that service to others over self is a necessary condition of what is “good” or “right” policy (Silva, 2002). Denhardt and Denhardt (2000) offer three perspectives on this matter: • Serve rather than steer. An increasingly important role of the public servant (e.g., nurses and administrators) is to help citizens articulate and meet their shared interests rather than to attempt to control or steer society in new directions (p. 553). • Serve citizens, not customers. The public interest results from a dialogue about shared values rather than the aggregation of individual self-interests. Therefore, public servants do not merely respond to the demands of “customers” but focus on building relationships of trust and collaboration with and among citizens (p. 555). • Value citizenship and public service above entrepreneurship. The public interest is better advanced by public servants and citizens committed to making meaningful contributions to society rather than by entrepreneurial managers acting as if public money were their own (p. 556). Service is at the core of these three perspectives, and service has always been one of the enduring values of nursing. The third ethical tenet holds that what is ethical is also good policy (Silva, 2002). What is ethical should be the singular foundational pillar on which nursing is based. Moral leadership is critical to policy development because it is the highest human standard and therefore should result in ethical health care policies. Assurance To review, “assurance refers to the role of public health in ensuring that essential community-oriented health services are available, which may include providing essential personal health services for those who would otherwise not receive them. Assurance also refers to making sure that a competent public health and personal health care workforce is available” (see Chapter 1). At least two ethical tenets underlie this core function. The first purports that all persons should receive essential personal health services or, put in terms of justice, “to each person a fair share” or, reworded, “to all groups or populations a fair share.” This is an egalitarian perspective of justice. This perspective does not mean that all persons in a society should share all of society’s benefits equally, but that they should share at least those benefits that are essential. People who see justice as fairness often think that basic health care for all is essential for social justice within a society. The case in Box 6-3 provides an example where the nurse needs to balance the client’s right to autonomy and the principle of distributive justice. Box 6-3 Case #1 Autonomy and Distributive Justice Amelia Lewis, a 31-year-old African American woman with multiple mental health diagnoses, has been monitored in the local mental health system for over 10 years. She is the mother of Tyesha, who is 3 years old. Multiple agencies have monitored Ms. Lewis and her little girl, who live in a sparsely furnished apartment in subsidized housing. A guardian handles all of Ms. Lewis’s financial affairs. Ms. Lewis’s relationship with the father of Tyesha has deteriorated, and he does not live with her. Ms. Lewis has issues of trust, and she is often suspicious of the care providers who come to her home. She does rely on some of the professionals with whom she interacts on a weekly or biweekly basis. She is both cognitively delayed and suffers from schizophrenia. Her developmental level places her at a stage at which her own needs are her primary focus, and this is not expected to change; her interaction with Tyesha is perfunctory, involving little outward affection. She is unable to understand that Tyesha is not capable of self-care and that her 3-year-old child will not always obey when Ms. Lewis instructs her to do something. Tyesha’s needs, level of functioning, and cognitive development are quickly surpassing her mother’s ability to cope. Frustration and misunderstanding ensue when Ms. Lewis thinks that Tyesha does not listen to her, and encouragement and parent education have done little to improve the situation as Tyesha gets older and more assertive. This has made toilet training, provision of an appropriate diet, and other aspects of normal child care problematic. Many services besides those for mental health are involved to help this family of two cope. There is concern about abuse or neglect of Tyesha due to Ms. Lewis’s lack of understanding of how to be a parent. Supplemental Security Income provides monetary support because of her mental disability and they have Medicaid coverage for their health care needs, as well as food stamps and modest financial assistance through Temporary Assistance for Needy Families (TANF). Ms. Lewis cannot currently work and take care of her child due to her mental disability. Before Tyesha’s birth, Ms. Lewis held a job and maintained self-care, but the care of Tyesha has precluded her managing employment at this time. Child Protective Services are also monitoring Ms. Lewis’s situation to determine to what extent she can meet the needs of her child. Ms. Lewis attends a local program to complete her General Education Development (GED), which provides child care during the day. Though Ms. Lewis is not expected to complete her GED, this program provides structured time for Tyesha three times a week. The child is considered developmentally normal at this time, and an infant development program monitors her progress on developmental issues. The Child Health Partnership, an agency that addresses the needs of challenged families, provides regular visits, family support, and parenting education, and the GED teachers make regular home visits to check on Ms. Lewis and Tyesha. Ms. Lewis thinks things are going just fine. The Child Health Partnership nurse is concerned about this family and thinks that some permanent resolution of the situation is inevitable. There is minimal coordination of services and there is no “lead agency” in the family’s care. Choose one of the ethical decision processes or one set of code of ethics discussed in the chapter and discuss and debate these questions: 1. Should the nurse involved in the Child Health Partnership program initiate any action to try to coordinate the work of the many agencies involved with this family? 2. Who has a professional responsibility to determine when the mother can no longer cope with the developing child? 3. Whose needs, Ms. Lewis’s or Tyesha’s, should take precedence? 4. Using one of the ethics decision processes, analyze the role of the nurse in this situation. For example, considering the utilitarian ethics decision process, decide if it is morally right for you to take the child away from the mother? If you do this, what are the implications for the mother, the child, and the community? What would be the possible consequences of removing the child? Of not removing the child? What principles can best guide your decision making? What possible moral dilemmas will you experience? 5. Safety is a core concept of public health nursing. Using two of the six quality and safety competences (patient-centered care and safety) for nurses identified in the Quality and Safety Education for Nurses (QSEN) work, develop a plan of action for the nurse who is caring for this family. Created by Mary E. Gibson, Assistant Professor, School of Nursing, University of Virginia. The second ethical tenet purports that providers of public health services be competent and available. Although the Public Health Code of Ethics (Public Health Leadership Society [PHLS], 2002) does not speak directly to workforce availability, it does speak directly to ensuring professional competency of public health employees. In addition to the Public Health Code of Ethics, the Healthy People 2020 objectives (U.S. Department of Health and Human Services [USDHHS], 2010) addresses competencies and workforce needs; a new objective (HP 2020-6) calls for an increased number of health care professionals certified in geriatrics. The Healthy People 2020 objectives address the need for all public health workers not only to have knowledge of public health, but also to have additional competencies as needed to fulfill their job responsibilities. Specific areas of knowledge include information technology, biostatistics, environmental health, cultural and linguistic competence, and genomics. The objectives also address needs of future public health leaders, who must be educated to meet new challenges in health care. Emphasis is also given to the availability and provision of life-long learning opportunities for public health employees. Nursing Code of Ethics As noted in the history section of this chapter, the Code of Ethics for Nurses with Interpretive Statements was adopted by 131the ANA House of Delegates in 2001. The Code was revised in 2015 and consists of nine provisions and the accompanying interpretive statements. The Code provides the following: • A succinct statement of the ethical values, obligations and duties of every individual who enters the nursing profession • Serves as the profession’s nonnegotiable ethical standard • Expresses nursing’s own understanding of its commitment to society (p. 5) These purposes are reflected in the nine provisional statements of the code. The Code of Ethics for Nurses and its interpretive statements apply to population-centered nurses, although the emphasis for each type of nursing sometimes varies (for the ANA Code of Ethics for Nurses, see http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses.aspx). As previously noted, the American Nurses Association has produced a Guide to the Code of Ethics for Nurses: Interpretation and Application, which serves as a companion reader to the 2001 Code of Ethics for Nurses (Fowler, 2008). This reader contains specific applications to nursing practice for each of the code’s nine interpretive statements. Whereas provisions 1 through 3 focus on the recipients of nursing care, provisions 4 through 6 focus on the nurse. This focus addresses nurses’ accountability, competency, and contributions to their employment conditions. Provisions 7 through 9 focus on the bigger picture of both the nursing profession and national and global health concerns. Regarding the nursing profession, the emphasis is on professional standards, active involvement in nursing, and the integrity of the profession. All nurses have a responsibility to meet these obligations. Regarding national and global health concerns, the emphasis is on social justice and reform. According to the ANA code (2015, p xi), The Code specifies that the patients and clients of nurses can be “individuals, families, communities or populations.” The Code also specifies that health is a universal right and this right has economic, political, social and cultural dimensions. Many of the components of the Code support and help to elaborate on the ethical responsibilities related to chapters and content throughout the text such as genomics, social determinants of health, cultural uniqueness and so forth, the Levels of Prevention box presents actions related to ethics. image Levels of Prevention Ethics Primary Prevention Use the Code of Ethics for Nurses to guide your nursing practice. Secondary Prevention If you are unable to behave in accordance with the Code of Ethics for Nurses (e.g., you speak in a way that does not communicate respect for a client), take steps to correct your behavior. You could explain to the client your error and apologize. Tertiary Prevention If you have treated a client or staff member in a way that is inconsistent with ethics practices, seek guidance on other choices you could have made. Public Health Code of Ethics The Public Health Code of Ethics (PHLS, 2002) mentioned in the history section of this chapter consists of a preamble; 12 132principles related to the ethical practice of public health (Box 6-4); 11 values and beliefs that focus on health, community, and action; and a commentary on each of the 12 principles. The preamble asserts the collective and societal nature of public health to keep people healthy. The 12 principles incorporate the ethical tenets of preventing harm; doing no harm; promoting good; respecting both individual and community rights; respecting autonomy, diversity, and confidentiality when possible; ensuring professional competency; manifesting trustworthiness; and promoting advocacy for disenfranchised persons within a community. Examples of values and beliefs include a right to health care resources, the interdependency of humans living in the community, and the importance of knowledge as a basis for action. The Healthy People box cites two new objectives that relate to ethics. image Healthy People 2020 There are two new objectives outlined in Healthy People 2020 related to access to health services: • AHS-1: Increasing the proportion of persons who receive appropriate evidence-based clinical preventive services • AHS-4: Increasing the proportion of practicing primary care providers, including nurse practitioners. Both of these objectives relate to access to care and reflect important ethical considerations for nurses. From U.S. Department of Health and Human Services: Healthy People 2020. Retrieved December 2014 from http://www.healthypeople.gov. Box 6-4 Principles of the Ethical Practice of Public Health* 1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. 2. Public health should achieve community health in a way that respects the rights of individuals in the community. 3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. 4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 5. Public health should seek the information needed to implement effective policies and programs that protect and promote health. 6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 7. Public health institutions should act in a timely manner on the information they have, within the resources and the mandate given to them by the public. 8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. 9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. 10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. 11. Public health institutions should ensure the professional competencies of their employees. 12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. *A section of the Public Health Code of Ethics is presented. Reprinted with permission from the Public Health Leadership Society: Public Health Code of Ethics, American Public Health Association (APHA), 2002. Available at http://phls.org/CMSuploads/Principles-of-the-Ethical-Practice-of-PH-Version-2.2-68496.pdf. When the Code of Ethics for Nurses and the Public Health Code of Ethics are assessed, some commonalities emerge. These codes provide general ethical principles and approaches that are both enduring and dynamic. They guide nurses and public health personnel in thinking about the underlying ethics of their profession. Although the two codes do not specify (nor should they specify) details for every ethical issue, other mechanisms such as standards of practice, ethical decision-making frameworks, and ethics committees help work out the details. Nevertheless, the preceding two codes address most approaches to ethical justification, including traditional and emerging ethical theories and principles, humanist and feminist ethics, virtue ethics, professional-individual and/or community relationships, and advocacy. Many websites provide further information on codes of ethics and other ethical concerns in public health; all can be accessed through the WebLinks section of this book’s Evolve website. Some of them are noted in the Additional Resources feature at the beginning of the chapter. Advocacy and Ethics Advocacy is an important concept in nursing that embodies an ethical focus grounded in quality of life. The American Public Health Association (APHA) represents a powerful voice for public health advocacy, focusing on finding ways to involve health care professionals in influencing policies related to protection of all Americans and their communities from preventable, serious health threats and helping to ensure access to health care and eliminating health disparities (APHA, 2014). 133The APHA notes the critical need to shift from a nation focused on treating individual illness to one that also promotes population-based health services that encourage preventive and early intervention practices. Also, the field of genetics has increasingly become an important ethical focus in public health; two new Healthy People 2020 objectives relate to genomics (G HP2020-1, G HP2020-2). The clinical case in Box 6-5 discusses the applicatioin of virtue ethics, truth telling and the deontological ethical decision-making process. Box 6-5 Case #2 Applying Virtue Ethics, Truth Telling, and the Deontological Ethical Decision-Making Process Because finding affordable housing was difficult, 26-year-old Terry White lived with her 6-month-old son, Tommy, and his father, Billy Smith, in one room of the landlord’s own house. Ms. White was morbidly obese and was diagnosed with bipolar disease; Mr. Smith had served time for drug dealing and was out on parole and staying straight. Neither had finished high school. Mr. Smith’s past drug use had rendered him unable to do much manual labor because of heart damage, but on occasion he would work in construction to support the family. Public health nurse Jim Lewis had received a referral on Tommy when he was diagnosed with failure to thrive (FTT) 2 months earlier. Ms. White, who had had two children removed from her custody by Child Protective Services (CPS) in the past, and Mr. Smith seemed to adore their baby, so much so that Ms. White would hold the baby all day long. In the past 2 months, the nurse had taught Ms. White about infant nutrition and gotten her enrolled in the Women, Infants, and Children (WIC) nutrition program; as a result, Tommy had increased his rate of physical growth and was above the 5% level of his growth percentile. Yet he was not meeting his gross motor milestones per Denver Developmental Screening Test II (DDST II) testing. Mr. Lewis thought that Tommy was not allowed to play on the floor enough to progress in sitting, pushing his shoulders up, or crawling. Most of their small room was taken up with the bed and the boxes that stored their belongings. There wasn’t really space for “tummy time” or play. When not in the room, the family would take the bus to a discount store and spend the day walking around to get a change of scene. One week Ms. White told the nurse she was not taking her medications for bipolar disease anymore because they caused her to gain weight. The next week she confided that Mr. Smith had had a “dirty” urine specimen check and would have to return to prison in the near future. The following week Mr. Lewis found the family living in a run-down motel since their landlord evicted them following a disagreement. Ms. White was agitated and told the nurse that they had only $100. Mr. Smith was going to have to return to prison that week, and the motel bill was already $240. Ms. White knew she would be homeless soon without Mr. Smith’s support but refused to talk with her social worker about her needs. She asked the nurse not to tell anyone about her situation because she was afraid CPS would take Tommy from her. It was clear to Mr. Lewis that Ms. White might not know what would happen to Tommy after they left this motel. 1. Considering the principle of truth telling, what are Mr. Lewis’ professional responsibilities to Ms. White, to Tommy, and to the social worker assigned to this family? 2. Using the generic ethical decision-making framework discussed earlier in the chapter and considering the deontological ethical decision-making process, answer the following questions. A. How should Mr. Lewis respond to Ms. White’s request to not tell anyone about their situation? B. What communication, about truth telling, if any, should the nurse initiate with the social worker? With others? C. Consistent with the principle of truth telling, how can the nurse involve Mr. Smith in the ongoing support and involvement with his family? 3. Using virtue ethics, what actions would you take to resolve any moral dilemmas you have about the safety of Tommy in this family situation? If you do not tell anyone about the possible dangers to the child, what moral principles come into play? If you do tell the social worker about the situation and the child is removed from the mother, what moral principles come into play for you? 4. What ethical dilemmas may you experience if you are the nurse in this case? How can you deal effectively with these potential dilemmas? Created by Deborah C. Conway, Assistant Professor of Nursing, School of Nursing, University of Virginia. Codes and Standards of Practice Several codes and standards of practice address advocacy. Four are noted here. Advocacy is addressed in codes of ethics put forth by the ANA (2015) and the Public Health Leadership Society (PHLS, 2002), as well as by the ANA (2013) in Standard 17, Public Health Nursing: Scope & Standards of Practice and the PHLS Skills for the Ethical Practice of Public Health (Thomas, 2004). The American Association of Colleges of Nursing (AACN) has developed a document entitled Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing that added specific public health nursing education competences to their competencies for baccalaureate education. Several of the competencies include a recommendation to include specific content related to ethics and public health nursing (AACN, 2013). According to the ANA (2015) Code of Ethics for Nurses, “The nurse promotes, advocates for, and protects the rights, health, and, safety of the patient” (p. 9). The focus of the interpretive statements regarding advocacy is the nurse’s responsibility to take action when the client’s best interests are jeopardized by questionable practice on the part of any member of the health team, the health care system, or others. The Public Health Code of Ethics (PHLS, 2002) and the PHLS Skills for the Ethical Practice of Public Health (Thomas, 2004) state that public health should advocate for disenfranchised community members, aiming to ensure that the basic resources necessary for health are accessible to all. The PHLS’s code addresses two important issues: that the voice of the community should be heard and that the marginalized or underserved in a community should receive “a decent minimum” (p. 4) of health resources. According to the ANA Public Health Nursing: Scope & Standards of Practice (2013), public health nurses have a moral mandate to establish ethical standards when advocating for health care policy. Specifically, Standard 7 says that public health nurses should practice ethically. image Focus on Quality and Safety Education for Nurses One of the six tenets of Quality and Safety Education for Nurses (QSEN) is patient-centered care (Barton et al, 2009). This chapter has discussed many ways in which an understanding of basic principles of ethics can guide safe and effective nursing practice. Some key aspects of patient-centered care in public health nursing include being certain that the information provided to individuals, families, and communities is accurate and reflects the most current evidence, and that it is presented in a timely fashion. Community health education should take into account the age, gender, and cultural and religious backgrounds of those who receive the information. Giving health information that does not meet these criteria can be unsafe and clearly does not reflect attention to quality nursing care. One of the QSEN competencies related to patient-centered care is as follows: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Specific aspects of patient-centered care related to communication are as follows: • Knowledge: Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education. • Skills: Communicate patient values, preferences, and expressed needs to other members of the health care team. • Attitudes: Respect and encourage individual expression of patient values, preferences, and expressed needs (Barton et al, 2009, p. 315). Specific aspects of patient-centered care related to the public health dilemma of serving the good of the population versus serving the good of the individual are as follows: • Knowledge: Explore ethical and legal implications of patient-centered care. • Skills: Recognize the boundaries of therapeutic relationships (Barton et al, 2009, p. 315). • Attitudes: Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional ethical care. Patient-centered ethical activity: Public health is more concerned about the good of the collective group than of the individual. In order to think more closely about quality and safety, debate with a classmate about whether children should be required to have all of the Centers for Disease Control and Prevention vaccines before they can enter school or remain the school. At the present time, some parents are choosing not to give their children all the recommended immunizations because of fear of side effects of the vaccines. To support your argument see http://www.cdc.gov/vaccines/schedules/index.html for what is required. See web articles such as www.responsibility-project.libertymutual.com for the parents’ point of view. Park EJ: The development and implications of a case-based computer program to train ethical decision-making. Nurs Ethics 20:943–956, 2013. Conceptual Framework for Advocacy One framework that can be used to define helpful behaviors for advocacy is to contrast social justice and market justice 134(Dorfman et al, 2005). As noted earlier in this chapter, it is important to recognize the potential conflict of individuals versus society. With communitarianism, individual rights need to be balanced with social responsibilities. When using a framework that contrasts social justice and market justice, the biggest barrier to achieving social justice is the competing concept of market justice. Market justice is grounded in the assumption that the best way to meet the needs of individuals in a society is to avoid regulations. The focus is on individual, not shared, needs (Table 6-2). A focus on market justice, rather than social justice, influences public dialogue about public health needs. It is important that existing values and beliefs in the society be understood in order to frame the public health message appropriately in terms of social justice values that relate to changes that they seek. Health care professionals must develop media skills to compete effectively with adversaries in public debate and learn to frame their advocacy initiatives. TABLE 6-2 Contrast of Social Justice and Market Justice as an Advocacy Framework Market Justice Values Social Justice Values Self-determination and self-discipline Shared responsibility Individual values and self-interest Interconnection and cooperation among individuals in a community Personal efforts key to desired benefits Community shares responsibility for providing basic benefits Limited responsibilities for good of the community Important obligations for the collective good Limited government intervention Government involvement is necessary Voluntary focus on individual moral behavior Community well-being supersedes individual focus on well-being Adapted from Dorfman L, Wallack L, Woodruff K: More than a message: framing public health advocacy to change corporate practices. Health Educ Behav 32:320–336, 2005. Practical Framework for Advocacy Bateman (2000) takes a practical approach to advocacy. He places the advocate’s core skills (i.e., interviewing, assertiveness and force, negotiation, self-management, legal knowledge and research, and litigation) within the context of six ethical principles for effective advocacy, as shown in Box 6-6. His focus is on the individual client, although the focus could also apply to groups and communities. Box 6-6 Ethical Principles for Effective Advocacy 1. Act in the client’s best interests. 2. Act in accordance with the client’s wishes and instructions. 3. Keep the client properly informed. 4. Carry out instructions with diligence and competence. 5. Act impartially and offer frank, independent advice. 6. Maintain client confidentiality. Regarding the first ethical principle, Bateman (2000) is sensitive to the ethical conflict between clients’ best interests and the best interests of groups, communities, or societies but does not elaborate on this conflict. The second ethical principle, which puts the client in charge, works in tandem with the first principle. It goes like this: “This is what I think we can do. What do you want me to do?” (Bateman, 2000, p. 51). Of course, the advocate can refuse the request if self or others may be harmed. By following the third ethical principle, the client is empowered to make knowledgeable decisions. The fourth ethical principle addresses standards of practice. The fifth ethical principle addresses fairness and respect for persons (population-centered 135nursing is more collaborative in nature than independent nursing). The last ethical principle, confidentiality, ensures that information will be shared only on a need-to-know basis. Advocacy: Issues that Have Ethical Implications Advocacy and Bioterrorism Before the terrorist attacks in the United States on September 11, 2001, the subject of terrorism was not a major focus in philosophical discussions (terrorism, in Stanford Encyclopedia of Philosophy, 2007). The September 11th attack, however, brought a frightening new awareness of the vulnerability of individuals and groups in our society and the need for advocacy. Although some countries have been forced to live with the knowledge of this type of vulnerability for years, today’s reality of global terrorism means that nurses must thoughtfully reflect on and debate ethical issues that arise with the threat, action, and aftermath of terrorism. They also must carefully consider their own responsibilities in terms of moral obligation to respond and make themselves available in a crisis that threatens the well-being of a community. As noted at the beginning of this chapter, population-centered nursing is concerned with protecting, promoting, preserving, and maintaining health while preventing disease. These goals that address the promotion of good and prevention of harm are intimately related to ethics and bioterrorism. It is often difficult to balance goals for the protection of the public and protection of the individual, as evidenced by an incident in which airport security personnel ordered a 4-year-old disabled child to remove his leg braces to go through a metal detector, even though his mother told the screeners that the child could not walk without the braces (Rubin, 2010). As a nurse, it is often hard when confronted with terrorism or a disaster to determine whether the needs of one’s family or the needs of one’s clients predominate. Silva and Ludwick (2003) provide a helpful framework related to the need for advocacy in bioterrorism, using the principles of nonmaleficence, beneficence, and distributive justice. These principles can guide nurses as they learn to speak out against violence and terrorism, work with agencies in the community for short-term and long-term efforts to do good and avoid harm, and participate in policy debates that attempt to determine fair distribution of scarce resources to fight terrorism globally. The ANA Center for Ethics and Human Rights maintains a helpful list of resource information addressing biodefense at http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsStandards/CEHR.aspx. Advocacy and Health Care Reform In the current focus on health care reform, it is critical that nurses advocate for reform that embodies ethical considerations that have been discussed in this chapter. Dr. Mary Wakefield, Administrator of the Health Resources and Services Administration (HRSA), noted that not only should nurses participate in implementing new directions for health care, but that it is important that they help to envision these new directions (Wakefield, 2008). Nurses can be an important voice in advocating for access to consistent, effective, efficient health care for all in our society. Wakefield says that educating the public can be a unique challenge because clever sound bites and attack ads in the media can lure consumers into thinking that the status quo is the best option. Nurses are an important part of the health care industry and are respected by the public; they can make meaningful contributions toward health care reform through advocating for clients and families. The signing of the 2010 health care bill by President Obama, after many years of controversial attempts at health care reform, provides an excellent opportunity for nurses to advocate for tying health care for all to ethics and social justice. Ethical Use of Social Media As the trend for using social media grows in both personal and professional arenas the implications for establishing boundaries for its use by health care professionals also grow. As Baker (2013, p. 501) says, “If the risks (of using social media) are managed well, social media can be a positive force for patient advocacy and education, as well as a resource for evidence-based practice and research.” She points out that nurses should practice within defined professional boundaries that center around four key elements: (1) promoting the dignity of the clients, (2) seeking client independence and working for their best interests, (3) abstaining from inappropriate involvement with clients, and (4) refraining from personal gain at the expense of the client. Ethical dilemmas arise when nurses act in ways that are not consistent with their professional boundaries. Baker (2013) points out that it is important to think through ethical concerns that are associated with social networking. This can be especially important when the nurse lives and works in a small community. For example, consider the public health nurse who goes to church with clients, attends the same parent-teacher meetings, and shops at the same stores as they do. Is it appropriate for her to then “friend” these clients on a social media site? Chapter 19 discusses rural health, and the issue of close relationships between nurses and clients is described there. image Linking Content to Practice Throughout this chapter, there has been application of the content related to ethics in public health nursing and the many documents that influence the role of public health nurses. These include the ANA Scope and Standards of Public Health Nursing, the ANA Code of Ethics, the core functions of public health as outlined by the Institute of Medicine, and the Healthy People 2020 objectives. Ethics is also an integral part of the Core Competencies for Public Health Professionals. Skill 8 in the section on analytic/assessment skills says that a public health professional uses “ethical principles in the collection, maintenance, use, and dissemination of data and information” and skill 2 under leadership and systems thinking says a professional “incorporates ethical standards of practice as the basis of all interactions with organization, communities, and individuals” (Council on Linkages between Academic and Public Health Practice, 2010). Council on Linkages Between Academic and Public Health Practice: Core competencies for public health professionals, Washington, DC, 2010. Public Health Foundation/Health Resources and Services Administration. 136 Practice Application The retiring director of the division of primary care in a state health department had recently hired Ann Green, a 34-year-old nurse with a master’s degree in public health, to be director of the division. Ms. Green’s work involved the monitoring of millions of dollars of state and federal money as well as the supervising of the funded programs within her division. Ms. Green received many requests for funding from a particular state agency that served a poor, large district. The poor people of the district primarily consisted of young families with children and homebound older adults with chronic illnesses. Over the past 3 years, the federal government had allocated considerable money to the state agency to subsidize pediatric primary care programs, but no formal evaluation of these programs had occurred. The director of the state agency was a physician who had been in this position for over 20 years. He was good at obtaining funding for primary care needs in his district, but the statistics related to the pediatric primary care program seemed implausible—that is, few physical examinations were performed on the children, which had resulted in extra money in the budget. This unspent federal money was being used to supplement home health care services for the indigent homebound older adults in his district. The thinking of the physician was that he was doing good by providing some needed services to both indigent groups in his district. Ms. Green felt moral discomfort because she did not have either the money or the personnel to provide both services. What should she do? A. What facts are the most relevant in this scenario? B. What are the ethical issues? C. How can Ms. Green resolve the issues? (The preceding case and answers are adapted and paraphrased from a real practice application shared by J.L. Chapin on the inappropriate distribution of primary health care funds [in Silva M, editor: Ethical Decision Making in Nursing Administration. Norwalk, CT, 1990, Appleton & Lange].) Answers can be found on the Evolve site. Key Points • Nursing has a rich heritage of ethics and morality, beginning with Florence Nightingale. • During the late 1960s, the field of bioethics began to emerge and influence nursing. • Ethical decision making is the component of ethics that focuses on the process of how ethical decisions are made. • Many different ethical decision-making frameworks exist; however, underlying each of them is the problem-solving process. • Ethical decision making applies to all approaches to ethics: utilitarianism, deontology, principlism, virtue ethics, caring and the ethic of care, and feminist ethics. • Cultural diversity makes ethical decision making more challenging. • Moral distress can lead to a personal sense of failure in providing nursing care and may lead to work and/or career dissatisfaction. • Classical ethical theories are utilitarianism and deontology. • Principlism consists of respect for autonomy, nonmaleficence, beneficence, and justice. • Other approaches to ethics include virtue ethics, caring and the ethic of care, and feminist ethics. • The core functions of public health nursing (i.e., assessment, policy development, and assurance) are all grounded in ethics. • Healthy People 2020 objectives address workforce competencies, training in essential public health services, and continuing education. • The 2015 Code of Ethics for Nurses contains nine statements that address the moral standards that delineate nursing’s values, goals, and obligations. • The 2002 Public Health Code of Ethics contains 12 statements that address the moral standards that delineate public health’s values, goals, and obligations. • Advocacy is the act of pleading for or supporting a course of action on behalf of a person, group, or community. • Effective advocacy incorporates ethical principles and concepts. • The Code of Ethics for Nurses, the Public Health Code of Ethics, Skills for the Ethical Practice of Public Health, and Public Health Nursing: Scope & Standards of Practice all address advocacy. • Public health advocacy is composed of both products and processes. • The products of advocacy are decreased morbidity and mortality. • The processes of public health advocacy include, but are not limited to, identifying problems, collecting data, developing and endorsing regulations and legislation, enforcing policies, and assessing the policy process. • Advocacy related to bioterrorism, health care reform, and ethical use of social media is important for community and public health nurses. 137 Clinical Decision-Making Activities 1. Think about the differences in duties between a nurse working in a critical care facility and a nurse working in a community care or public health setting. How might these differences lead to differences in ethical problems and decision making? 2. Interview a long-retired nurse about the most important ethical issues that this nurse faced when practicing in the community. Next, interview a nurse actively practicing in the community about the most important ethical issues that this nurse is now facing. Compare and contrast the ethical issues in the two interviews and place each within a historical context. 3. In a local or national newspaper, read one or more articles that discuss health care public policy with which you agree or disagree. Compose a letter to the editor analyzing why you agree or disagree with the policy but only after you take into account any of your own biases or vested interests. References American Association of Colleges of Nursing (AACN). Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing. AACN: Washington, DC; 2013. American Nurses Association (ANA). Code of Ethics for Nurses with Interpretive Statements. 2015 [Silver Spring, MD] Nursebooks.org. American Nurses Association (ANA). Public Health Nursing: Scope & Standards of Practice. American Nurses Publishing: Washington, DC; 2013. American Public Health Association. Advocacy and Policy, 2014. [Retrieved December 2014 from] www.apha.org/policies-and-advocacy/advocacy-for-public-health. Baker JD. Social networking and professional boundaries. AORN J. 2013;97:501–506. Barton AJ, Armstrong G, Preheim G, et al. A national Delphi to determine developmental progression of quality and safety competencies in nursing education. Nurs Outlook. 2009;57:313–322. Bateman N. Advocacy Skills for Health and Social Care Professionals. Jessica Kingsley: Philadelphia; 2000. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. ed 6. Oxford University Press: New York; 2008. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. ed 7. Oxford University Press: New York; 2013. Bekemeier B, Butterfield P. Unreconciled inconsistencies: a critical review of the concept of social justice in 3 national nursing documents. ANS Adv Nurs Sci. 2005;28:152–162. Bernheim RG, Childress JF, Bonnie RJ, et al. Essentials of Public Health Ethics. Jones & Bartlett: Burlington, MA; 2015. Callahan D. Universalism and particularism fighting to a draw. Hastings Cent Rep. 2000;30:37. Callahan D. Principlism and communitarianism. J Med Ethics. 2003;29:287–291. Callahan D, Jennings B. Ethics and public health: forging a strong relationship. Am J Public Health. 2002;92:169. Carlock C, Spader C. Communication and understanding: best vs distress. Nurs Spectr. October 8, 2007 [Retrieved December 2014 from] http://news.nurse.com/apps/pbcs. dll/article?AID=2007710080311. Council on Linkages between Academic and Public Health Practice. Core Competencies for Public Health Professionals. Public Health Foundation/Health Resources and Services Administration: Washington, DC; 2010. Coursin CC. Inequalities affecting access to healthcare: a philosophical reflection. Int J Hum Caring. 2009;13:7–15. Denhardt RB, Denhardt JV. The new public service: serving rather than steering. Public Admin Rev. 2000;60:549–552. Dorfman L, Wallack L, Woodruff K. More than a message: framing public health advocacy to change corporate practices. Health Educ Behav. 2005;32:320–336. Eriksson K. Caring science in a new way. Nurs Sci Q. 2002;15:61. Fowler MDM. Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association: Silver Spring, MD; 2008. Gilligan C. In a Different Voice: Psychological Theory and Women’s Development. Harvard University Press: Cambridge, MA; 1982. Gjengedal E, Ekra EM, Hol H, et al. Vulnerability in health care—reflections on encounters in every day practice. Nurs Philos. 2013;14:127–138. Hellsten S. Theories of distributive justice. Academic Press: New York; 1998:815–827. Chadwick R. Encyclopedia of Applied Ethics. vol 1. Holstein MB. Bringing ethics home: a new look at ethics in the home and the community. Holstein MB, Mitzen PB. Ethics in Community-Based Elder Care. Springer: New York; 2001. International Council of Nurses (ICN). ICN Code of Ethics for Nurses. ICN: Geneva; 1953. International Council of Nurses (ICN). ICN Code of Ethics for Nurses. ICN: Geneva; 2012. Leininger M. Care: The Essence of Nursing and Health. Slack: Thorofare, NJ; 1984. Noddings N. Caring: A Feminine Approach to Ethics & Moral Education. University of California Press: Berkeley, CA; 1984. Olick RS. From the column editor: ethics in public health. J Public Health Manag Pract. 2005;11:258–259. Olson LL. Provision Six. Fowler MDM. Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association: Silver Spring, MD; 2008:72–88. Park EJ. The development and implications of a case-based computer program to train ethical decision-making. Nurs Ethics. 2013;20:943–956. Petrini C. Theoretical models and operational frameworks in public health ethics. Int J Environ Res Public Health. 2010;7:189–202. Pinch WJE, Haddad AM. Nursing and Health Care Ethics: A Legacy and a Vision. American Nurses Association: Silver Spring, MD; 2008. Public Health Leadership Society. Public Health Code of Ethics. American Public Health Association (APHA); 2002 [Retrieved December 2014 from] www.phls.org/home/section/3-26. Rawls J, Kelly E. Justice as Fairness: A Restatement. Harvard University Press: Cambridge MA; 2001. Rogers WA. Feminism and public health ethics. J Med Ethics. 2006;32:351–354. Rubin D. Another case of TSA overkill. Philadelphia Inquirer. February 15, 2010 [Retrieved December 2014 from] http://www.philly.com/philly/news/20100215_Daniel_Rubin_Another_case_of_TSA_overkill.html. Ruger JP. Ethics in American health. 2. An ethical framework for health system reform. Am J Public Health. 2008;98:1756–1763. Silva MC. Ethical issues in health care, public policy, and politics. Mason D, Leavitt J, Chaffee M. Policy and Politics in Nursing and Health Care. ed 4. Saunders: Philadelphia; 2002. Silva MC. Provision Eight. Fowler MDM. Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association: Silver Spring, MD; 2008:72–88. Silva MC, Ludwick R. Ethics and terrorism: September 11, 2001 and its aftermath. Online J Issues Nurs. January 31, 2003 [Retrieved December 2014 from] http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No1Jan2003/EthicsandTerrorism.html. Skloot R. The Immortal Life of Henrietta Lacks. Crown Publishers: New York; 2010. Stanford Encyclopedia of Philosophy. Terrorism. [revised August 8, 2011]. 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Wringe C. Communitarianism. Philosophy & Education. Springer: New York; 2006:74–82. Moral Education: Beyond the Teaching of Right and Wrong. vol 14. *Special thank you to Dr. Mary Silva who offered valuable guidance for the revision of this chapter. Ch 7 Culture, Race, and Ethnicity Culture Culture is a set of beliefs, values, and assumptions about life that are widely held among a group of people and is transmitted intergenerationally (Leininger, 2002a). The term culture encompasses a broad range of concepts. It is an individual concept, a group phenomenon, and an organizational reality. Culture pervades all aspects of life and of health care. Culture determines how health care information is processed, received, and distributed; how rights and protections are exercised; what is considered to be a health problem; how symptoms and concerns of the problem are expressed; who provides treatment for the problem; and what type of treatment should be given (Giger, 2012; Purnell and Paulanka, 2012; Spector, 2012). Culture is applicable not only to minority groups, but also to majority groups such as white Americans of European descent (i.e. Irish, Italian, and Russian). Individuals are usually members of more than one culture. Each individual should be viewed as a unique human being with differences that are respected. Box 7-1 summarizes factors that may influence individual differences within cultural groups. Box 7-1 Factors Influencing Individual Differences Within Cultural Groups • Age • Religion • Dialect and language spoken • Gender identity roles • Socioeconomic background • Geographic location in the country of origin • Geographic location in the current country • History of the subcultural group with which clients identify in their current country of residence • History of the subcultural group with which clients identify in their country of origin • Amount of interaction between older and younger generations • Degree of assimilation in the current country of residence • Immigration status* • Conditions under which migration occurred Except where noted with an asterisk, from Orque M: Orque’s ethnic/cultural system: a framework for ethnic nursing care. In Orque MS, Bloch B, Monrroy LSA, editors: Ethnic Nursing Care. A Multicultural Approach. St. Louis, 1983, Mosby. In response to the needs of its members and the environment, culture provides tested solutions to life’s problems and guides our thinking, discourse, attitudes, and actions. In the present health care system, nurses have the chief responsibility for translating health information so that clients can understand it and engage in more effective strategies to achieve positive health outcomes. Understanding the beliefs and practices these clients bring to the clinical setting, their responses to health and illness, and the type of health care they expect to receive are important data that nurses should draw on when developing a plan of care for clients. Individuals learn about their culture during the process of socialization and language development (Box 7-2). Parents and other family members are the primary sources for the transfer of traditions and teaching explicit and implicit behaviors of the culture. Schools, community, and cultural organizations are secondary sources of socialization. Explicit behaviors are straightforward and do not leave room for misinterpretation of what the person wants to communicate. Implicit behaviors are less exact and include the use of body language to communicate rather than persons saying verbally what is on their mind. An example of an explicit message is “No smoking is permitted” and an implicit message is: “Thank you for not smoking” (Figures 7-1 and 7-2). Box 7-2 Early Cultural Awareness Think about the first time you had contact with someone you realized was culturally different from you. Briefly describe the situation/event. How old were you? What were your feelings? What were your thoughts? What did your parents and other significant adults say about those who were culturally different from you or your family? What adjectives were used? What attitudes were conveyed? As you got older, what messages did you receive about minority groups from members of your family, school, recreation facilities, and church? As an adult, when you hear others talk about culturally different people, what images do they conjure up for you? What knowledge source is evident in the comment of the person? Do the views of the person reinforce or contradict the views that you hold today? Give an example. What parts of your culture make it difficult to work with clients from different cultural groups? What parts of your culture facilitate your work with clients from different cultural groups? From Randall DE: Culturally Competent HIV Counseling and Education. McLean, VA, 1994, Maternal and Child Health Clearinghouse. image FIG 7-1 The sign is from a culture that values directness in communication. (© 2012 Photos.com, a division of Getty Images. All rights reserved. Image 91883504.) image FIG 7-2 The sign is from a culture that values indirectness in communication. (© 2012 Photos.com, a division of Getty Images. All rights reserved. Image 122153579.) Race Concepts of race and ethnicity within American society play a strong role in understanding human behavior and health. In everyday language, these two concepts are often used interchangeably. Nurses are expected to understand and appreciate the meaning of each concept as each relates to providing culturally competent health care to persons of diverse cultures. 142 Race is a biological variation within population groups based on physical markers derived from genetic ancestry such as skin color, physical features, and hair texture. It is a characteristic that allows for some groups to be separated, treated as superior, and given access to power and other valued resources, while others are treated as inferior and have limited access to power and resources. Race differences include areas of growth and development, skin color, enzymatic differences, susceptibility to disease, and laboratory test findings. Individuals may be of the same race but of different cultures. For example, African Americans, who may have been born in Africa, the Caribbean, North America, or elsewhere, are a heterogeneous group, but they may be considered culturally homogeneous by persons who think of African Americans as one group. Monolithic thinking means that the many cultural differences of individuals from these diverse geographic regions may be overlooked because of the similar racial characteristics (Degazon, 1994). Individuals who belong to the Caucasian race also experience this same over-generalization of individuals along racial/ethnic lines. Ethnicity Ethnicity, in contrast to race, is the shared feeling of peoplehood among a group of individuals and relates to cultural factors such as nationality, geographic region, culture, ancestry, language, beliefs, and traditions (Giger, 2012) (Figure 7-3). These ethnicity and racial patterns have been developed in a socioeconomic context with historical and political underpinnings. They are equally influenced by education, income, and cross-cultural experiences. Race and ethnicity account for much of the health disparities in the United States. Members of an ethnic group are likely to give up aspects of their identity and society when they adopt characteristics of another group’s identity. However, when there is a strong ethnic identity, the individual maintains the values, beliefs, behaviors, practices, and ways of thinking of their group. Ethnic disparities in health care are explained largely by differences in English fluency whereas racial disparities in health care are best explained by delayed care due to a lack of knowledge by caregivers about culture and ethnic values, norms and thinking outside of their reference group, lack of insurance, and lack of transportation. image FIG 7-3 In countries around the world, there are distinct differences in people who represent the same cultural group. (Copyright © 2013 Thinkstock. All rights reserved. Image # 117003112). Cultural Diversity Cultural diversity refers to the degrees of variation that is represented among populations based on lifestyle, ethnicity, race, interest, across place, and place of origin across time. It includes other aspects of variation among people, such as social class, gender identity, sexual orientation, physical abilities/disabilities and care beyond multiculturalism. Cultural diversity also refers to the changing populations of the world as it becomes more of a global village. It is about understanding and embracing each other’s differences and similarities. 143 Cultural Variations among Selected Groups Each culture has an organizational structure that distinguishes it from others and provides the direction for what members of the cultural group determine is appropriate or inappropriate behavior. The organizational elements of health culture have been described in nursing by Andrews and Boyle (2012), Giger (2012), Leininger (2002b), Purnell and Paulanka (2012), and Spector (2012). As part of the nursing process, nurses are expected to accurately assess a client’s health needs based on information about seven primary cultural elements: biological variations, personal space, time, environmental control, social organizations, communication patterns, nutrition, and religion (Table 7-1). Usually, the assessment takes place in the initial nurse–client interview. It is important that nurses use this information to develop a client-centered care plan. Once this information is gathered, the nurse should schedule a second interview with the client to determine ways to individualize culturally congruent care so that it is acceptable to the client. TABLE 7-1 Cultural Variations among Selected Groups African Americans Asians Hispanics American Indian/Native Alaskans Verbal Communication Asking personal questions of someone that you have met for the first time is seen as improper and intrusive. High level of respect for others, especially those in positions of authority. Expression of negative feelings is considered impolite. Speak in a low tone of voice and expect the listener to be attentive. Nonverbal Communication Direct eye contact in conversation is often considered rude. Direct eye contact with elders and authority figures may be considered disrespectful. Avoidance of eye contact is usually a sign of attentiveness and respect. Direct eye contact is often considered disrespectful. Avoidance of eye contact should not be interpreted as inattentiveness or evasiveness. Touch Very affectionate and expressive. Touching of one’s hair by another is often considered offensive. It is not customary to shake hands with persons of the opposite sex. Very affectionate and use hand, face, and body gestures to express self. Touching is often observed between two persons in conversation. Modesty. A light touch of the person’s hand instead of a firm handshake is often used when greeting a person. Family Organization Usually have close extended family networks; women play key roles in health care decisions. Usually have close extended family ties; emphasis may be on family needs rather than individual needs. Usually have close extended family ties; all members of the family may be involved in health care decisions. Usually have close extended family; emphasis tends to be on family rather than on individual needs. Decision making may vary among tribes. Time Perception Often present oriented. Often present oriented. Often present oriented. Often past oriented Environmental Control Harmony of mind, health, body, and spirit with nature. Balance between the “yin” and “yang” energy forces. Balance and harmony among mind, body, spirit, and nature. Harmony of mind, body, spirit, and emotions with nature. Alternative Healers “Granny,” “root doctor,” voodoo priest, and spiritualist. Acupuncture, acupressure, acumassage, herbalist, moodang. Curandero, espiritualista, Santero priest, yerbero, faith healers. Medicine man, shaman. Self-care Practices Poultices, herbal medicine, oils, teas, massage, hot baths, and roots. Hot and cold foods, herbal medicine, teas, soups, cupping, burning, rubbing, pinching. Hot and cold foods, herbal teas. Herbs, corn meal, medicine bundle. Biological Variations Sickle cell anemia, Mongolian spots, keloid formations, inverted “T” waves, lactose intolerance, skin color. Thalassemia, alcohol intolerance, drug interactions, Mongolian spots, lactose intolerance, skin color. Mongolian spots, lactose intolerance, skin color. Cleft uvula, lactose intolerance, skin color, lumbar pigmented spots, and epicanthal eye folds, Mongolian spots. *Australia, New Zealand, and the nearby islands. From Office of Immigration Statistics, Office of Management, Department of Homeland Security: 2008 yearbook of immigration statistics, Washington, DC, 2008, U.S. Government Printing Office. Biological Variations Biological variations are the physical, biological, and physiological characteristics that exist between racial groups and distinguish one race from another. These characteristics occur in areas of growth and development, skin color, enzymatic differences, susceptibility to disease, and laboratory test findings (Andrews and Boyle, 2012; Giger, 2012). For example, Western-born neonates are slightly heavier at birth than those born in non-Western cultures. Variations in growth and development may be influenced by environmental conditions such as nutrition, climate, and disease. Mongolian spots are bluish discolorations that are sometimes present on the skin of African American, Asian, Hispanic, and Native American/Alaskan Native babies. These spots may be mistaken for bruises. When nurses encounter situations involving unfamiliar biological variations, they may create embarrassing situations. Consider the following scenario: The school nurse observed a bluish discoloration on the thigh of a Filipino child that she mistook for a bruise. The nurse reported her observation to the child protective agency in her state. The mother had to disprove the allegation to the agency’s social worker before her child could be released into her care. Other common and obvious variations include eye shape, hair texture, adipose tissue, shape of earlobes, thickness of lips, and body configuration. A common enzyme deficiency is glucose-6-phosphate dehydrogenase (G6PD), which is responsible for lactose intolerance in many ethnic groups (Giger, 2012). The findings that DNA composition for any two humans across race is 99.9% genetically identical and that difference between races occur only in 1 in 1000 people diminishes the ethnocentric debate about the importance of race. Another factor making race less important is the increasing numbers of interracial marriages that result in interracial children whose physical and genetic pool dilute the racial characteristics of their parents. Racial categories originated from a shared genealogy due to geographic isolation. In today’s global village, this isolation has been broken down and there are more mixed groups. In the United States, children of biracial parents are usually assigned the race of the mother. The Levels of Prevention Box gives examples of cultural strategies for primary, secondary, and tertiary levels of prevention. image Levels of Prevention Hypertension, Stroke, and Heart Disease Related to Cultural Differences Primary Prevention Provide health teaching about balanced diet and exercise. Based on the details of the individual’s culture, the teaching should include members of the family and identification of culturally appropriate foods and the means for preparing them. Secondary Prevention Teach clients and/or family to monitor blood pressure. Teach about diet, keeping in mind the client’s cultural preferences. Talk about health beliefs and cultural implications, such as the use of alternative therapies; make sure alternative therapies are compatible with any medications that may be prescribed. Tertiary Prevention If blood pressure cannot be controlled by diet and/or exercise, refer the client to a culturally appropriate medical practitioner for medication and supervision; advise the client to engage in a cardiac program that will oversee diet and exercise. Personal Space Personal space is the physical distance maintained between individuals during an interaction (Giger, 2012). The amount of space varies among individuals and between cultures. When this space is violated, the nurse or the client may experience discomfort. There are four zones of interpersonal space—intimate space (direct contact to 1.5 feet), personal distance (1.5 to 4 feet), social distance (4 to 12 feet), or public distance (greater than 12 feet)—that may be observed when nurses care for clients. Cultural groups also have spatial preferences. To illustrate, Hispanic cultures tend to be comfortable with less space because individuals like to touch some persons with whom they 144are speaking. In the Filipino culture individuals may view touching strangers as inappropriate; therefore, nurses who wish to be culturally appropriate may elect to stand farther away from Filipinos than from Hispanics. On the other hand, clients who are comfortable with closer distances may experience discomfort when nurses stand farther away, interpreting the behavior as rejecting. Nurses should take cues from clients to place themselves in the appropriate spatial zone and avoid misinterpretation of clients’ behavior as they handle their spatial needs. Perception of Time Perception of time refers to past, present, and future time as well as to the duration of and period between events. Some cultures assign greater or lesser value to events that occur in the past, the present, or the future. If members of a cultural group tend to be future oriented, they often will delay immediate gratification until future goals are accomplished. For example, some future-oriented persons who value longevity may engage in health promotion activities to moderate their dietary intake and engage in exercise activities to minimize future health risks. In contrast, some present-oriented cultural groups may place greater emphasis on the here and now and view information about their present set of circumstances as more important than what will happen in the future. Other cultures believe that their ancestral lineage determines their current health status. When nurses discuss health promotion and disease prevention strategies with persons who have a present orientation, they should focus on the immediate benefits these clients will gain rather than emphasizing 145future outcomes. That is not to say that clients cannot or will not learn about preventing future complications of illness, but nurses need to connect their teaching to the “here and now.” It is important to listen carefully to what the clients say in order to gather information about their time orientation. In cultures that focus on a past orientation (e.g., the Vietnamese culture), individuals may be less concerned about planning ahead and focus more on wishes and memories of their ancestors (Giger, 2012). In a past-oriented culture, time is viewed as being more flexible than in a present-oriented culture. It has less of a fixed point, and individuals may not be offended by being late or early for appointments. Nurses socialized in the Western culture may view time as money and equate punctuality with correctness and being responsible. Working with clients who have a different time perception than the nurse can pose a dilemma for the nurse who wishes to be culturally competent and accountable for helping her client receive adequate health care. Nurses should clarify the clients’ perceptions to avoid misunderstanding; however, nurses should explain the importance of keeping appointments from the Western perspective. For example, the nurse can communicate a willingness to be flexible in scheduling appointments and explain to clients that the time will be set aside, specifically for them. Along with culture, socioeconomic status and religion may influence the client’s perception of time. Environmental Control Environmental control refers to the person’s relationship with nature and efforts to plan and direct factors in the environment that affect them. Different cultures can be distinguished on the basis of one of three views of nature and the role of environment in everyday life: (1) nature controls the environment, (2) nature and the environment work in harmony to promote health and wellness, and (3) the environment has mastery over nature. In cultures that perceive individuals as having mastery over the environment, one can expect that a client with the diagnosis of cancer will be willing to engage in a rigorous treatment, include chemotherapy, radiation, and laser therapy to beat the disease. Persons who value harmony with the environment (e.g., African Americans, Asians, and American Indian/Alaskan Natives) may perceive cancer as disharmony with other forces and that medicine can only relieve the symptoms rather than cure the disease. They would look to the mind, body, and spirit connection, for healing comes from within, to find treatments for the malignancy. Naturalistic solutions, such as herbs, acupuncture, and hot and cold treatments would be their treatment of choice to resolve the suffering associated with the cancerous condition. Individuals from cultures that view the environment as dominant over nature (e.g., Hispanics) may believe that they have little or no control over the serious illness for which they have been diagnosed. These individuals are less likely to engage in illness management interventions that are harsh and that they cannot trust to yield a positive health outcome. Social Organization Social organization refers to the way in which families are structured to carry out role functions. Members depend on the extended family and kinship networks for emotional, social, and financial support in times of crises. The significance of kinship in the formation of family relations varies across cultures. Some cultures adopt individuals who are unrelated or remotely related as family members. Some Hispanic and Asian cultures place the needs of the family above those of the individual. In the American Indian/Alaskan Native family, members honor and respect their elders and look to them for leadership, believing that wisdom comes with increasing age. When working with clients who prefer family decision making over individual choice, nurses should be aware that it may be counterproductive to exclude family involvement—particularly mothers and grandmothers—in the health care decision making. At the same time, nurses should advocate for the individual, making sure that when families make decisions, the individual’s needs have been considered. Communication Communication is the means by which culture is shared. Both verbal and nonverbal communications are learned in one’s culture. Communication is the most significant problem that presents itself in working with cross-cultural groups. Cross-cultural variations in verbal style can range from pronunciation, word meaning, voice quality, and humor, to nonverbal communication with eye contact, gesture, touch, body posture, facial expression, and silence. In all forms of communication, maintain respect for individuals. Often in cultures where the elderly are held in high esteem, they are addressed in a formal manner. Communicating trust is also important because it facilitates the nurse–client interaction and determines the extent to which the client will share information with the nurse (Morgan et al, 2006). The following example involving a nurse giving instructions to Asian clients about taking anti-tuberculin drugs illustrates the need to understand cultural communication. The clients responded with a smile and a nod. The nurse interpreted this response to mean that the clients understood the instructions and had accepted the treatment protocol. A week later, when the clients returned for a follow-up visit, the nurse discovered that the medications had not been taken. The nurse knew that acceptance by and avoidance of confrontation or disagreement with those in authority are important behaviors in Asian culture. Interventions were adjusted accordingly: the nurse repeated the medication instructions and gave the clients an opportunity to raise questions and concerns and to repeat the instructions that were given; the nurse also discussed the cultural meaning and treatment of tuberculosis. Other factors influencing communication include forms of address such as the use of first names or surnames, and whether it is polite to wait until a person finishes speaking or to talk over each other. Nutrition For many cultures, the preparation and eating of food is a social activity and members of the group come together to celebrate life and comfort with one another. Almost all family rituals, including birth, baptisms, graduations, marriages, retirements, and deaths, include food as part of the ceremony. Many of these practices may have their origin in religious (for example, Muslims avoid pork and foods cooked with alcohol) as well as 146cultural (for example, African Americans may have a large meal with family and friends after church on Sunday) traditions. The culture domain of nutrition includes much more than having adequate food to sustain dietary requirements. Efforts to understand dietary patterns of clients should go beyond relying on membership in a defined group. Knowing the client’s nutritional practices enables nurses to develop dietary regimens that do not conflict with their cultural food requirements. Health care teams that prescribe an American diet to a Hispanic or an Asian client whose mealtime and food choices may be different from American food patterns may be negligent. Specific foods have been developed for several subcultures such as Vietnamese, Cuban, Puerto Rican, Navajo, Japanese, and Jewish. When engaging in mutual goal setting with the client and a nutritionist to change harmful dietary practices, the team might need to consult culturally oriented magazines before prescribing particular food items. A number of popular magazines such as Essence, Ebony, and Latina have created healthier dishes from revised old family recipes for Hispanic and African American families. These dishes are tasty and resemble old traditions, yet they are nutritious. Although the foods may differ culturally, excesses often lead to similar risk factors. Box 7-3 identifies several questions that nurses should ask when conducting a nutritional assessment. Box 7-3 Assessment of Dietary Practices and Food Consumption Patterns 1. Does the food have nutritional value based on My Plate? 2. What is the social significance of food in the family? Has the family adopted foods from other cultural groups? 3. What foods are most frequently purchased for family consumption? Who decides and from where is the food purchased? 4. What foods, if any, are prohibited for the family? 5. What variables play a significant role in food selection (cost, variability, family rituals, religion, family tradition, celebrations)? 6. How often does the family prepare food at home? Who prepares the food? How is it prepared? 7. How much food is eaten? When is it eaten and with whom? 8. Are fresh fruits and vegetables easily accessible for purchase in the community? 9. What spices do the family use in the preparation of the food? What are the family favorite recipes? 10. What are the characteristics of restaurants and other eating facilities that the family uses outside of the home? Many of clients’ health lifestyle choices are associated with their nutritional practices. As a result, before nurses begin a dietary intervention, they should perform a nutritional assessment to determine food preferences, rituals, and taboos. For many cultures, eating is a social activity and people get together for celebration and to comfort each other. Table 7-2 depicts various food preferences that are present among some cultural groups in American society and the associated risk factors when there is excessive use. Efforts to understand dietary patterns of clients should go beyond relying on membership in a defined group. Knowing the client’s nutritional practices makes it possible for nurses to develop treatment regimens that will not conflict with their cultural food practices. TABLE 7-2 Food Preferences and Associated Risk Factors in Selected Cultural Groups Cultural Group Food Preferences Nutritional Excess Risk Factors African Americans Fried foods, greens, bread, pork, rice, foods with high sodium and starch content Cholesterol, fat, sodium, carbohydrates, calories Obesity, coronary heart disease, hypertension, cancer, diabetes, and HIV/AIDS Asians Soy sauce, rice, pickled dishes, raw fish, tea, balance between yin (cold) and yang (hot) concepts Cholesterol, fat, sodium, carbohydrates, calories Coronary heart disease, liver disease, cancer of the stomach, ulcers Hispanics Fried foods, beans and rice, chili, carbonated beverages, high-fat and high-sodium foods Cholesterol, fat, sodium, carbohydrates, calories Obesity, coronary heart disease, diabetes American Indian/Alaskan Natives Blue corn meal, beans, squash, game and fish Carbohydrates, calories Depression, suicide, diabetes, malnutrition, tuberculosis, infant and maternal mortality From Andrews MM, Boyle JS: Transcultural Concepts in Nursing Care, ed 6. Philadelphia, 2012, JB Lippincott; Giger JN: Transcultural Nursing: Assessment and Intervention, ed 6. St Louis, 2012, Mosby. Religion The expression of spiritually is a component of health and illness coping for most people. The Joint Commission requires that health professionals conduct a spiritual assessment on individuals. Prayer and religion play a dominant role in protecting health and supporting healing in many cultural traditions. Among all the ethnic groups in the United States, African Americans are most likely to report a formal religious affiliation (Pew Forum on Religion & Public Life, 2008). Among Hispanics, Roman Catholic and Pentecostal beliefs and practices are prevalent. Hispanics who practice Pentecostal beliefs may engage in prayer and believe in miraculous healing. Muslims are the most racially diverse group and the second largest and fastest growing religion in the world. In the United States, the majority of Muslims are white (37%), African American (24%), Asian (20%), mixed race (15%), and Latino (4%). Muslims are considered either Sunni or Shia Muslim. Muslims face Mecca (which is northeast) when they pray, and when death is imminent they want their faces turned toward Mecca. Sunni Muslims pray five times a day and Shiite Muslims pray three times a day. Muslims gather for corporate worship on Fridays. Tradition says that Muslims pray on the floor, but during illness they may pray in bed. Exceptions from traditional Muslim practices can sometimes be permitted during 147pregnancy, breast feeding, illness, or travel; but the nurse should always ask the client because some Muslims may observe the practices even though they may have received permission for an exception. Some African Americans practice Muslim traditions although most belong to a Christian faith. Many African Americans find comfort and support in their spiritual beliefs, believe God is responsible for health, and view health professionals as God’s instruments for healing. African Americans with Haitian background may practice voodoo in conjunction with a traditional religion. Most Jews observe the holidays of Rosh Hashanah and Yom Kippur. Many Jews observe Sabbath, which extends from sundown on Friday until sundown on Saturday. Jews of European origin are called Ashkenazi Jews; Middle Easterners and non-European Jews are called Sephardic. Chinese and other Asian people often practice Eastern religions such as Confucianism, Buddhism, and Taoism (Lai and Sunrood, 2009). Confucianism emphasizes respect for the elderly and people in authority. Practitioners believe that moral conduct and maintaining harmonious relationships are the keys to life. The five most important attributes are benevolence, righteousness, loyalty, filial piety, and virtue. The Buddhist principles embrace three attributes: mercy, thriftiness, and humility. Buddhists believe that people receive good fortune for doing the right thing and misfortune for doing the wrong thing. Taoism embraces selflessness and emotional calm. The most important thing to them is to be in harmony with nature. An important element of health is outdoor exercise for peace of mind and outside air. Part of achieving good health is to adjust the thinking and the body to fit in with the natural rhythm of the universe. Immigrants and Cultural Diversity Immigrants to the United States are born in countries or territories external to the United States and migrate to the United States, contributing to its vast diversity. Place of origin for the immigrant is distinguished from nationality, which refers to the place where the individual has or had citizenship. For example, if individuals were born in the Dominican Republic, they may be naturalized citizens, but their ethnicity is likely to be Hispanic with a Dominican place of origin. It is estimated that the U.S. population consists of 39 million (foreign-born) immigrants accounting for 12% of the total population of which 11.7 million have illegal status (Congress of the United States, 2012). Foreign-born refers to all residents who were not a U.S citizen at birth, regardless of their current legal or citizen status or those whose parents were not U.S. citizens. More than two thirds of the foreign-born population lives in or around major metropolitan areas in four states: Nevada, Texas, California, and Arizona (Congress of the United States, 2012). Their employment tends to be associated with the region of the world from which they came. For example, persons from South America may be in construction- or agriculture-related occupations (21%), while persons from Asia tend to be associated with professional or technical occupations (39%). The foreign-born are likely to be poorer (23%) than the U.S.-born population (13.5%); 36% of immigrant-headed households use at least one major welfare program (primarily food assistance and Medicaid) compared to 23% of the U.S.-born population. They comprise 16% of the total adult workforce with more than 54% of the adults in the labor force having completed high school (Camarota, 2012). These immigrants bring with them unique cultural, health care, and religious backgrounds (Figure 7-4). image FIG 7-4 A child from Nepal living in the United States. The child has a black dot on her forehead to protect her from the “evil eye.” There are four categories of foreign-born. The first category is legal immigrants, also known as lawful permanent residents. This group constitutes about 85% of the immigrant population. They are not citizens but are legally allowed to live and work in the United States, usually because they fulfill labor demands or have family ties. Legal immigrants usually have a five-year waiting period living in the United States after receiving “qualified” immigration status before they are eligible to receive entitlements such as Medicaid and CHIP (Camarota, 2012). The second category of foreign-born consists of refugees and persons seeking asylum. The Refugee Act of 1980 provided a uniform procedure for refugees (based on the United Nations definition) to be admitted to the United States (U.S. Department of Health and Human Services, 2001). This included refugees from Cuba, Vietnam, Laos, Cambodia, and Russian Jewish refugees. These are people who seek protection in the United States because of fear of persecution (on the basis of race, religion, nationality, political view, or membership in a certain 148group) if they were to return to their homeland. Refugees are immediately eligible to receive Temporary Assistance for Needy Families, Supplemental Security Income, and Medicaid. The third category of foreign-born is the non-immigrants; these are people admitted to the United States for a limited duration and for a specified purpose. Non-immigrants include students, tourists, temporary workers, business executives, career diplomats, their spouses and children, artists, entertainers, and reporters. The fourth category of foreign-born is unauthorized immigrants, or undocumented or illegal aliens. These persons may have crossed a border into the United States illegally, or their legal permission to stay in the United States may have expired. Unauthorized immigrants are eligible to receive emergency medical services, immunizations, treatment for the symptoms of communicable diseases, and access to school lunches only. They are not eligible for federal public benefits through the Affordable Care Act. Between 2007 and 2012, increased apprehensions by the U.S. Border Patrol accounted for a smaller number of persons entering the United States illegally than in the previous decade (Pew Research Center, 2013). A description of the immigrant populations and what benefits they are eligible to receive can be found in A Description of Immigrant Population: An Update (Congress of the United States, 2012). National debate about immigration policy has intensified, particularly about amnesty for illegal aliens, since the events of September 11, 2001. As a result, a variety of immigration laws have been enacted (Changes in Immigration Law, 2013). These changes reflect tightened and more restrictive visa procedures as well as greater scrutiny given to all visas and entry documents. The complex issues involved with the foreign-born population and health care accessibility restrict the opportunity for public health nurses to provide culturally competent care to this population. Misperceptions abound about the economic value of allowing immigrants to enter, or to stay in, the United States. It is estimated that immigrants increase the gross domestic product by 37 billion dollars each year because of their presence in the labor force and contributions in skills, education and capital investments by adding workers to the pool (Immigration Policy Center, 2012), The dilemma for communities, however, is that immigrants typically pay federal taxes yet the services they receive are paid for by the states and localities. Although federal matching funds for Medicaid are not available to the states for immigrants, some states have found compelling public health reasons to use their own funds to cover even undocumented immigrant children, pregnant women with low incomes, disabled persons, and older adults (Camarota, 2012). There are other health care issues in addition to financial constraints on providing health care for immigrants. Some of these are language barriers; differences in social, religious, and cultural backgrounds between the immigrant and the health care provider; and the use of traditional healing or folk health care practices that may be unfamiliar to U.S. health care providers. Providers may lack knowledge about high-risk diseases in the specific immigrant groups for whom they care. For example, some groups are more at risk for hepatitis B (with its attendant effects on the liver), tuberculosis, intestinal parasites, and visual, hearing, and dental problems. Many of these conditions are either preventable or treatable if managed correctly. Nurses need to know the major health problems and risk factors that are specific to the immigrant populations for whom they provide care. Nurses need to understand the difficulty of the acculturation process for immigrant families and to treat individuals in the context of the culture from which they come. Often children and adolescents adjust to the new culture more easily than adults. This can lead to a shift in the balance of power between adults and children, contributing to family conflict and at times violence. Inability of elders to acculturate may play a large part in their lack of adherence to health care guidelines. When conducting a health history, nurses should be alert for warning signs of family stress and tension. Remember that older family members can help translate their culture, beliefs, religious practices, dietary habits, support systems, and risk factors for the health care provider. They can also assist with decision making and provide support to enable the person or group seeking care to change behaviors and increase their health promotion practices. Similarly, understanding the role of the community in the care of immigrants is important. Communities can help clients (and thus providers) with communication, crisis intervention, housing, and emotional and other forms of support. Nurses need to carefully assess the community and learn what strengths, resources, and talents are available. Nurses need knowledge about the traditional healing practices that immigrants use. Many of these practices have therapeutic value and can be blended with traditional Western medicine (Figure 7-5). The key is to know what practices are being used so the blending can be done knowledgeably. Community members are excellent sources of this information, and nurses working with immigrant populations should use the community assessment, group work, and family techniques described in other chapters to partner with immigrant clients. image FIG 7-5 Mi-yuk kook (seaweed soup) is a Korean dish eaten by postpartum women to stop bleeding and to cleanse body fluids. It is also eaten every birthday. Culturally appropriate nursing actions that can be implemented to increase authenticity, accuracy, and approachability when working with immigrant populations include the following: 1. Self-awareness: Recognize the values, beliefs, and practices that comprise your own culture. Nurses, like clients, are influenced by culture, values, and language. 2. Identify the client’s preferred or native language. When nurses do not speak or understand the client’s language, they must obtain assistance from an interpreter to ensure that full and effective communication occurs. Health care institutions must provide clients with an interpreter. The interpreter should have knowledge of the client’s culture and medical terminology. Interpreters should be trained, qualified, and hired to ensure that they have met minimum standards to provide accurate and safe interpretation. Using family members, friends, and staff who are not trained as health/medical interpreters can create errors in understanding and communicating, pose grave risks for the client and liability to the health care institution. While both an interpreter and a translator interpret and translate information from one language to another, there are significant differences between the two. A translator is usually 149associated with translating written documents such as medical records and legal documents; in contrast, the interpreter is associated with verbal communication that focuses on accurate expression of equivalent meanings rather than on word-to-word equivalence. Many nurses cite linguistic barriers as the largest issue they encounter when trying to provide culturally competent care for linguistically different clients (Starr and Wallace, 2009). Experiences of success that nurses report when working with an interpreter include proper use of interpreters to assure that clients understand health care instructions; provision of linguistically appropriate educational material; ability to communicate in the client’s language to provide health care instructions; and ensuring proper use of instructions. Experiences of difficulty include language barriers preventing appropriate communications; lack of available interpreters overall and for specific languages; and lack of appropriate translation by interpreter. Nurses can minimize some of these difficulties by learning basic words and sentences of the most commonly spoken languages in the community and observing client reactions when asking them questions. Also, nurses should provide written material in the client’s primary language, so that family members can reinforce information when at home with the client. The How To Box provides guidelines for using an interpreter. 3. Learn the health-seeking behaviors of your client and their family members. In asking the client about family members, you might try using a simple genogram, which places family members on a diagram. Ask who the family members are, where they live, and who is missing or deceased. You might also ask them to talk about holiday celebrations: who comes, who is missing, what do they do? 4. Get to know the community where the immigrant client lives. Read about the culture of your clients. Take a course. Volunteer to participate in the acculturation process of the community (e.g., to give talks, hold forums with free-flowing and two-way communication), and learn who the formal and informal resources are. 5. Get to know some of the traditional practices and remedies used by families and communities. Coordinate health teaching seminars with traditional healing courses for the community so you can work with, not against them. 6. Learn how cultural subgroups explain common illnesses or events. In cultures where the body and mind are seen as one entity or in cultures in which there is a high degree of stigma associated with mental illness, people or individuals somaticize their feelings of psychological distress. In somatization, psychological distress is experienced as a physical illness. 7. Try to see things from the viewpoint of the client, family, and community and accommodate rather than squash the client’s view. 8. Conduct a cultural assessment focusing on what is working, what is not working, and changes that need to be made to accommodate cultural norms and promote positive health behaviors. How To Guidelines for Selecting and Using an Interpreter 1. The interpreter must interpret everything that is said by all the people in the interaction and inform the public health nurse if the content might be perceived as insensitive or harmful to the dignity of the client. 2. The interpreter conveys the content, the spirit of what is said without omitting or adding. 3. The educational level and the socioeconomic status of the interpreter are important. The nurse should know that the interpreter understands the community’s interpretation of the disease and the nurse should understand the community’s health care practices around the disease. 4. The nurse needs to evaluate the interpreter’s style, approach to clients, and ability to develop a relationship of trust and respect. 5. The gender and/or age of the interpreter may be of concern; in some cultures, women may prefer a female interpreter and men may prefer a male, and older clients may want a more mature interpreter. Avoid using children as interpreters, particularly when the client is an adult. 6. Identify the client’s country of origin and language or dialect spoken before selecting the interpreter. For example, Chinese clients speak different dialects depending on the region in which they were born. 7. Observe the client for nonverbal messages such as facial expressions, gestures, and other forms of body language. If the client’s responses do not fit with the question, the nurse should check to be sure that the interpreter understood the question. 8. Make phrase charts and picture cards available. 9. Increase accuracy in transmission of information by asking the interpreter to translate the client’s own words, and ask the client to repeat the information that was communicated. 10. The interpreter must maintain confidentiality of all information and interactions. At the end of the interview, review the material with the client and the interpreter to ensure that nothing has been missed or misunderstood. 150 Cultural Diversity and Health Disparities Disparities in Health Disparities are used to describe incongruent elements. Health disparities are associated with inequity in social structures based on particular characteristics such as ethnicity, race, immigrant status, gender, age, and sexual orientation (Levine et al, 2011). Health disparities stem from characteristics historically linked to discrimination. They are also expressed in differences in morbidity and mortality rates among population groups linked to factors such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, place of origin, and residence. Health disparities are monitored annually by various departments within The U.S. Department of Health and Human Services as part of the national goal to achieve health equity for all within the United States (see the Healthy People 2020 box related to health disparities). image Healthy People 2020 Goals and Objectives of Healthy People 2020 Related to Cultural Issues Goal: Eliminate health disparities among different segments of the population as defined by gender, race or ethnicity, education, income, disability, living in rural areas, and sexual orientation. Selected Objectives • AHS-1: Increase the proportion of persons with health insurance. • AHS-2: Increase the proportion of insured persons with clinical preventive services coverage. • AHS-3: Increase the proportion of persons with a usual primary care provider. • AHS-6: Increase the proportion of persons who have a specific source of ongoing care. • AHS-7: Reduce the proportion of individuals who are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicine. Social Determinants of Health Social determinants of health are the circumstances in which people are born, grow up, live, work, age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces such as economic stability (indicators such as poverty and unemployment), education (indicators such as reading levels, graduation rates, and enrollment in higher education), social and community context (indicators such as family structure and social cohesion), health and health care (indicators such as access to health services and access to primary care), and neighborhood (indicators such as quality of schools and housing, access to healthy foods, and incidences of crime and violence) (Healthy People 2020, 2013). Marginalization Marginalization of vulnerable populations occurs when a segment of the population has been excluded from the mainstream in social, economic, cultural, or political life. Marginalization is brought about by policies, practices, and programs that have relegated these populations to the fringe of society and which prevents them from meaningfully participating in society. Examples of these vulnerable populations include but are not limited to groups excluded due to race/ethnicity, homelessness, immigrants with linguistic challenges, drug abuse, sexual orientation, economics, and gender, which are devalued and not granted certain privileges that are given to others. In some instances, vulnerable populations may be considered an equivalent term for marginalization. Health Equity Health equity is concerned with providing social justice in health so that individuals are not disadvantaged from achieving the highest possible standard of health based on membership in a group that has historically been disadvantaged (Braveman, 2014). It is the principle underlying a commitment to reduce and ultimately eliminate disparities in health. Achieving health equity requires giving recognition to social barriers as well as barriers that have their origins in genetics, economics, and lifestyle factors that contribute to inequality of health. Health inequities are avoidable treatment between groups of people. They are reflected in differences in length of life, quality of life, rates of disease and disability, severity of disease, access to treatment among groups of people, and death. Social Justice Social justice is concerned with values of impartiality and objectivity at a systems or governmental level and is founded on principles of fairness, equity, respect for self and human dignity, and tolerance. Practicing social justice is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation. Health Literacy The Centers for Disease Control and Prevention (CDC) define health literacy as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health care decisions. Low health literacy negatively influences understanding of medical information (such as illness condition, treatment plan), obtaining health care services, managing chronic conditions, and use of medication and avoidance of medication errors, and places individuals at a safety risk. Low literacy is more common among the elderly, minority populations, immigrants, individuals with lower socioeconomic status, and the medically underserved. Individuals with low health literacy are adversely affected by low educational skills, cultural barriers to health care, and by nurses who use language that the patient does not understand. Often these individuals may have a different perspective about their illness and what to do about it. The pattern in which they present their illness might be different from the pattern persons with high literacy skills would use to present their illness. When caring for persons with low literacy skills, nurses should ask the client to repeat instructions to assess the client’s level of literacy, repeat information as needed, 151allow the client time to process the information, use face-to-face communication whenever possible, make the information personally relevant, give reasons for short-term benefits for taking the specific action, and provide sufficient follow-up for each person (CDC, 2009). Health Disparities and Socioeconomic Status The relationship between health disparities and socioeconomic status is reflected in life expectancy, infant death rates, low birth rates, and many other health measures (Agency for Healthcare Research & Quality, 2013). Members of minority groups may be marginalized, preventing them from enjoying the same opportunities and resources for education, occupation, income earning, and property ownership that the dominant group has, thus relegating them to the fringe of society. Between 2007 and 2011 the poverty rate in the United States was 14.3% (Macartney et al, 2013), but there were differences in poverty rates associated with membership in various racial/ethnic groups. Table 7-3 indicates that there are more white families than minorities below the poverty level. However, the proportion of poor families in a minority group is greater. For example, 11.6% of white families are living in poverty, whereas 25.8% of African Americans, 23.2% of Hispanics, and 27% of American Indian/Alaskan Natives are doing so. Consequently, minority families are disproportionately represented on the lower tiers of the socioeconomic ladder. The mortality rate among individuals from lower socioeconomic status is significantly higher than among those from higher income levels (Cheng and Kindig, 2012). TABLE 7-3 Poverty Rates by Ethnic Groups Ethnic Groups Percent of Total Populations Percent of Poverty Rate Non-Hispanic Whites 42.4% 11.6% Blacks 12.6% 25.8% Asians 4.8% 11.7% Hispanics 16.4% 23.2% American Indian/Alaskan Natives .09% 27.0% Native Hawaiians 0.02% 17.6% From U.S. Census Bureau: Income, Poverty, and Health Insurance Coverage in the US: 2010 and Macartney S, Bishaw A, Fontenot K: Poverty rates for selected detailed race and Hispanic groups by state and place: 2007–2011. Poor economic achievement is also a common characteristic found among populations at risk, such as single-parent head of households, the homeless, migrant workers, and refugees. Nurses should be able to distinguish between cultural and socioeconomic issues. Attributing behaviors stemming from socioeconomic deficits to behaviors embedded in cultural origins can result in misinterpretations of the client’s motivation to adhere to treatment regimens. Data suggest that when nurses and clients come from the same social class, it is more likely that they operate from the same health belief model, and consequently there is less opportunity for misinterpretation and communication problems. Nevertheless, research on health disparities has shown that individuals from minority racial and ethnic groups are disproportionately likely to develop severe health problems and to experience lower quality care and poor outcomes in relation to health problems even after controlling for socioeconomic status, insurance status, and age (Agency for Healthcare Research & Quality, 2014; 2013). There is danger in believing that only individuals in the lower socioeconomic rung use cultural behaviors such as folk (natural and magico-religious) practices. More individuals in Western cultures, including health professionals, are integrating folk practices with the biomedical system to promote, protect, and restore their health. Acceptance of this is reflected in courses being offered in universities, the arrival of newer disciplines in health care such as homeopathic medicine, and more acceptance of traditional medicine (such as acupressure and acupuncture). Nurses can consult and seek guidance from non-Western practitioners to better understand how clients and families integrate cultural concepts with other aspects of client care to meet their clients’ total health care needs. Cultural Competent Nursing Interventions Cultural Competence Transcultural nursing recognizes and appreciates differences in health care values, beliefs, and customs. Transcultural theorists subscribe to the belief that nurses must acquire knowledge, skill, and attitudes in cultural competence and be committed to change to ensure positive outcomes, eliminate health disparities, and increase client satisfaction. A number of governmental agencies such as the U.S. Department of Health and Human Services, state regulations, and private and quasi-governmental regulators such as The Joint Commission have attempted to address the need for cultural competence through various standards and legislation. For instance, standards of practice for culturally competent nursing care were developed by a task force of the expert panel for Global Nursing and Health of the American Academy of Nursing in concert with members of the Transcultural Nursing Society to help nurses apply these standards universally in the arenas of clinical practice, research, education, and administration (American Academy of Nursing Expert Panel, 2010). The 12 standards address core values inherent in professional nursing practice and include behaviors, attitudes, and skills requisite for cultural competence. These standards are described in Box 7-4. Box 7-4 Standards of Practice for Culturally Competent Nursing Care Standard 1. Social justice: Nurses use principles of social justice to guide them as they advocate for the patient, family, community, and other health care professionals. Standard 2. Critical reflection: Nurses critically reflect on their own values, beliefs, and cultural heritage to determine the influence of these qualities and issues on providing culturally congruent nursing care. Standard 3. Knowledge of cultures: Nurses understand the perspectives, traditions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations for whom they care, as well as having knowledge of the complex variables that affect the achievement of health and well-being. Standard 4. Culturally competent practice: Nurses use cross-cultural knowledge and culturally sensitive skills when implementing culturally congruent nursing care. Standard 5. Cultural competence in health care systems and organizations: Health care organizations provide the structure and resources for nurses to evaluate and meet the cultural and language needs of their culturally diverse clientele. Standard 6. Patient advocacy and empowerment: Nurses recognize the impact that health care policies, delivery systems, and resources have on their populations and advocate on the patients’ behalf for inclusion of their cultural beliefs and practices in all dimensions of their health care. Standard 7. Multicultural workforce: Nurses engage in activities to ensure multicultural workforce health care settings, such as those that strengthen recruitment and retention in hospitals and academic settings. Standard 8. Education and training in culturally competent care: Nurses shall have knowledge and skills to ensure that the delivery of patient care is culturally congruent and includes global health care agendas that mandate formal education and clinical training as well as ongoing continuing education for all practicing nurses. Standard 9. Cross-cultural communication: Nurses use culturally appropriate verbal and nonverbal communication skills to identify patient’s values, beliefs, practices, perceptions, and unique health care needs. Standard 10. Cross-cultural leadership: Nurses influence individuals, groups, and systems to achieve positive health outcomes of culturally competent care for diverse populations. Standard 11. Policy development: Nurses have the knowledge and skills to work with public and private organizations, professional associations, and communities to develop policies and standards for comprehensive implementation and evaluation of culturally competent care. Standard 12. Evidence-based practice and research: Nurses use tested interventions shown to be effective for the culturally diverse populations that they serve. The nurse also engages in research to test the effectiveness of interventions appropriate for specific culturally diverse clients. Adapted from American Academy of Nursing Expert Panel: Standards of practice for culturally competent nursing care, 2010. Available at http://www.tcns.org/files/Standards_of_Practice_for_Culturally_Compt_Nsg_Care-Revised.pdf. Accessed February 25, 2014. Both of the accreditation bodies for nursing education, the Accreditation Commission for Education in Nursing (ACEN) and the Commission on Collegiate Nursing Education (CCNE), address the need for cultural competence as essential content in nursing education. State Boards of Nursing are requiring cultural competence education in nursing schools and recent legislation in many states includes requiring cultural competency training for health care providers to receive licensure or relicensure. Cultural competence entails a combination of culturally congruent behaviors, practice attitudes, and policies that allow nurses to use interpersonal communication, relationship skills, 152and behavioral flexibility to work effectively in cross-cultural situations. Cultural competence allows nurses to partner with the client to deliver health promotion, disease prevention, and health restoration (Campinha-Bacote, 2011; Leininger, 2002a). Culturally competent nurses respect individuals from different cultures, value diversity, and function effectively when caring for clients from other cultures. Cultural competence reflects a higher level of knowledge than cultural sensitivity, which was once thought to be all that was needed for nurses to effectively care for their client. In contrast, cultural sensitivity suggests that the nurse has basic knowledge of the client’s culture but does not use the information to devise a plan of care that reflects the client’s total cultural needs. Nurses should be aware of the social determinants of health in the environment that prevent individuals from achieving good health. It is generally accepted that culturally competent nursing care is guided by the following principles (American Academy of Nursing Expert Panel, 2010): 1. Care must be client centered, that is, designed for the specific client, family, or community. 2. Care must be based on the uniqueness of the client’s culture and incorporate the cultural norms and values of the client in the management of the care plan. 3. Self-empowerment strategies of the client are identified and viewed as strengths to facilitate client decision making and self-care management in health and illness situations. Cultural competence is also one of the core attributes of public health nurses (Quad Council, 2011). Nurses work toward becoming culturally competent for a number of reasons. First, nurses who come from a culture different from that of the client may not be knowledgeable about the client’s culture. Nurses come from a variety of cultural backgrounds and have their own cultural traditions. Each nurse has unique cultural experiences that give meaning and understanding to his or her behavior. Because of differences between the client’s cultural system and the nurse’s cultural system, when the client and the nurse interact they may have different understandings about the meaning of the health issue and different ideas about what to do to promote and protect health. In these circumstances, nurses who value and practice cultural competence use communication and relational strategies that respect clients’ values, expectations, and goals without diminishing the nurses’ own values, expectations, and goals. To illustrate, a recent Mexican immigrant who speaks little English goes to a community health center because of a urinary tract infection. The nurse understands that she must use strategies that would allow her to effectively communicate with the client. She also understands that the client has the right to receive effective care that is based upon culturally informed nursing science, to judge whether she has received the care she wanted, and to follow up with appropriate action if she did not receive the expected care. Nurses must be culturally competent to modify nursing interventions that are specific to the needs of cultural and ethnic groups. Second, care that is not culturally competent may further increase the gap in racial and health disparities between minority and majority populations. Failure to effectively respond to the health care needs and preferences of culturally and linguistically diverse individuals may (1) increase barriers to equitable access to care, (2) inhibit effective communication between the client and the nurse, and (3) create obstacles in gathering assessment data, thus limiting the development and implementation of effective treatment plans. Third, nurses use culturally competent practice to improve the quality, cost, and safety of care and health outcomes. The health care industry focuses on cost-effectiveness to balance 153cost and quality (Agency for Healthcare Research & Quality, 2012). Quality of care means that the client has access to health care and that the care is delivered by culturally competent nurses to help clients achieve positive health outcomes. Care that is not focused on the clients’ values, expectations, and goals is likely to increase cost and diminish quality. For example, when clients are using both folk medicine and traditional Western medicine and nurses fail to assess and use this information in teaching, the clients may not get the full benefits of the treatment protocol. Positive outcomes, which are indicators of quality, may not be met. When quality is compromised, additional resources that typically increase costs may be needed to achieve the desired health care outcomes. Fourth, legal regulations and accreditation mandates specify that culturally competent health care must be provided so that health disparities can be reduced and ultimately eliminated. For example, the specific Healthy People 2020 objectives for persons of different cultures need to be met (USDHHS, 2010). To accomplish these objectives, the client’s lifestyle and personal choices must be considered beyond the cursory ways that health care providers have interacted with clients in the past. Clients may present their symptoms vastly differently from the way they are presented in medical and nursing text books; they may present with different threshold for seeking care or expectations about their care. They may have beliefs about the origin and treatment of disease that affect their willingness to adhere to the treatment regimen, and they may have limited English proficiency and low health literacy. For example, American health care professionals frequently view excessive drinking as a sign of disease and alcoholism as a mental illness. However, in the American Indian/Alaskan Native culture, these signify a disharmony between the individual and the spirit world, and biomedical interventions alone may not be adequate to reduce alcoholism within this culture. American Indians and Alaskan Natives have an alcohol-related death rate that is two times higher than it is in the general population. This is particularly devastating among American Indian males in the 35 to 49 age group, and contributes to a loss of 6.4 more years of potential life compared with those in the general population (CDC, 2008). The national goal is to reduce this disparity. However, many American Indian/Alaskan Natives view alcohol consumption as an acceptable way to participate in family celebrations and tribal ceremonies, and refusal to drink with family may be viewed as a sign of rejection. West (1993, p. 234) suggested that nurses understand the possible ramifications of not having culturally competent staff available to care for the American Indian/Alaskan Native population. She stated, “If the government sends Indians to a health clinic where personnel do not understand the holistic health practices of Indians and where young white people serve as caregivers and authority figures, failure is likely to result.” To have successful outcomes, nurses who develop population-based programs to reduce alcohol-related deaths must be willing to respect the cultural uniqueness of Native Americans and to explore individuals’ life experiences to find the underlying causes of their behaviors. Fifth, to gain a competitive edge in the marketplace, the private sector is incorporating culturally competent policies and care practices for its diverse populations and providers. Insurance companies, health maintenance organizations, and other private health entities have developed initiatives in cultural competence for their providers and engage in cultural competence strategies to improve patient satisfaction and patient care outcomes. Sixth, in an effort to decrease the risk of liability from malpractice claims and to increase client satisfaction, health care providers and health care organizations are engaging in cultural negotiations. For example, a communication strategy focused on increasing productive health care services for clients was initiated. The strategy utilizes a nurse–client partnership and underscores openness, mutual respect, and flexibility when communicating. Developing Provider Cultural Competence Cultural competence is an ongoing life process in which the nurse is challenged to break with the old and engage in new ways of thinking and performing. Nurses develop cultural competence through the critical reflective use of self-awareness skills, communications skills, relationship-building skills, and intervention skills that promote mutual respect for differences in the use of participatory decision making. In developing cultural competence, nurses may be guided by two principles suggested by Leininger (2002a): (1) maintain a broad objective and open attitude toward individuals and their cultures, and (2) avoid seeing all individuals as alike. Because there are varying degrees of cultural competence, not all nurses will achieve the same level of development concurrently. For example, Starr and Wallace (2009) reported that public health nurses in a southeastern public health department rated themselves higher on cultural thoughts (cultural awareness and sensitivity) than on cultural competence behaviors. Over all, the nurses reported a moderate level of cultural competence that was increased through online and class room courses. In an early model developed by Orlandi (1992), three stages to developing cultural competence were depicted (culturally incompetent, culturally sensitive, and culturally competent). Table 7-4 shows that each stage has three dimensions—cognitive 154(thinking), affective (feeling), and psychomotor (doing)—that have an overall effect on nursing outcomes. The most effective outcomes are knowledgeable, committed to change, and highly skilled. The most destructive outcomes are oblivious, apathetic, and unskilled. TABLE 7-4 The Cultural Competence Framework: Stages of Competence Development Culturally Incompetent Culturally Sensitive Culturally Competent Cognitive Oblivious Aware Knowledgeable Affective Apathetic Sympathetic Committed to change Psychomotor (skills) Unskilled Lacking some skills Highly skilled Overall effect Destructive Neutral Constructive From Orlandi MA: Defining cultural competence: an organizing framework. In Orlandi MA, editor: Cultural Competence for Evaluators. Washington, DC, 1992, U.S. Department of Health and Human Services. A widely used model to explain the process of cultural competence was created by Campinha-Bacote (2011). The most recent model depicts five elements of cultural competence: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill, (4) cultural encounter, and (5) cultural desire. Cultural Awareness Cultural awareness refers to the self-examination and in-depth exploration of one’s own biases, stereotypes, and prejudices as they influence behavior toward other cultural groups (Campinha-Bacote, 2011). Culturally aware nurses are conscious of culture as an influencing factor on differences between themselves and others, and are receptive to learning about the cultural dimensions of diverse clients. They understand the basis for their own behavior and how it helps or hinders the delivery of competent care to persons from cultures other than their own (American Academy of Nursing Expert Panel, 2010). Culturally aware nurses recognize that health is expressed differently across cultures and that culture influences an individual’s responses to health, illness, disease, and death. Culturally competent care can be delivered in a variety of modes consistent with the client’s health values. For example, at a community outreach program, a nurse was teaching a racially mixed group the screening protocol for breast and cervical cancer detection. An African American woman in the group refused to give the return demonstration for breast self-examination. When encouraged to do so, she said, “My breasts are much larger than those on the model. Besides, the models are not like me. They are all white.” After hearing the client’s comments, the nurse realized that she did not take into account the significance of breasts based on ethnicity and culture, the size of the breast, and had made no reference in her talk to the influence of culture or race on screening for breast and cervical cancer. The nurse then talked with the client, asked for her recommendations, and encouraged her to return the demonstration. The nurse coached the client through the self-examination process while pointing out that regardless of breast size, shape, and color, the technique is the same for feeling the tissue and squeezing the nipple to make certain that there is no discharge. Because this nurse was culturally aware, she neither became angry with herself or the client nor imposed her own values on the client. Rather, she elicited a discussion with the client about her beliefs, attitudes, and feelings about screening for cancer that may have been influenced by her culture. The nurse understood that she had to tailor her teaching material to the needs of diverse client groups. Subsequently, she advocated for her agency to purchase a model of an African American woman’s breast to be used in future health education programs with African American women. If the nurse had not been culturally aware, she might have misunderstood the client’s concerns and acted in a defensive manner. Such an interaction would have failed to identify client assets and barriers and appropriate intervention strategies. A confrontation might have ensued that would not have been helpful to the client or the nurse. Nurses should champion the cause for clients seeking health care to have health care professionals respect their cultural traditions. Cultural Knowledge Cultural knowledge refers to the process of searching for and obtaining a sound educational understanding about culturally diverse groups (Campinha-Bacote, 2011). Emphasis is on learning about the clients’ worldview from an emic (native) perspective as it pertains to health beliefs and practices, cultural values, and disease incidence and prevalence. For example, cultural knowledge indicates that Middle Eastern women might not attend prenatal classes without encouragement and support from the nurse (Meleis, 2005). Attendance at prenatal classes is about the future of the baby while the mother’s main focus may be on the present and what is happening in the immediate environment. The nurse’s understanding of the client’s concept of time would decrease misinterpretation that the mother might undermine efforts to promote a healthy baby, and allows the nurse to select strategies to ensure the client’s cooperation in providing the best care for the baby. In contrast, knowledge of Nigerian culture indicates that while women will start prenatal care as soon as pregnancy is confirmed, they view pregnancy and birth as natural events and may not continue to attend prenatal classes throughout the prenatal phase (Ogbu, 2005). Although the behavior of the women from these two countries may be the same, the rationale for their action is different. Leininger (2002a) points out that nurses who lack cultural knowledge may develop feelings of inadequacy and helplessness because they are often unable to effectively help their clients. Although it is unrealistic to expect that nurses will have knowledge of all cultures, they should know how and where to obtain information that impacts the individual with whom they have frequent interaction. Missing or inadequate knowledge of the client’s culture can contribute to negative situations such as client’s inadequate use of health resources. Because cultural competence is a requirement in nursing education, students are now exposed to a variety of individuals who hold membership in cultures that are different from their own. Students therefore have an opportunity to assess gaps in their cultural knowledge about how to care for individuals, families, and communities from diverse groups. Students also learn that clients are a rich source of information about their own culture. The Evidence-Based Practice box provides an example of learning how to meet the needs of a cultural group that is different from that of the nurse. Evidence-Based Practice The purpose of this descriptive correlation designed study was to assess the personal beliefs about the causes and meaning of having diabetes among members of the Lumbee Indian tribe living in rural southeastern North Carolina. The sample consisted of 40 adult men and women. A mixed method approach to consist of qualitative and quantitative data was used to conduct this study. The participant responses indicated a moderate belief in the efficacy of diabetes treatment, a moderate belief in their ability to understand a coherent model of diabetes, and a low level of emotional distress related to having diabetes. Two major themes emerged from the open-ended questions about the causes of diabetes: (1) genetic predetermination and (2) lifestyle practices. Although participants believed that their prescribed diabetes medications were a necessary part of controlling their illness, several expressed fatigue and “felt worn out” with having to persist with their treatment expectations. Limitations were that the sample only included persons who were seeking health care treatment for diabetes and did not include those who were not scheduled for an appointment at the clinic during the data collection period, or included those who did not have access to health care. Nurse Use Nurses should be aware that their Lumbee Indian clients may not always have a high degree of confidence in conventional treatment regimens nor understand the unpredictable course of diabetes. Nurses should work with these clients to provide culturally congruent education using appropriate communication to increase clients’ knowledge about current treatment regimens. Nurses should incorporate culturally specific strategies that will empower clients to take a more active role in their illness management, dispel the attitude that a diagnosis of diabetes is genetically predetermined, link concrete behaviors to disease progression and outcomes, and demonstrate to clients how attainable decreases in blood sugar can reduce the risk of long-term consequences. Such strategies would help eliminate negative perceptions that may interfere with the health care delivery process. The researchers suggested that by using a broad systems approach, nurses will increase the availability of Native American health care providers who can serve as role models for the community as well as become activists for developing community infrastructure to support healthy lifestyles. From Jacobs A, Kemppainen JK, Taylor JS, et al: Beliefs about diabetes and medication adherence among Lumbee Indians living in rural southeastern North Carolina. J Transcult Nurs 25:167–175, 2014. Cultural Skill Cultural skill is the third element of developing cultural competence. Cultural skill refers to the ability of nurses to effectively integrate cultural awareness and cultural knowledge when conducting a cultural assessment as well as a culturally based physical assessment and to use the data to meet the specific client’s needs (Campinha-Bacote, 2011). Culturally skillful nurses elicit 155from clients their perception of the health problem, discuss treatment protocol, negotiate acceptable options, select interventions that incorporate alternative treatment plans, and collaborate with all stakeholders. For example, culturally competent nurses use appropriate touch during conversation and modify the physical distance between themselves and others while meeting mutually agreed upon goals. Cultural Encounter Cultural encounter is the fourth element essential to becoming culturally competent. Cultural encounter refers to the process that permits nurses to seek opportunities to directly engage in cross-cultural interactions with clients of diverse cultures to modify existing beliefs about a specific cultural group and possibly avoid stereotyping (Campinha-Bacote, 2011). Culture encounters, a key element in becoming culturally competent, have their roots in the nurse–client interpersonal relationship that focuses on caring, compassion, presence, caring consciousness, and empathy. There are two types of cultural encounters: direct (face-to-face) and indirect. An example of a direct cultural encounter occurs when nurses learn directly from their Puerto Rican clients about spicy foods that they avoid during periods of breastfeeding. Indirect cultural encounters occur when nurses share these assessment findings with other nurses to help them develop their knowledge to effectively care for other Puerto Rican clients who are breastfeeding. The most important encounters are those in which nurses engage in effective communication, use appropriate language and literacy level, and learn about clients’ life experiences and the significance of these experiences for health (Leininger, 2002a). In some communities, nurses may have few opportunities to work directly with persons of other cultures. Thus, when nurses come in contact with clients who are culturally different from the nurse, they should adapt general cultural concepts to the situation until they are able to learn directly from the clients about their culture. Developing cultural competence also comes from reading about, taking courses on, and discussing different cultures within multicultural settings. Successful cultural encounters embrace. Continuously interact with patients from diverse backgrounds to validate, refine, or modify existing values, beliefs and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge (Figure 7-6). image FIG 7-6 A Hispanic nursing student interacting with African American men at a nutritional center. To interact in a culturally competent manner, the student needs to have awareness of and knowledge about the differences between her culture and the men’s culture and the skill to portray this in her behavior toward them. Cultural Desire Cultural desire is the fifth element needed in the process of developing cultural competence. It refers to nurses’ intrinsic motivation to want to engage in the previous four elements necessary to provide culturally competent care (Campinha-Bacote, 2012). It is based on the humanistic value of caring for the individual. Nurses who wish to become culturally competent do so because they want to, rather than because they are directed to do so. They demonstrate a sense of energy and enthusiasm about the possibility of providing culturally competent nursing interventions. Unlike the other elements, cultural desire cannot be directly taught in the classroom or in other educational or work settings. Nurses are more likely to demonstrate cultural desire when the environment at all levels of the organization reflects a philosophy that values cultural competence for all its clients. Campinha-Bacote (2011) recommends that nurses who want to develop cultural competence should not fear making mistakes, but should internalize and incorporate into their own worldview selected beliefs, values, practices, life-ways, and problem-solving skills of other cultures with which they have the most frequent encounters. Several measures of the cultural competence construct have been reported in the nursing literature: the Interpersonal Process of Care survey (IPC-18, Chart Form: Stewart et al, 2007) and the Cultural Competent Assessment (CCA–25; Doorenbos et al, 2005). The IPC survey consists of two subscales that are used to determine disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities. The CCA consists of two subscales that 156examine nurses’ cultural diversity experience, cultural awareness and sensitivity, and performance of cultural competence behaviors. Barriers to Developing Cultural Competence Nurses fail to provide culturally competent nursing care for a variety of reasons: they may have had minimal opportunity to learn about cross-cultural nursing; their supervisors may encourage them to increase productivity at the expense of quality; or they may be pressured by colleagues who are not knowledgeable about cultural concepts and are offended when others use the concepts. These and similar issues may result in nurses engaging in behaviors such as stereotyping, prejudice and racism, ethnocentrism, cultural imposition, cultural conflict, and culture shock. Stereotyping Stereotyping is ascribing certain beliefs and behaviors about a given racial and ethnic group to an individual without assessing for individual differences. Stereotyping blocks the willingness of a person to be open and to learn about specific individuals or groups. When information is not immediately available, nurses may generalize about an individual’s group behavioral pattern as a guide until they have had time to observe and assess the client’s behavior. This can be a problem, and it may lead to a nurse’s unwillingness to incorporate new and specific data about the client. New information may be distorted to fit with preconceived ideas. The generalizing that was a beginning point for understanding the individual becomes a final point. The individual is thus stereotyped on the basis of the group’s ascribed behavior. Stereotypes can be either positive or negative. For example, Asians are often positively stereotyped as the “model” minority group, leading to an expectation that they will always behave in ways that reinforce the stereotypical notion. Other groups are stereotyped as “industrious and hard working,” while some groups are stereotyped as negative and noncompliant. To illustrate, a nurse who believes that young African American women are sexually permissive may label a woman in this group who is complaining of abdominal pain as having symptoms of a sexually transmitted disease. Clients who perceive they are being stereotyped may respond with anger and hostility. This in turn perpetuates the stereotype and creates barriers to health-seeking behavior. To minimize the use of stereotypes, nurses should rely on their ability to conduct good health assessment and engage in culturally competent discussions. Prejudice Prejudice is the emotional manifestation of deeply held beliefs (stereotypes) about a group. These beliefs are directed toward a person who is a member of that group, and who is presumed to have the qualities ascribed to the group. Prejudice is not based on reason or experience but rather on negative or favorable preconceived feelings. These feelings are often precursors for discriminatory acts based on prejudging, limited knowledge about, misinformation about, fear of, or limited contact with individuals from that group. Those who are prejudiced wish to deny the individuals, on the basis of race, skin color, ethnicity, or social standing, the opportunity to benefit fully from society’s offerings of accessible health care, education, good jobs, and community activities. Racism Racism is a form of prejudice that occurs through the exercise of power by individuals and institutions against people who are 157judged to be inferior on the basis of intelligence, morals, beauty, inheritance, and self-worth. Individuals are denied certain opportunities (e.g., jobs, housing, education, and health care) typically enjoyed by the larger group because of some characteristic over which they have no control. When racism is acted upon, it results in perceived or actual harm to the individual. Three types of racism exist: individual, institutional, and cultural. Individual racism refers to discriminatory behavior or acts directed toward individuals or groups because of identified characteristics, such as skin color, hair texture, and facial features. Institutional racism refers to discriminatory behavior or acts by an institution, as expressed in policies, priority setting, hiring, and resource allocation practices that are directed toward individuals and groups and restrict their access to opportunities or resources. Institutional racism provides the structure for racism at the individual level to be accepted and condoned. Cultural racism refers to discriminatory behavior or acts directed by the dominant group toward another cultural group. The cultural group is depicted in derogatory or stereotypical ways because of, for example, language or dress. All forms of racism can have individual, as well as community and population, effects. The Tuskegee Syphilis Study is a well-known example of racism (Gamble, 1997). This study was conducted by the U.S. Public Health Service to observe the effects of syphilis on African American men over a period of 40 years, beginning in 1932. When African American men with syphilis were recruited for the study, they were told that they were being treated for “bad blood,” and treatment for syphilis was withheld intentionally so that the study on the deleterious effect of syphilis could be completed. As a result, hundreds of men lost their lives because of discriminatory policies that promoted substandard health care. The consequence of such racism has contributed to the long-held beliefs by some African Americans that health research might be designed to harm them and that accessible health care for African Americans might be part of a research study, especially government-sponsored programs. In 2005, Dwayne, Isaac, and Laveist reported that a telephone survey revealed that no differences by race existed between African Americans and whites in knowledge about the Tuskegee study. There were significant race differences in medical care that the researchers attributed to broader historical and personal experiences of African Americans. Perceived racism by cultural groups can have physiological and psychological negative health outcomes that include high blood pressure, stroke, engaging in risky behaviors such as smoking and substance abuse, depression, and low self-esteem. Nurses too may be recipients of prejudicial or racist acts (Fielo and Degazon, 1997), but they do not have to accept such behavior from clients. Rather, they should set limits, discuss the behavior with other colleagues when appropriate, and avoid personalizing the behavior. One way to depict the effects of prejudice and racism is to use a two-dimensional matrix: overt versus covert, and intentional versus unintentional. Locke and Hardaway (1992) depict four types of prejudice and racism that result from this matrix: overt intentional, covert intentional, overt unintentional, and covert unintentional. Overt intentional prejudice or racism means that the behavior is both apparent and purposeful. The nurse is aware of personal biases and beliefs and integrates them into a plan of action to negatively manage client problems. With overt unintentional, the behavior is apparent but not purposeful, and no harm is intended, although harm may result. Covert intentional means that the behavior is subtle and purposeful but the person tries to avoid being viewed as prejudicial or racist. Covert unintentional means that the person’s behavior is neither apparent nor purposeful. The person is unaware of the behavior. Regardless of the type of prejudice or racism, the behavior is harmful to the client. Examples of each type of prejudice and racism are presented in Box 7-5. Box 7-5 Types of Prejudice and Racist Behaviors Overt Intentional Prejudice/Racism Two homeless women, one African American and the other Irish, are clients at the oncology clinic at the free neighborhood health care center. Both of the women have a history of ovarian cancer and are experiencing financial difficulty from time to time due to the cost of medical care associated with the illness. Although the African American client has been homeless longer, both clients have health issues associated with diminished quality of life and functional status related to the length of the illness, the progression of the illness, and the seriousness of the illness. The nurse as case manager referred the Irish client to the social services department to inquire about available resources but did not refer the African American client. The nurse reasoned that minority clients have direct contact with some local and national government programs, know about available resources, and have experience negotiating the social system for themselves and their family. In contrast, the nurse reasoned that because the Irish woman had no prior experience negotiating government programs, she needed to advocate for her client. The nurse did not assess the health-seeking behaviors of either client before coming to these conclusions, stereotyped both women, and intentionally used her informational power to help one client while denying assistance to the other client. Overt Unintentional Prejudice/Racism The community health nurse was assigned to make an initial home visit to two clients recently discharged from the hospital with a diagnosis of hypertension. The nurse performed physical assessments on both clients. He developed an extensive culturally relevant teaching plan with the Filipino client that included information on sodium restriction and its effect on kidney functioning, ways to integrate cultural foods into the diet, and support in lifestyle changes. With the Puerto Rican client, the nurse performed a routine physical assessment and did not discuss the client’s culturally special dietary requirements. The nurse reasoned that the Puerto Rican client was not capable of understanding such complex information and would most likely seek information from her curandera (a folk practitioner) to manage the hypertension. At the end of the visit, the nurse said to this client, “Take care of yourself. See you next time.” This nurse did not realize that he had stereotyped the client and that his nursing interventions were minimal. He believed that he had delivered patient-centered care and the difference in his assessment and implementation approach reflected his understanding of cultural competence theory. Covert Intentional Prejudice/Racism A Native American nurse works in a home health agency that serves an ethnically diverse community. The nurse has observed that her assigned clients are always among the poorest and live in the unsafe ZIP code areas of the community. Her nonminority nurse colleagues are not assigned to clients residing in those ZIP codes. In a recent staff meeting, the Native American nurse expressed discomfort about the assignment patterns that she had observed with her nursing supervisors. Upon hearing her observations, the supervisors looked at the nurse in a surprised and skeptical manner and asked her to give a specific example. This is an example of covert racism because the nursing supervisors were aware of the informal policy that they assign minority nurses to clients residing in designated minority neighborhoods. The nursing supervisors were aware of this long-standing practice to assign minority nurses to minority clients and Caucasian nurses to Caucasian clients but would never admit to it. The supervisors thought that the best way for minority clients to be the recipients of culturally competent care was to assign a minority nurse to care for their own. Covert Unintentional Prejudice/Racism Ashley is the seven-year-old daughter of a lesbian middle-class couple. The school nurse is frustrated that Ashley’s parents refuse to disclose the father and insist on altering the demographic form to include the two mothers as parents. Ashley frequently shows up to the nurse’s office with stomach upsets and the nurse attributes the upsets to the parents’ sexual orientation. The school nurse has not conducted an in-depth assessment of the child’s chief complaint. This is unusual behavior for the school nurse as she has been cited for her thorough assessments of children that have resulted in early diagnosis and treatment of disorders for this age group. This school nurse is unaware that her intolerance for the parents’ sexual orientation and family’s lifestyle has contributed to her decision to provide a cursory assessment for Ashley. Ethnocentrism Ethnocentrism, or cultural prejudice, is the belief that one’s own cultural group determines the standards by which another group’s behavior is judged. The implication is that one’s own standards are better than and superior to the other person’s standards. Ethnocentric nurses favor their own professional values and find unacceptable that which is different from their culture. Their inability to accept different worldviews often leads them to devalue the experiences of others, judge them to be inferior, and treat those who are different from themselves with suspicion or hostility (Andrews and Boyle, 2012). Ethnoculturalism is in contrast to cultural blindness, in which there is an inability to recognize the differences between one’s own cultural beliefs, values, and practices and those of another culture. The tendency is to believe that the recognition of racial, ethnic, religious, or gender difference is itself prejudicial and discriminatory. Hence, nurses who state that they treat all clients the same, regardless of cultural orientation, are demonstrating cultural blindness. Cultural Imposition Cultural imposition is the belief in one’s own superiority, or ethnocentrism, and is the act of imposing one’s cultural beliefs, values, and practices on individuals from another culture. Nurses impose their values on clients when they forcefully promote biomedical traditions while ignoring the clients’ valuing of non-Western treatments such as acupuncture, herbal therapy, or spiritualistic rituals. A goal for nurses is to develop an approach of cultural relativism, whereby they recognize that clients have different approaches to health, and that each culture should be judged on its own merit and not on the nurse’s personal beliefs. Cultural Conflict Cultural conflict is a perceived threat that may arise from a misunderstanding of expectations when nurses are unable to respond appropriately to another individual’s cultural practice because of unfamiliarity with the practice (Andrews and Boyle, 2012). Although cultural conflicts are unavoidable, the nursing goal is to manage conflicts so that they do not affect the delivery of culturally competent nursing care. Knowing how conflict is managed in the particular culture can minimize the conflict. It is important, when resolving the conflict, that all persons involved in the conflict have a way to “save face.” 158 Culture Shock Culture shock is the feeling of helplessness, discomfort, and disorientation experienced by an individual attempting to understand or effectively adapt to a cultural group whose beliefs and values are radically different from the individual’s culture. When nurses experience culture shock, it may be a normal reaction to a client’s beliefs and practices that are not allowed or approved in the nurse’s own culture (Andrews and Boyle, 2012). Culture shock is brought on by anxiety that results from losing familiar signs and symbols of social interaction. As nurses change their practice environments and leave the safety of the hospital for community settings, they may experience heightened discomfort and feelings of powerlessness to confront differences between themselves and clients. This is especially true when nurses have little knowledge or exposure to the culture from which the client comes. For example, nurses who are unfamiliar with “cupping” may experience culture shock when Cambodians use this practice to relieve headaches, to reduce stress and sinus tension, or to delay the onset of colds. Being aware of the clients’ own cultural beliefs and having knowledge of other cultures may help nurses to be more accepting of cultural differences. Culturally Competent Nursing Interventions In culturally competent nursing interventions nurses integrate their professional knowledge with the client’s knowledge and practices to maintain, protect, and restore the client’s health. Leininger (2002a) developed a nursing intervention framework to increase culturally competent care; this framework suggests three modes of action, based on negotiation between the client and nurse, which guide the nurse to deliver culturally competent care: cultural preservation, cultural accommodation, and cultural repatterning. When these decisions and actions are used with cultural brokering, the nurse is able to provide holistic care for culturally diverse clients (individual, family, or community). Cultural Preservation Cultural preservation refers to assistive, supportive, facilitative, or enabling nurse actions and decisions that help the clients of a particular culture to retain and preserve traditional values, so they can maintain, promote, and restore health. For example, acupuncture, an ancient Chinese practice of inserting needles in specific points on the skin through which life energy flows, is used to relieve pain or cure diseases by restoring balance of 159yin and yang (Spector, 2012). This practice is being accepted by increasing numbers of Western practitioners as a legitimate treatment for many health problems. Thus, when Western practitioners integrate modalities such as acupuncture in the plan of care to maintain and protect the health of Asian clients who subscribe to the practice, they are providing care that is consistent with the clients’ beliefs and values and helping to preserve their culture. In another example, the nurse helps maintain cultural family values of Ms. Rodriquez, a 73-year-old Filipino woman who was discharged from hospital to home care after surgery for cancer of the large intestine. During the home visit, the nurse discussed with the client and her husband about making a referral to have a home health aide assist with physical care and light housekeeping chores. The family was gracious but seemed hesitant to accept the referral. The nurse knew that in the Filipino family the older daughter is expected to be the caregiver for her mother and father. She asked the couple if they would like to discuss the situation with their daughters. Both the client and her husband seemed pleased with the idea, and the nurse promised to get back to them the next day. When the nurse returned for her visit, Ms. Rodriquez’s older daughter was present and told the nurse that she would manage without additional help. The three daughters had made a schedule to take turns caring for their parents. The nurse accepted and supported the family’s decision and told them that if they decided at a later time to accept the services of a home health aide, they should call the agency. The nurse then gave the family the telephone number of the agency, and scheduled the next follow-up visit with them. Cultural Accommodation Cultural accommodation refers to assistive, supportive, facilitative, or enabling nurse actions and decisions that help clients of a particular culture accept nursing strategies, or negotiate with nurses to achieve satisfying health care outcomes. Nurses may support and facilitate successful use of home burial of placenta alongside interventions from the biomedical health care system. For example, the delivery nurse was very helpful when Ms. Sanchez asked her not to discard a piece of the amniotic sac that was present on her grandbaby’s face immediately after birth. Ms. Sanchez asked the nurse to give it to her instead. The grandmother believed that being born with a piece of the amniotic sac on the face was a visible sign that something special was going to happen in the person’s life. The grandmother explained that after she dried the piece of the amniotic sac, she would keep it in a safe place. She would also spend extra time protecting the baby to prevent her from being harmed. Although the delivery room nurse was not knowledgeable about this practice, she was assistive and gave the grandmother the piece of the sac as she requested. Cultural Repatterning Cultural repatterning refers to assistive, supportive, facilitative, or enabling nurse actions and decisions that help clients of a particular culture to change or modify a cultural practice for new or different health care patterns that are meaningful, satisfying, and beneficial. Successful repatterning is likely to occur when cultural values and beliefs are respected while at the same time there is a cocreation of interventions with the client to provide for a healthier pattern than before the changes were developed. For example, a culturally competent school nurse who works with Mexican Americans knows of the high incidence of obesity among women 20 years and older. Using this information, she developed a health education program for Mexican teenagers in the local high school. While respecting their cultural traditions, the nurse discussed weight management strategies with the teenagers. The nurse understood the teenagers’ cultural issues pertaining to food and knew how to negotiate with them. She discouraged the use of fried foods (such as tortillas), sour cream, and regular cheese and encouraged and demonstrated the use of baked tortillas and salsa as dip and topping. In another example, a nurse discovered during her instructions on diabetes self-management that pregnant Haitian women were visiting an herbalist to obtain teas so they would not have to take insulin. The nurse asked for the names of the herbs in the teas that they were drinking and scheduled a conference with the pharmacist to discuss the specific ingredients in the herbs as well as ways that they might help clients meet their cultural needs. The nurse found out that one of the herbs contributed to high blood pressure, a problem that many of the women were experiencing. She negotiated with the women not to take the tea with the specific herb. The nurse understood the importance of supernatural causes of illness in the Haitian culture and sought cooperation from the herbalist. Another example of cultural repatterning occurs when nurses assist older Chinese clients to use low-sodium soy sauce, rather than soy sauce with high sodium, in their cooking as a means to more effectively manage their hypertension. Similarly, nurses should guide African Americans to eat more broiled and less fried foods. Culture Brokering Culture brokering is advocating, mediating, negotiating, and intervening between the client’s culture and the biomedical health care culture on behalf of clients. Nurses as culture brokers act as go-betweens or advocates between groups of persons or persons of different cultural backgrounds to reduce conflict or produce change to facilitate client access to health care. As client advocates, nurse brokers are positioned to understand both cultures (the client’s culture and the culture of the health care system) and resolve or lessen problems that result when individuals in either culture do not understand the other person’s values. To illustrate, migrant workers tend to have high occupational mobility; many are poor and have limited formal education. They may seek health care only when they are ill and cannot work. Nurses who staff mobile health care vans often come in contact with migrant workers and usually take the opportunity to teach these individuals about prevention, health maintenance, environmental sanitation, and nutrition because it may be the only opportunity they will ever have to care for that particular migrant worker. These public health nurses also advocate for the rights of the migrant worker to receive quality health care. In this instance mobile health care nurses who provide manpower for the health mobile care van clinic may 160contact the migrant health services for follow-up or referral care for the migrant workers who received health care from the mobile health care van. image Linking Content to Practice As has been discussed throughout the chapter, culturally competent nursing care uses many of the standards, guidelines, and competencies from key nursing and public health documents. For example, the Council on Linkages (Council on Linkages, 2010) has a set of skills related to cultural competency and a set related to communication that are consistent with the information in this chapter. Likewise, the Quad Council further develops and applies the skills of the Council on Linkages related to both cultural competency and communication to public health nursing practice. As an example, the Council on Linkages states that a necessary skill in public health is to consider “the role of cultural, social, and behavioral factors in the accessibility, availability, acceptability and delivery of public health services.” The Quad Council states that “public health nurses should consider the role of cultural, social, and behavioral factors in the accessibility, availability, acceptability and delivery of public health nursing services.” Each of the competencies in the Council on Linkages core competencies is applied directly to public health nursing practice by the Quad Council (2011). Also, the American Academy Expert Panel on Global Nursing and Health (2010) identifies 12 standards that serve as a resource and guide for nurses in practice, administration, education, and research by underscoring cultural competence as a priority of care for the populations that they serve. Developing Organizational Cultural Competence Cultural competence barriers extend beyond the individual health care provider. Institutions and agencies can facilitate cultural competence. For example, a number of organizations subscribe to the nine cultural competence strategies that Lie and colleagues (2010) targeted at the institutional level: (1) providing interpreter services, (2) establishing recruitment and retention policies to increase ethnic minority representation, (3) providing training in cultural competence and sensitivity, (4) coordinating with traditional healers in the community, (5) using community health workers, (6) carrying out culturally competent health promotion that incorporates cultural notions of health and well-being, (7) including families and community members in care and decision making, (8) facilitating provider immersion into another culture and administrative and organizational accommodation, such as providing a welcoming environment, and (9) ensuring linguistic appropriateness of materials and information. By incorporating culturally competent behaviors that are embedded in the culture of the organization into the cultural competence framework, institutions have expanded the reach of their resources into the community and are addressing social determinants of health care. Tripp-Reimer et al (2001) described another organizational cultural competence intervention model. They described four levels of systems interventions: (1) being culturally neutral refers to the standard practice typically developed by whites for whites; (2) being culturally insensitive refers to addressing issues of accessibility of services by using bilingual and bicultural health informational material that incorporates surface-level cultural knowledge, such as dietary preferences into practice; (3) being culturally innovative refers to the use of cultural symbols and notions of health and well-being to convey health promotion messages, working with established social institutions in the community; and (4) being cultural transformative refers to using principles of social activism and change to unearth power relationships and partnering with communities to alter aspects of the basic social structure. The assertion by these authors that social activism can and should be a part of social competence underscores the commitment that organized nursing has to address social justice issues rooted in larger systems problems of inequality and discrimination. Nurses, as providers, are expected to develop cultural competence to change the dynamic of the nurse–client relationship. As leaders, nurses are expected to use leadership skills to advocate for social justice by promoting community empowerment, liberation, and relief of suffering and human oppression. Betancourt et al (2003) presented a three-tier cultural competence framework—clinical, organizational, and structural—through which culturally competent strategies can be implemented to reduce health disparities. According to Betancourt, the rationale for these three levels of focus is that all three levels contribute to disparate health outcomes; therefore they must all be addressed to level the playing field and equalize health outcomes. Social cultural barriers to culturally competent care in this model are clinical barriers (poor provider communication, provider stereotyping and discrimination, and misunderstanding of culture perspective on health issues), organizational barriers (the lack of minorities in institutional leadership and the health care workforce), and structural (lack of interpreter services, bureaucratic intake processes, and difficulties accessing specialty care for minorities). Interventions to overcome these barriers are suggested for each level. Structural interventions include improving access to processes within the delivery health care system that includes expanding interpreter services and health teaching; organizational interventions include increasing diversity within the workforce and the health care leadership; and clinical interventions include working to enhance provider knowledge of the relationship between sociocultural factors and health beliefs and behaviors, and equipping providers with tools and skills to manage these factors appropriately. Institutional level interventions could include agency engagement with the broader community, increased access to care for socioeconomically disadvantaged groups, and selection of interventions that are culturally appropriate. This macro level model provides direction for agencies that want to adopt culturally competent practices as part of their operational procedures and to facilitate provider level culturally competent care. When describing these broad-base interventions, cultural competence becomes an umbrella term to address the many individual level skills, attitudes, and knowledge and organizational level structures, policies, and protocols that come together in a profession, organization, or community to provide effective care to culturally diverse populations. How well do culturally competent interventions fare in improving positive health outcomes for culturally diverse clients? Many studies demonstrate a beneficial effect on 161provider knowledge, provider attitudes, and provider skills. Favorable patient satisfaction measures and improvement in adherence to follow-up among client assignees to intervention group providers have also been reported. Interventions that focus on the avoidance of bias, gender concepts of culture, and client-centeredness demonstrate promise as lasting strategies to decrease health disparities. These strategies include availability and access to assessment of problems in their social and cultural context, selection of culturally and socially acceptable interventions, and increased accountability to recipients of services and their community. Institutional level interventions could include agency engagement with the broader community, increased access to care for socially disadvantaged groups, and selection of interventions that are culturally appropriate. These four macro level modes provide direction to agencies that want to adopt culturally competent practices as part of their operational procedure and to facilitate provider level culturally competent care. When describing these broad-based interventions, cultural competence becomes an umbrella term to address the many individual level competencies, skills, attitudes, and knowledge, and organizational level competencies, structures, policies, and protocols that come together in a profession, organization, or community to provide effective care to culturally diverse populations. Positive Health Outcomes Associated with Cultural Competence Nurse clinicians and educators are beginning to understand how to provide critical learning environments and workplaces for students, faculty, and practitioners to apply the concepts of cultural competence in their practice in order to improve the effectiveness of their actions. The majority of nurses continue to believe that they are less confident and inadequately prepared to provide sustained culturally competent care to clients from diverse cultures (Esposito, 2014). It is important to disseminate cultural competence outcomes in nursing through public health and research conferences, staff development programs, continuing education programs, and the student nursing associations. Sealey et al (2006) examined the cultural competence of nurse educators in Louisiana and found that very few of the nurse educators had formal preparation to teach transcultural nursing and that they felt uncomfortable attempting to do so. A study conducted on community-based nurses’ perceptions of cultural competence offers some encouragement (Starr and Wallace, 2009). The study indicated that about 85% of clients participating in the study perceived that nursing care today contains key components of decision making, communication, and interpersonal styles that reflect cultural components, 57% indicated that their communication style was culturally competent, 61% rated their decision-making choices as reflective of cultural competence behaviors, and about 70% said their interpersonal style was indicative of cultural competence behaviors. Evidence-based cultural competence practice in nursing connecting culturally competent health care goals with the professional values of nursing and patient care outcomes and satisfaction has been the subject of recent research activity in nursing. The majority of studies of the effectiveness of culturally competent nursing interventions are descriptive. Few studies have employed a randomized clinical trial design. Fisher et al (2007) identified 38 nursing interventions that used some form of culturally oriented interventions to target racial and ethnic disparities. Kulbok et al (2012) cited several examples from the evidence-based nursing literature of public health nursing using the technique of participatory practice, defined as the building of partnerships with community members to assess, plan, analyze data, and implement sustainable health promotion and prevention programs to reach marginalized populations in vulnerable communities. For instance, Andrews et al (2007) used participatory methods to assess an African American population living in an impoverished neighborhood. To gain in-depth insights about the community’s assets and needs, the research team involved community advisory board members and community health workers to assist them in conducting a series of community forums and interpreting the data gathered at the forums. Anderson and her research team (2007) were able to identify multilevel factors related to smoking patterns of the community. Thomas et al (2009) worked with a tribal community council to attain culturally sensitive knowledge of the tradition, history, and strength of that community in projects to reduce substance abuse. McQuiston et al (2005) used ethnographic community participatory strategies to set up a nominal group process to obtain important cultural aspects of health when assessing health disparities in a Latino population. Zandee et al (2010) described how public health nursing students used cultural competence principles to better understand the cultural background of the communities in which they were placed. By partnering with community health workers, the students were able to improve their cultural competence. image Focus on Quality and Safety Education for Nurses The six quality and safety competencies for nurses that were identified in the Quality and Safety Education for Nurses (QSEN) project are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. While each of these is important and pertinent to the nursing actions taken with people from cultural groups other than that of the nurse, perhaps the most significant is that of patient-centered care. The chapter presents many guidelines and principles for aiding nurses in providing culturally competent care. One of the areas in which patient-centered care is lacking occurs when the nurse and the patient are not communicating effectively. The lack of communication may occur when they speak different languages, have different cultural practices and expectations that lead them to hear messages differently or when the persons being served simply do not understand what the nurse is saying and are reluctant to acknowledge this. Nurses must observe for both verbal and nonverbal cues that a message is either understood or not understood. When the latter occurs, the nurse should take action to clarify the message. This may include asking someone from that cultural group to assist or to enlist the aid of an interpreter. See: Issel LM, Bekemeier B: Safe practice of population-focused nursing care: Development of a public health nursing concept, Nursing Outlook, 58(5):226-232, 2010. The following applies the QSEN competency of client-centered interventions that reflect cultural competence. Targeted Competency: Client-Centered Intervention—Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated interventions based on respect for the client’s preferences, values, and needs. Important aspects of client-centered intervention include: • Knowledge: Describe strategies to empower clients or families in all aspects of the health care process • Skills: Communicate client values, preferences, and expressed needs to other members of the health care team • Attitudes: Willingly support client-centered care for individuals and groups whose values differ from your own. Client-Centered Care Question Competence in providing client-centered interventions involves not only effective interviewing of individual clients, but developing an awareness of their context. As a community-based clinician, it is helpful to familiarize yourself with the cultural context of your clients. Learning about community resources can sometimes be helpful in learning about the cultural context. You have just been hired as a visiting nurse in a Hispanic community. What community resources could you explore to assist you in providing effective client-centered care? Answer • You might explore community centers. Where are they? How well frequented are the community centers? Which programs are most popular? Which community center programs are health-oriented? • Are community members very involved with one or more churches? You might familiarize yourself with elements of this faith tradition. • Are there community elders who are publically recognized as leaders in the community? Can you meet with them to understand how the community has changed and evolved over time? Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing. Cultural Nursing Assessment A cultural nursing assessment is “a systematic identification and documentation of the culture care beliefs, meanings, values, symbols, and practices of individuals or groups within a holistic perspective, which includes the worldview, life experiences, environmental context, ethno history, language, and diverse social structure influences” (Leininger, 2002b, pp. 117-118). A cultural assessment is the basis for providing culturally competent health care and helps to ensure that nurses will understand and respect the client’s beliefs, values, and health care practices and take these cultural data into consideration when creating a treatment plan for the client. A cultural assessment should focus on those aspects relevant to the presenting problem, necessary intervention, and participatory education. Nurses use the information gathered to help them identify and understand clients’ beliefs and practices about health and illness. By adopting a relativistic approach, nurses avoid judging or evaluating the clients in terms of their own culture. A nonjudgmental approach toward the client’s culture is facilitated through having a skill set that includes understanding, eliciting, listening, explaining, acknowledging, recommending, and negotiating. It is vital that nurses listen to clients’ 162perceptions of their problem and, in turn, that nurses explain to clients their own perceptions of the problem. Nurses and clients should acknowledge and discuss similarities and differences between the two perceptions to develop recommendations and suggestions for management of problems. A variety of tools are available to assist nurses in conducting cultural assessments (Andrews and Boyle, 2012; Leininger, 2002b). The focus of such tools varies, and selection is determined by the dimensions of the culture to be assessed. During an initial contact with clients, nurses should perform a general cultural assessment to obtain an overview of the clients’ characteristics. Nurses ask clients about their ethnic background, language, education, religious affiliation, dietary practices, family relationships, hospital experiences, occupation and socioeconomic status, cultural beliefs, and language. Nurses also want to know about clients’ distinctive features, perceptions of the health issue, causation, treatment, anticipated results, and the impact the issue might have on the client. Such basic data help nurses understand the clients from the clients’ points of view and recognize their uniqueness, thus avoiding stereotyping. Data for an in-depth cultural assessment should be gathered over a period of time and not restricted to the first encounter with the client. This gives both the client and the nurse time to get to know each other, and it is especially beneficial for the client to see the nurse in a helping relationship. An in-depth cultural assessment should be conducted in two phases: a data collection phase and an organization phase. The data collection phase consists of three steps: 1. The nurse collects self-identifying data similar to those collected in the brief assessment. 2. The nurse raises a variety of questions that seek information on the client’s perception of what brings them to the health care system, the illness, and previous and anticipated treatments. 3. After the nursing diagnosis is made, the nurse identifies cultural factors that may influence the effectiveness of nursing care actions. In the organization phase, data related to the client’s and family’s views on optimal treatment choices are routinely examined, and areas of difference between the client’s cultural needs and the goals of Western medicine are identified. Nurses may use Leininger’s (2002a) three actions (discussed previously in this chapter) to guide them in selecting and discussing culturally appropriate interventions with clients. The key to a successful cultural assessment lies in nurses being aware of their own culture. The nurse should consider the following suggestions when eliciting cultural information: • Be sensitive to the cues in the environment and be in tune with the verbal and nonverbal communications before taking action. • Know about the resources in the community such as schools, churches, hospitals, tribal councils, restaurants, taverns, and bars. • Know the specific areas to focus on before beginning the cultural assessment. • Select a strategy for gathering cultural data. Possible strategies include in-depth interviews, informal conversations, 163observations of the client’s everyday activities or specific events, survey research, and a case method approach to study certain aspects of a client. • Identify a confidante who will help “bridge the gap” between cultures. Be aware that in some cultures the woman’s husband or a close male family friend may be the person from whom the nurse may need to obtain the cultural information. • Know the appropriate questions to ask without offending the client. • Interview other nurses or health care professionals who have worked with the specific individual, family, or community to get their input. • Use a trained interpreter if the client has limited proficiency with English. • Talk with formal and informal community leaders to gain a comprehensive understanding about significant aspects of community life. • Be aware that all information has both subjective and objective aspects, and verify and cross-check the information that is collected before acting on it. • Avoid the pitfalls that may occur when making premature generalizations. • Be sincere, open, and honest with yourself and the client. Practice Application Mr. Nguyen, a 64-year-old man from rural Vietnam, entered the United States with his family 3 years ago through the refugee program. Mr. Nguyen was a farmer in his homeland, and since his arrival he has been unable to obtain a stable job that would allow him to adequately care for his family. His financial resources are limited, and he has no insurance. He speaks enough English to interact directly with people outside his family and community. His oldest daughter, Aeyoung, is enrolled in a 2-year program to become a registered nurse. The Nguyen family attends the neighborhood church with other Vietnamese families. Mr. Nguyen has been attending the clinic at the hospital but refuses to discuss with his family, even with Aeyoung, the reason for these visits. Aeyoung became increasingly concerned as she observed her father to have insomnia, retarded motor activity, an inability to concentrate, and weight loss. However, Mr. Nguyen denied that he was not well. Aeyoung decided to discuss her concerns with a nurse, with whom she had developed an attachment, at the church. She invited the nurse to her home for lunch on a Saturday so she could meet her father and validate her impressions. After several visits with the family, the nurse was able to establish a close enough relationship with Mr. Nguyen so that she could engage him in a discussion of his health. Because of her extensive work with other Vietnamese immigrants, the nurse was familiar with themes of loss and decided to focus her conversation with Mr. Nguyen on his adjustment to the new community living, gains and losses as a result of immigration, and coping strategies. After several discussions with Mr. Nguyen, he confided in the nurse that he feared that he was dying because he had been diagnosed with cancer of the small intestine. He further revealed that he had not shared the diagnosis with the family because he did not want them to know of his “bad news.” Mr. Nguyen had refused treatment because he knew that people never get better when they have cancer; they always die. A. Which of the following actions best characterize the nurse’s willingness to provide culturally competent care to Mr. Nguyen and his family? 1. Discuss with the client his understanding of his diagnosis. 2. Discuss with the client the prognosis for a person diagnosed with cancer of the small intestine in the United States. 3. Discuss with the client the prognosis for a person diagnosed with cancer of the small intestine in Vietnam. 4. Discuss the medical treatment and surgical intervention for cancer of the small intestine. B. The way in which the nurse poses questions to Mr. Nguyen is very important and determines the kind of responses the client gives to the nurse. What types of questions should the nurse pose to Mr. Nguyen to get the best responses from him? C. Which resources should a community health agency have available to assist Mr. Nguyen with his health care concerns? Answers can be found on the Evolve site. Key Points • The U.S. population is becoming increasingly diverse, and nurses and health care organizations need to learn more about the culture of individuals to whom they provide care and the impact of culture on health care. • Culture is a learned set of behaviors that are widely shared among a group of people and helps guide individuals in problem solving and decision making processes. • Cultural differences exist among groups and they may be observed in areas such as biological variations, personal space, perception of time, environmental control, family organization, communication, nutrition, and religion. • There are individual differences among people within a cultural group. • Changes in immigration laws and policies have increased migration, contributing to changes in community demographics and challenges for nurses to effectively communicate with their clients and help them understand the basic health information needed to make appropriate health 164decisions. When nurses do not speak or understand the client’s language, interpreters should be available to assist them in communicating with clients. • In selecting an interpreter, nurses should not only consider the clients’ cultural needs but also respect their right to privacy. • Members of minority groups are over-represented on the lower tiers of the socioeconomic ladder. Poor economic achievement is also a common characteristic among populations at risk, such as the homeless, migrant workers, and refugees. Nurses should be able to distinguish between culture and socioeconomic class issues and not interpret behavior as having a cultural origin when in fact it is based on socioeconomic class. • Clients who are excluded from full participation in the economic, social, and political life of the society may have more complex health issues and more difficulty accessing and receiving services from health care institutions. • The social determinants of health are the circumstances in which people are born and grow up, live, work, and age, and the systems put in place to deal with illness. They are shaped by race, economics, education, the family structure, health, and access to health resources. • Efforts to understand dietary practices should go beyond relying on the individual having membership in a specific group and include religious requirements. • Culturally competent nursing care is designed for a specific client, reflects the nurse’s knowledge and the individual’s knowledge and practices, and is implemented with care and sensitivity. Such nursing care helps to improve health outcomes and reduce health care costs. • Standards of practice have been developed to guide nurses around the world in the areas of clinical practice, research, education, and administration. • Culturally competent nurses are empowered to provide equitable nursing care that is focused on meeting the physical, physiological, social, and cultural needs of the client. • Culturally competent nurses are aware of their own cultures, use cultural knowledge, have cultural skill, and select culturally appropriate interventions to care for the client holistically. The most important aspect is cultural encounter with the client. • Nurses must have the desire or intrinsic motivation to want to provide culturally competent nursing care. • Barriers to providing culturally competent care include stereotyping, prejudice and racism, ethnocentrism, cultural imposition, cultural conflict, and culture shock. • Culturally competent nurses may select from four modes of interventions when providing care: cultural preservation, cultural accommodation, cultural repatterning, and culture brokering. • Organizations, institutions, and professional associations should have policies, procedures, and practices that support a climate in which nurses can deliver culturally competent care to clients whom they serve. • Nurses should perform a cultural assessment on every client with whom they interact. Cultural assessments help nurses understand clients’ perspectives of health and illness and thereby guide them to implement culturally competent interventions. The needs of clients vary with their age, education, religion, and socioeconomic status. Clinical Decision-Making Activities 1. Select a culture that you would like to study. Go to the appropriate websites and gather information about the cultural group. Identify the group’s cultural beliefs and practices and health-seeking behaviors. Share what you have obtained from websites and ask the person to evaluate the information. Discuss this information with at least one member of that cultural group. Compare and contrast information obtained from the two sources. Describe how you would use this information in your clinical practice. 2. Discuss how you would interview older clients who are considering giving up their independence and living in a nursing home. Prepare them for the likelihood that their health care providers are likely to be culturally diverse and may not share the same race or ethnicity. How will they engage in communication with the care provider about their health needs, family of origin, and important routine behaviors? How will they share their daily routine, dietary practices, and memories of family and friends? 3. Identify an alternative health care practitioner in the community of your clinical placement where you have been assigned. Prepare six questions and use them as a guide to interview the alternative healer about cultural health beliefs, healing practice, and alternative biomedical explanation of illness systems. 4. Select from one of the standards of practice for culturally competent care (Office of Minority Health, Expert Panel for Global Nursing and Health of the American Academy of Nursing and the Transculutral Nursing Society, the Quad Council, and the Joint Commission) and examine the extent to which the public health agency in your community is in compliance with cultural competence standards as identified by one of these organizations. 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Effectiveness of community health worker/nursing student teams as a strategy for public health nursing education. Public Health Nurs. 2010;27:277–284. Ch 8 Nurses are an important part of the health care system and are greatly affected by governmental and legal systems. Nurses who select the community as their area of practice must be especially aware of the impact of government, law, and health policy on nursing, health, and the communities in which they practice. Insight into how government, law, and political action have changed over time is necessary to understand how the health care system has been shaped by these factors. Also, understanding how these factors have influenced the current and future roles for nurses and the public health system is critical for better health policy for the nation. Nurses have historically viewed themselves as advocates for the health of the population. It is this heritage that has moved the discipline into the policy and political arenas. To secure a more positive health care system, nurse professionals must develop a working knowledge of government, key governmental and quasi-governmental organizations and agencies, health care law, the policy process, and the political forces that are shaping the future of health care. This knowledge and the motivation to be an agent of change in the discipline and in the community are necessary ingredients for success as a population-centered nurse. Definitions To understand the relationship between health policy, politics, and laws, one must first understand the definitions of the terms. Policy is a settled course of action to be followed by a government or institution to obtain a desired end (CDC, 2014). Public policy is described as all governmental activities, direct or indirect, that influence the lives of all citizens (Birkland, 2010). Health policy, in contrast, is a set course of action to obtain a desired health outcome for an individual, family, group, community, or society (WHO, 2014). Policies are made not only by governments, but also by such institutions as a health department or other health care agency, a family, a community, or a professional organization. Politics plays a role in the development of such policies. Politics is found in families, professional and employing agencies, and governments. Politics determines who gets what and when and how they get it (Birkland, 2010). Politics is the art of influencing others to accept a specific course of action. Therefore, political activities are used to arrive at a course of action (the policy). Law is a system of privileges and processes by which people solve problems based on a set of established rules; it is intended to minimize the use of force (Yourdictionary, 2014). Laws govern the relationships of individuals and organizations to other individuals and to government. Through political action, a policy may become a law, a regulation, a judicial ruling, a decision, or an order. After a law is established, regulations further define the course of action (policy) to be taken by organizations or individuals in reaching an outcome. Government is the ultimate authority in society and is designated to enforce the policy whether it is related to health, education, economics, social welfare, or any other society issue. The following discussion explains the role of government in health policy. Governmental Role in U.S. Health Care In the United States, the federal and most state and local governments are composed of three branches, each of which has separate and important functions (Truman, 2014). The executive branch is composed of the president (or state governor or local mayor) along with the staff and cabinet appointed by this executive, various administrative and regulatory departments, and agencies such as the U.S. Department of Health and Human Services (USDHHS). The legislative branch (i.e., Congress at the federal level) is made up of two bodies: the Senate and the House of Representatives, whose members are elected by the citizens of particular geographic areas. There is a federal Division of Nursing, a section within the Health Resources and Services Agency (HRSA) of the USDHHS, that refines criteria 169for nursing education programs as funded by Congress and affirmed by the President. The judicial branch is composed of a system of federal, state, and local courts guided by the opinions of the Supreme Court. Each of these branches is established by the Constitution, and each plays an important role in the development and implementation of health law and public policy. The executive branch suggests, administers, and regulates policy. The role of the legislative branch is to identify problems and to propose, debate, pass, and modify laws to address those problems. The judicial branch interprets laws and their meaning, as in its ongoing interpretation of states’ rights to define access to reproductive health services to citizens of the states. One of the first constitutional challenges to a federal law passed by Congress was in the area of health and welfare in 1937, after the 74th Congress had established unemployment compensation and old-age benefits for U.S. citizens (U.S. Law, 1937a). Although Congress had created other health programs previously, its legal basis for doing so had never been challenged. In Stewart Machine Co. v. Davis (U.S. Law, 1937b), the Supreme Court (judicial branch) reviewed this legislation and determined, through interpretation of the Constitution, that such federal governmental action was within the powers of Congress to promote the general welfare. It was obvious in 2008 and beyond that unemployment benefits are important to the economy and to individuals who lose jobs during a national economic crisis (BLS, 2010). Most legal bases for the actions of Congress in health care are found in Article I, Section 8 of the U.S. Constitution, including the following: 1. Provide for the general welfare. 2. Regulate commerce among the states. 3. Raise funds to support the military. 4. Provide spending power. Through a continuing number and variety of cases and controversies, these Section 8 provisions have been interpreted by the courts to appropriately include a wide variety of federal powers and activities. State power concerning health care is called police power (Legal Information Institute, 2014). This power allows states to act to protect the health, safety, and welfare of their citizens. Such police power must be used fairly, and the state must show that it has a compelling interest in taking actions, especially actions that might infringe on individual rights. Examples of a state using its police powers include requiring immunization of children before being admitted to school and requiring case finding, reporting, treating, and follow-up care of persons with tuberculosis. These activities protect the health, safety, and welfare of state citizens. Trends and Shifts in Governmental Roles The government’s role in health care at both the state and federal level began gradually. Wars, economic instability, and political differences between parties all shaped the government’s role. The first major federal governmental action relating to health was the creation in 1798 of the Public Health Service (PHS). Then in 1890 federal laws were passed to promote the public health of merchant seamen and Native Americans. In 1934 Senator Wagner of New York initiated the first national health insurance bill. The Social Security Act of 1935 was passed to provide assistance to older adults and the unemployed, and it offered survivors’ insurance for widows and children. It also provided for child welfare, health department grants, and maternal and child health projects. In 1948 Congress created the National Institutes of Health (NIH), and in 1965 it passed very important health legislation creating Medicare and Medicaid to provide health care service payments for older adults, the disabled, and the categorically poor. These legislative acts by Congress created programs that were implemented by the executive branch. In March 2010, the most recent legislation passed and signed by President Obama to improve the health of the nation and access to care was the health reform law, the Patient Protection and Affordable Care Act (US LAW, PL 111-148). See Chapter 3 for in-depth information (Kaiser Family Foundation, 2010a). The U.S. Department of Health and Human Services (USDHHS) (known first as the Department of Health, Education, and Welfare [DHEW]) was created in 1953. The Health Care Financing Administration (HCFA) was created in 1977 as the key agency within the USDHHS to provide direction for Medicare and Medicaid. In 2002 HCFA was renamed the Center for Medicare and Medicaid Services (CMS). During the 1980s, a major effort of the Reagan administration was to shift federal government activities to the states, including federal programs for health care. The process of shifting the responsibility for planning, delivering, and financing programs from the federal level to the states is called devolution. Throughout the 1980s and 1990s, Congress has increasingly funded health programs by giving block grants to the states. Devolution processes including block granting should alert professional nurses that state and local policy has grown in importance to the health care arena. With the new health reform law, stimulus grants have been provided to state and local areas to improve health care access (HRSA, 2010). The role of government in health care is shaped both by the needs and demands of its citizens and by the citizens’ beliefs and values about personal responsibility and self-sufficiency. These beliefs and values often clash with society’s sense of responsibility and need for equality for all citizens. A federal example of this ideological debate occurred in the 1990s over health care reform. The Democratic agenda called for a health care system that was universally accessible, with a focus on primary care and prevention. The Republican agenda supported more modest changes within the medical model of the delivery system. This agenda also supported reducing the federal government’s role in health care delivery through cuts in Medicare and Medicaid benefits. The Democrats proposed the Health Security Act of 1993, which failed to gain Congress’s approval. In an effort to make some incremental health care changes, both the Democrats and the Republicans in Congress passed two new laws. The Health Insurance Portability and Accountability Act (HIPAA) allows working persons to keep their employee group health insurance for up to 16 months after they leave a job (U.S. Law 107-105, 1996). The State Child Health Improvement Act (SCHIP) of 1997 provides insurance for children and families who cannot otherwise afford health insurance (U.S. Law, 1997). 170 With the latest health care reform, numerous debates occurred in the House of Representatives and the Senate until there was agreement that the Senate version of the bill would be passed. On March 30, 2010 President Obama signed into law the Health Care and Education Reconciliation Act of 2010, which made some changes to the comprehensive health reform law and included House amendments to the new law (Kaiser, 2010B). See Chapter 3 for further discussion. This discussion has focused primarily on trends in and shifts between different levels of government. An additional aspect of governmental action is the relationship between government and individuals. Freedom of individuals must be balanced with governmental powers. After the terrorist attacks on the United States in September (World Trade Center attack) and October (anthrax outbreak) of 2001, much government activity was being conducted in the name of national security. It is interesting to note that before September 11, 2001, the Congress and President, recognizing that the public health system infrastructure needed help, passed “The Public Health Threats and Emergencies Act” (PL 106-505) in 2000. This law “addresses emerging threats to the public’s health and authorizes the Secretary of HHS to take appropriate response actions during a public health emergency, including investigations, treatment, and prevention” (Katz et al, 2014, p. 133). This legislation is said to have signaled the beginning of renewed interest in public health as the protector for entire communities. In June 2002 the Public Health Security and Bioterrorism Preparedness and Response Act was signed into law (US Law 2002, PL 107-188), with $3 billion appropriated by Congress, to implement the following antibioterrorism activities: • Improving public health capacity • Upgrading of health professionals’ ability to recognize and treat diseases caused by bioterrorism • Speeding the development of new vaccines and other countermeasures • Improving water and food supply protection • Tracking and regulating the use of dangerous pathogens within the United States (Katz et al, 2014) Yet there is considerable debate on just how much governmental intervention is necessary and effective and how much will be tolerated by citizens. For example, in 2010 approximately 49% of citizens were against the new health care reform acts, and the Republicans were seen as being obstructionists. In 2014, 50% of citizens were for government intervention and 50% against (Debate.org, 2013). Government Health Care Functions Federal, state, and local governments carry out five health care functions, which fall into the general categories of direct services, financing, information, policy setting, and public protection. Direct Services Federal, state, and local governments provide direct health services to certain individuals and groups. For example, the federal government provides health care to members and dependents of the military, certain veterans, and federal prisoners. State and local governments employ nurses to deliver a variety of services to individuals and families, frequently on the basis of factors such as financial need or the need for a particular service, such as hypertension or tuberculosis screening, immunizations for children and older adults, and primary care for inmates in local jails or state prisons. The Evidence-Based Practice box presents a study that examined the use of a state health insurance program. Evidence-Based Practice The purpose of this study was to examine the changes in access to care, use of services, and quality of care among children enrolled in Child Health Plus (CHPlus), a state health insurance program for low-income children that became a model for the State Child Health Insurance Program (SCHIP). A before-and-after design was used to evaluate the health care experience of children the year before and the year after enrollment in the state health insurance program. The study consisted of 2126 children from New York State, ranging from birth to 12.99 years of age. Results indicated that the state health insurance program for low-income children was associated with improved access, use, and quality of care. The development and implementation of SCHIP was an outcome of the soaring costs of health care and the fact that there were 11 million uninsured children in the United States at the time of the study. It was the largest public investment in child health in 30 years. Nurse Use This study supports the value of health policy and the need to evaluate the effectiveness of policy in accomplishing the purposes of the policy. From U.S. Department of Health and Human Services: Healthy People 2010: understanding and improving health, ed 2, Washington, DC,2000, U.S. Government Printing Office. Financing Governments pay for some health care services; the 2011 percentage of the bill paid by the government was about 46.3%, and this is projected to increase to 47.6% by the year 2015. The government also pays for training some health personnel and for biomedical and health care research (NCHS, 2014). Support in these areas has greatly affected both consumers and health care providers. Federal governments finance the direct care of clients through the Medicare, Medicaid, Social Security, and SCHIP programs. State governments contribute to the costs of Medicaid and SCHIP programs. Many nurses have been educated with government funds through grants and loans, and schools of nursing in the past have been built and equipped using federal funds. Governments also have financially supported other health care providers, such as physicians, most significantly through the program of Graduate Medical Education funds. The federal government invests in research and new program demonstration projects, with NIH receiving a large portion of the monies. The National Institute of Nursing Research (NINR) is a part of the NIH and, as such, provides a substantial sum of money to the discipline of nursing for the purpose of developing the knowledge base of nursing and promoting nursing services in health care (NINR, 2014). Information All branches and levels of government collect, analyze, and disseminate data about health care and health status of the citizens. 171An example is the annual report Health: United States, 2013, compiled each year by the USDHHS (NCHS, 2014). Collecting vital statistics, including mortality and morbidity data, gathering of census data, and conducting health care status surveys are all government activities. Table 8-1 lists examples of available federal and international data sources on the health status of populations in the United States and around the world. These sources are available on the Internet and in the governmental documents’ section of most large libraries. This information is especially important because it can help nurses understand the major health problems in the United States and those in their own states and local communities. TABLE 8-1 International and National Sources of Data on the Health Status of the U.S. Population Organization Data Sources International United Nations http://www.un.org/ Demographic Yearbook World Health Organization http://www.who.int/en/ World Health Statistics Annual Federal Department of Health and Human Services http://www.hhs.gov National Vital Statistics System National Survey of Family Growth National Health Interview Survey National Health Examination Survey National Health and Nutrition Examination Survey National Master Facility Inventory National Hospital Discharge Survey National Nursing Home Survey National Ambulatory Medical Care Survey National Morbidity Reporting System U.S. Immunization Survey Surveys of Mental Health Facilities Estimates of National Health Expenditures AIDS Surveillance Nurse Supply Estimates Department of Commerce http://www.commerce.gov U.S. Census of Population Current Population Survey Population Estimates and Projections Department of Labor http://www.dol.gov Consumer Price Index Employment and Earnings Policy Setting Policy setting is a chief governmental function. Governments at all levels and within all branches make policy decisions about health care. These health policy decisions have broad implications for financial expenses, resource use, delivery system change, and innovation in the health care field. One law that has played a very important role in the development of public health policy, public health nursing, and social welfare policy in the United States is the Sheppard-Towner Act of 1921 (USDHHS, HRSA, 2010). The Sheppard-Towner Act made nurses available to provide health services for women and children, including well-child and child-development services; provided adequate hospital services and facilities for women and children; and provided grants-in-aid for establishing maternal–child welfare programs. The act helped set precedents and patterns for the growth of modern-day public health policy. It defined the role of the federal government in creating standards to be followed by states in conducting categorical programs such as the Women, Infants, and Children (WIC) and Early Periodic Screening and Developmental Testing (EPSDT) programs. The act also defined the position of the consumer in influencing, formulating, and shaping public policy; the government’s role in research; a system for collecting national health statistics; and the integrating of health and social services. This act established the importance of prenatal care, anticipatory guidance, client education, and nurse–client conferences, all of which are viewed today as essential nursing responsibilities. Public Protection The U.S. Constitution gives the federal government the authority to provide for the protection of the public’s health. This function is carried out in numerous venues, such as by regulating air and water quality and protecting the borders from the influx of diseases by controlling food, drugs, and animal transportation, to name a few. The Supreme Court interprets and makes decisions related to public health, such as affirming a woman’s rights to reproductive privacy (Roe v. Wade), requiring vaccinations, and setting conditions for states to receive public funds for highway construction/repair by requiring a minimum drinking age. Healthy People 2020: an Example of National Health Policy Guidance In 1979 the surgeon general issued a report that began a 30-year focus on promoting health and preventing disease for all Americans (DHEW, 1979). In 1989, Healthy People 2000 became a national effort with many stakeholders representing the perspectives of government, state, and local agencies; advocacy groups; academia; and health organizations (USDHHS, 1991). Throughout the 1990s states used Healthy People 2000 objectives to identify emerging public health issues. The success of this national program was accomplished and measured through state and local efforts. The Healthy People 2010 document focused on a vision of healthy people living in healthy communities. Healthy People 2020 has four overarching goals, which can be found in the Healthy People 2020 box; this box compares the goals of Healthy People documents from 2000 to 2020. image Healthy People 2020 A Comparison of the Goals of Healthy People 2000, Healthy People 2010, and Healthy People 2020 Healthy People 2000 Healthy People 2010 Healthy People 2020 Increase the years of healthy life for Americans Reduce health disparities among Americans Achieve access to preventive services for all Americans Increase quality and years of healthy life Eliminate health disparities Attaining high quality, longer lives free of preventable disease, disability, injury, and premature death Achieving health equity, eliminating disparities, and improving the health of all groups Creating social and physical environments that promote good health for all Promoting quality of life, healthy development, and healthy behaviors across all life stages From U.S. Department of Health and Human Services: Leading indicators.In Healthy People 2000, 2010, & 2020, Washington, DC, 1989,1999, 2010, U.S. Government Printing Office.​ Organizations and Agencies That Influence Health International Organizations In June 1945, following World War II, many national governments joined together to create the United Nations (UN). By charter, the aims and goals of the UN deal with human rights, 172world peace, international security, and the promotion of economic and social advancement of all the world’s peoples. The UN, headquartered in New York City, is made up of six principal divisions, several subgroups, and many specialized agencies and autonomous organizations. With the approval and support of the UN Commission on the Status of Women, five world conferences on women have been held. At these conferences, the health of women and children and their rights to personal, educational, and economic security as well as initiatives to achieve these goals at the country level were debated and explored, and policies were formulated (United Nations, 1975, 1980, 1985, 1995, 2000). The work of the UN and the world conferences continues with agendas to include the development of human beings, eradication of poverty, protection of human rights, investment in health, education, training, trade, economic growth, and a continued emphasis on women (United Nations, 2014). One of the special autonomous organizations growing out of the UN is the World Health Organization (WHO). Established in 1946, WHO relates to the UN through the Economic and Social Council to achieve its goal to attain the highest possible level of health for all persons. “Health for All” is the creed of the WHO. Headquartered in Geneva, Switzerland, the WHO has six regional offices. The office for the Americas is located in Washington, DC, and is known as the Pan American Health Organization (PAHO). The WHO provides services worldwide to promote health, it cooperates with member countries in promoting their health efforts, and it coordinates the collaborating efforts between countries and the disseminating of biomedical research. Its services, which benefit all countries, include a day-to-day information service on the occurrence of internationally important diseases; the publishing of the international list of causes of disease, injury, and death; monitoring of adverse reactions to drugs; and establishing of world standards for antibiotics and vaccines. Assistance available to individual countries includes support for national programs to fight disease, to train health workers, and to strengthen the delivery of health services. The World Health Assembly (WHA) is the WHO’s policy-making body, and it meets annually. The WHA’s health policy work provides policy options for many countries of the world in their development of in-country initiatives and priorities; however, although WHA policy statements are important everywhere, they are guides and not law. The WHA’s most recent policy statement on nursing and midwifery was released in 2013, and the current worldwide shortage of professional nurses is now on the WHO agenda and is being addressed by country (WHA, 2011; WHO, 2010; WHO, 2013). The World Health Report, first published in 1995, is WHO’s leading publication. Each year the report combines an expert assessment of global health, including statistics relating to all countries, with a focus on a specific subject. The main purpose of the report is to provide countries, donor agencies, international organizations, and others with the information they need to help them make policy and funding decisions. In the 2010 report, the WHO mapped out what countries can do to modify their financing systems so they can move more quickly toward this goal—universal coverage—and sustain the gains that have been achieved. The report builds on new research and lessons learned from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low-income countries to achieve universal coverage and improve health outcomes (WHO, 2010). The presence of nursing in international health is increasing. Besides offering direct health services in every country in the world, nurses serve as consultants, educators, and program planners and evaluators. Nurses focus their work on a variety of public health issues, including the health care workforce and education, environment, sanitation, infectious diseases, wellness promotion, maternal and child health, and primary care. Dr. Naeema Al-Gasseer of Bahrain has served as the scientist for nursing and midwifery at the WHO; Marla Salmon, former dean of nursing at The University of Washington, chaired a Global Advisory Group on Nursing and Midwifery; and Linda Tarr Whelan served as the U.S. Ambassador to the UN Commission on the Status of Women. Virginia Trotter Betts, past president of the American Nurses Association (ANA), served as a U.S. delegate to both the WHA and the Fourth World Conference on Women in Beijing in 1995, where she participated on the negotiating team of the conference to develop a platform on the health of women across the life span. Many U.S. nurse leaders, such as Dr. Carolyn Williams, current author in this book, have been WHO consultants. Federal Health Agencies Laws passed by Congress may be assigned to any administrative agency within the executive branch of government for implementing, supervising, regulating, and enforcing. Congress decides which agency will monitor specific laws. For example, most health care legislation is delegated to the USDHHS. However, legislation concerning the environment would most 173likely be implemented and monitored by the Environmental Protection Agency (EPA), and that concerning occupational health by the Occupational Safety and Health Administration (OSHA) in the U.S. Department of Labor. U.S. Department of Health and Human Services The USDHHS is the agency most heavily involved with the health and welfare of U.S. citizens. It touches more lives than any other federal agency. The following agencies have been selected for their relevance to this chapter. Health Resources and Services Administration. The Health Resources and Services Administration (HRSA) has been a long-standing contributor to the improved health status of Americans through the programs of services and health professions education that it funds. The HRSA contains the Bureau of Health Professions (BHPr), which includes the Division of Nursing as well as the Divisions of Medicine, Dentistry, and Allied Health Professions. The Division of Nursing is the key federal focus for nursing education and practice, and it provides national leadership to ensure an adequate supply and distribution of qualified nursing personnel to meet the health needs of the nation. At the 122nd meeting of the Division of Nursing’s National Advisory Council for Nursing Education and Practice (NACNEP), the participants discussed the role of public health nurses in participating in primary care in their communities. The speaker indicated several factors that need to be in place to support the public health nurse role: • Baccalaureate standard for entry into practice • Ongoing stable funding for health departments • Competitive salaries commensurate with responsibilities • Interventions grounded in and responsive to community needs • Consideration of health determinants • Experience in health promotion and prevention • Long-term trusting relationships in the community (i.e., with clients) • Established network of community partners • Commitment to social justice and eliminating health disparities In the council’s twelfth report to Congress (USDHHS, 2013a) the council recommended further investment by the government in public health nursing, arguing the need based on system changes and the Affordable Care Act implementation, greater need to connect public health and care delivery with front-line public health nurses, plus the economic benefits of supporting this investment. Through the input of the NACNEP, the Division of Nursing sets policy for nursing nationally. Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention (CDC) serve as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. The mission of the CDC is to protect America from health, safety and security threats, both foreign and in the United States. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same. As such CDC increases the health security of our nation (CDC, 2014A) The CDC seeks to accomplish its mission by working with partners throughout the nation and the world in the following ways: • To provide health security • To detect and investigate health threats • To tackle the biggest health problems causing death and disability • To conduct research that will enhance prevention • To promote healthy and safe behaviors, communities, and environments • To develop leaders and train the public health workforce, including disease detectives • To develop and advocate sound public health policies • To implement prevention strategies • To promote healthy behaviors • To foster safe and healthful environments • To provide leadership and training The outbreak of summer 2014 is an example of how the CDC fulfills its mission. The Shiga toxin-producing Escherichia coli outbreak linked to raw clover sprouts affected six states and 19 people, and 44% were hospitalized. Idaho was the state that was most likely the source of the outbreak. The CDC regularly collects data about foodborne illnesses through the National Notifiable Disease Surveillance System on a weekly basis through the CDC MMWR weekly report from states. Because of the recognized increase in cases, states were asked to report aggregate numbers of cases twice a week along with foodborne-related hospitalizations and complications. The CDC implemented an investigation to track the cases and worked with state and local health departments to perform the following: • Detect the possible outbreak • Define and find cases • Generate hypotheses about the likely source • Test the hypothesis • Find the point of contamination • Control the outbreak from further spread • Decide when the outbreak is over. By August 2014, there had been about 19 cases beginning in June 2014. In 3 months there were cases in 6 states. Figure 8-1 presents a CDC map indicating cases per state (CDC, MMWR Dispatch, 2014b). The six states involved were California (1), Idaho (3), Michigan (1), Montana (2), Utah (1), and Washington (11). By August 2014 CDC determined the outbreak to be over. Although few people were involved in this outbreak, the outcome could have been deadly to the persons who ate the sprouts. While the Ebola virus of West Africa continues to spread, the CDC is monitoring the effects of the virus as part of their global monitoring system. CDC has information and training materials ready for those who may need to use the materials (CDC, 2014c). The CDC has taken an active role in the recent outbreak of measles as a result of exposure to the virus at Disneyland in California. This outbreak resulted in 140 people from seven states being infected. On 1/23/2015, the CDC issued a health advisory to all public health and health care facilities nationwide (Zipprich et al, 2015). image FIG 8-1 The number of reported Escherichia coli cases linked to multistate outbreak, by state—United States, May to August, 2014 (From Centers for Disease Control and Prevention: Epidemiology of Escherichia coli outbreak, United States, Atlanta, 2014 USDHHS.) National Institutes of Health. Founded in 1887, NIH today is one of the world’s foremost biomedical research centers, and the federal focus point for biomedical research in the United States. 174The NIH is composed of 27 separate institutes and centers. The goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. The NIH mission is to uncover new knowledge that will lead to better health for everyone. The NIH works toward that mission by conducting research in its own laboratories; supporting the research of nonfederal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad; helping in the training of research investigators; and fostering communication of medical and health sciences’ information (NIH, 2010a). In late 1985 Congress overrode a presidential veto, allowing the creation of the National Center for Nursing Research within the NIH. In 1993 the Center became one of the divisions of the NIH and was renamed the National Institute of Nursing Research (NINR). The research and research-related training activities previously supported by the Division of Nursing were transferred to the new Institute. The NINR is the focal point of the nation’s nursing research activities. It promotes the growth and quality of research in nursing and client care, provides important leadership, expands the pool of experienced nurse researchers, and serves as a point of interaction with other bases of health care research. The mission of NINR is to promote and improve the health of individuals, families, communities, and populations. NINR supports and conducts clinical and basic research and research training on health and illness across the life span. The research focus encompasses health promotion and disease prevention, quality of life, health disparities, and end of life. NINR seeks to extend nursing science by integrating the biological and behavioral sciences, using new technologies to research questions, improving research methods, and developing the scientists of the future (NINR, 2011). Agency for Healthcare Research and Quality. The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As one of 12 agencies within the USDHHS, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision making. AHRQ is committed to improving care safety and quality by developing successful partnerships and generating the knowledge and tools required for long-term improvement. The goal of AHRQ research is to promote measurable improvements in health care in America. The outcomes are gauged in terms of improved quality of life and client outcomes, lives saved, and value gained for what we spend (AHRQ, 2014a). By examining what works and what does not work in health care, the AHRQ fulfills its missions of translating research findings into better client care and providing consumers, policy makers, and other health care leaders with information needed to make critical health care decisions. In 1999, Congress, through legislation, specifically directed AHRQ to focus on measuring and improving health care quality; promoting client safety and reducing medical errors; advancing the use of information technology for coordinating client care and conducting quality and outcomes research; and seeking to eliminate disparities in health care delivery for the priority populations of low-income groups, minorities, women, children, older adults, and individuals with special health care needs. The AHRQ published protocols for care of clients with a variety of health problems. These protocols became the standards of health care delivery. The agency continues to maintain a clinical practice guidelines clearinghouse for use by clinicians and others. In addition, the AHRQ had a project called “Put Prevention into Practice” to promote the use of standardized protocols for primary care delivery for clients across the age span (see Schedule of Clinical Preventive Services in AHRQ, 2014b). Today there is a program titled The Practice-Based Research Network that rapidly develops and assesses methods 175and tools to ensure that new scientific evidence is incorporated into real-world practice settings (AHRQ, 2014c). Centers for Medicare and Medicaid Services. One of the most powerful agencies within the USDHHS is the CMS, which administers Medicare and Medicaid accounts and guided payment policy and delivery rules for services for 100 million people in 2014 (CMS, 2014). In addition to providing health insurance, CMS also performs a number of quality-focused health care or health-related activities, including regulating of laboratory testing, developing coverage policies, and improving quality of care. CMS maintains oversight of the surveying and certifying of nursing homes and continuing care providers (including home health agencies, intermediate care facilities for the developmentally disabled, and hospitals). It makes available to beneficiaries, providers, researchers, and state surveyors information about these activities and nursing home quality. Federal Non-Health Agencies Although the USDHHS has primary responsibility for federal health functions, several other departments of the executive branch carry out important health functions for the nation. Among these are the Defense, Labor, Agriculture, and Justice Departments. Department of Defense The Department of Defense delivers health care to members of the military, to their dependents and survivors, to National Guard and reserve members, and to retired members and their families. The assistant secretary of defense for health affairs administers a variety of health care plans for service personnel: TriCare Prime (a managed care arrangement) and an option for fee-for-service plans called TriCare Standard as well as TriCare Extra with many other options available. In each branch of the uniformed services, nurses of high military rank are part of the administration of these health services (U.S. Department of Defense, 2014). Department of Labor The Department of Labor houses OSHA, which imposes workplace requirements on industries. These requirements shape the functions of nurses and the types of health services provided to workers in the workplace. A record-keeping system required by OSHA greatly affects health records in the workplace. Each state has an agency similar to OSHA that also monitors and inspects industries, as well as the health services delivered to them by nurses. Needlestick injuries and other sharps-related injuries that result in occupational bloodborne pathogen exposure continue to be an important public health concern, especially to health care workers. In response to this serious situation, Congress passed the Needle Stick Safety and Prevention Act, which became law on November 6, 2000. To meet the requirements of this act, OSHA revised its Bloodborne Pathogen Standard to become effective on April 18, 2002. This act clarified the responsibility of employers to select safer needle devices as they become available and to involve employees in identifying and choosing the devices. The updated standard also required employers to maintain a log of injuries from contaminated sharps (OSHA, 2008; 2011; OSHA, 2013). Department of Agriculture The Department of Agriculture houses the Food and Nutrition Service, which oversees a variety of food assistance activities. This service collaborates with state and local government welfare agencies to provide food stamps to needy persons to increase their food purchasing power. Other programs include school breakfast and lunch programs, WIC, and grants to states for nutrition education and training. In 2013, WIC provided support for 53% of all infants born in the United States. Although these programs have been successful, the increasing use of the process of giving federal block grants to states (rather than implementing national programs) may threaten the effectiveness of these programs because of differences in how decisions are made at the state level on how to spend money on nutrition (USDA, 2013). Department of Justice Health services to federal prisoners are administered within the Department of Justice. The Federal Bureau of Prisons is responsible for the custody and care of approximately 214,000 federal offenders (Bureau of Federal Prisons, 2014). The Medical and Services Division of the Bureau of Prisons includes medical, psychiatric, dental, and health support services with community standards in a correctional environment. Health promotion is emphasized through counseling during examinations, education about effects of medications, infectious disease prevention and education, and chronic care clinics for conditions such as cardiovascular disease, diabetes, and hypertension. The Bureau also provides forensic services to the courts, including a range of evaluative mental health studies outlined in federal statutes. Health care for prisoners is highly regulated because of a series of court decisions on inmates’ rights. State and Local Health Departments Depending on funding, public commitment and interest, and access to other resources, programs offered by state and local health departments vary greatly. Many state and local health officials report that employees in public health agencies lack skills in the core sciences of public health, and that this has hindered their effectiveness. The lack of specialized education and skill is a significant barrier to population-based preventive care and the delivery of quality health care to the public. Public health workforce specialists report that the number of retirees expected in this decade will result in a major shortage of public health workers, including nurses. More often than at other levels of government, nurses at the local level provide direct services. Some nurses deliver special or selected services, such as follow-up of contacts in cases of tuberculosis or venereal disease or providing child immunization clinics. Other nurses have a more generalized practice, delivering services to families in certain geographic areas (PHF, 2010; University of Michigan Center of Excellence in Public Health Workforce Studies, 2013). At the local and state levels, coordinating health efforts between health departments and other county or city departments is essential. Gaps in community coordination are showing up in glaring ways as states and communities scramble to 176address bioterrorism preparedness since September 11, 2001, and since such natural disasters as Hurricane Katrina. The United States had 220,000 people lose their homes in 2013 due to extreme storms and tornadoes in Oklahoma and another 100,000 from flooding in Colorado. Health departments are on the front line in such occurrences (see Chapter 46). Impact of Government Health Functions and Structures on Nursing The variety and range of functions of governmental agencies have had a major impact on the practice of nursing. Funding, in particular, has shaped roles and tasks of population-centered nurses. The designation of money for specific needs, or categorical funding, has led to special and more narrowly focused nursing roles. Examples are in emergency preparedness, school nursing, and family planning. Funds assigned to antibioterrorism cannot be used to support unrelated communicable disease programs or family planning. The events of September 11, 2001, have had the public and the profession of nursing concerned about the ability of the present public health system and its workforce to deal with bioterrorism, especially outbreaks of deadly and serious communicable diseases. For example, smallpox vaccinations were stopped in 1972, but immunity lasts for only 10 years; although there have been no reported cases since the early 1970s, almost no one in the United States retains their immunity. Thus, the population is vulnerable to a smallpox outbreak, and smallpox could be used as a weapon of bioterrorism. Two laboratories in the world retain a small amount of the smallpox virus. Because of these potential threats, the U.S. government has begun to increase production of the vaccine (NIH, 2010b). Few public health professionals are knowledgeable of the symptoms, treatment, or mode of transmission of this disease. Most health professionals, including registered nurses (RNs), who currently work in the United States, have never seen a case of anthrax, smallpox, or plague—the three major biological weapons of concern in the world today. A few have now seen the effects of the Ebola virus. The USDHHS and the federal Office of Homeland Security have provided funds to address this serious threat to the people of the United States. One of the first things being done is the rebuilding of the crumbling public health infrastructures of each state to provide surveillance, intervention, and communication in the face of future bioterrorism events and natural disasters. On December 19, 2006, President George W. Bush signed the Pandemic and All-Hazards Preparedness Act (PAHPA), which was intended to improve the organization, direction, and utility of preparedness efforts. PAHPA centralizes federal responsibilities, requires state-based accountability, proposes new national surveillance methods, addresses surge capacity, and facilitates the development of vaccines and other scarce resources (Morhard and Franco, 2013). On March 13, 2013, President Barrack Obama signed the Pandemic and All-Hazards Preparedness Reauthorization Act into law. The 2013 law reauthorizes funding for public health and medical preparedness programs that enable communities to build systems to support people in need during and after disasters (USDHHS, 2013B). The LAW and Health Care The United States is a nation of laws, which are subject to the U.S. Constitution. The law is a system of privileges and processes by which people solve problems on the basis of a set of established rules. It is intended to minimize the use of force. Laws govern the relationships of individuals and organizations to other individuals and to government. After a law is established, regulations further define the course of actions to be taken by the government, organizations, or individuals in reaching an agreed-on outcome. Government and its laws are the ultimate authority in society and are designed to enforce official policy whether it is related to health, education, economics, social welfare, or any other society issue. The number and types of laws influencing health care are ever increasing. Definitions of law (Catholic University of America, 2010) include the following: • A rule established by authority, society, or custom • The body of rules governing the affairs of people, communities, states, corporations, and nations • A set of rules or customs governing a discrete field or activity (e.g., criminal law, contract law) These definitions reflect the close relationship of law to the community and to society’s customs and beliefs. The law has had a major impact on nursing practice. Although nursing emerged from individual voluntary activities, society passed laws to give formality to public health and, through legal mandates (i.e., laws), positions and functions for nurses in community settings were created. These functions in many instances carry the force of law. For example, if the nurse discovers a person with smallpox, the law directs the nurse and others in the public health community to take specific actions. In another example, in a mumps outbreak, a nurse and other health professionals are required to report mumps cases. This reporting requirement helps with locating and treating cases so cases can be treated or isolated as they occur to prevent further spreading of disease. Three types of laws in the United States have particular importance. Constitutional Law Constitutional law derives from federal and state constitutions. It provides overall guidance for selected practice situations. For example, on what basis can the state require quarantine or isolation of individuals with tuberculosis? The U.S. Constitution specifies the explicit and limited functions of the federal government. All other powers and functions are left to the individual states. The major constitutional power of the states relating to population-centered nursing practice is the state’s right to intervene in a reasonable manner to protect the health, safety, and welfare of its citizens. The state has police power to act through its public health system, but it has limits. First, it must be a “reasonable” exercise of power. Second, if the power interferes or infringes on individual rights, the state must demonstrate that there is a “compelling state interest” in exercising its power. Isolating an individual or separating someone from a community because that person has a communicable disease has been deemed an appropriate exercise of state powers. The 177state can isolate an individual even though it infringes on individual rights (such as freedom and autonomy), under the following conditions (Lee et al, 2012): • There is a compelling state interest in preventing an epidemic. • The isolation is necessary to protect the health, safety, and welfare of individuals in the community or the public as a whole. • The isolation is done in a reasonable manner. The legal and medical communities along with AIDS (acquired immunodeficiency syndrome) activists rejected (and made the case) that the social quarantine of individuals with AIDS was unnecessary. Thus, individual freedom and autonomy of the individual come before “compelling state interest” unless science warrants another conclusion (Swendiman and Elsea, 2010). Legislation and Regulation Legislation is law that comes from the legislative branches of federal, state, or local government. This is referred to as Statute Law because it becomes coded in the statutes of a government (Birkland, 2010). Much legislation has an effect on nursing. Regulations are specific statements of law related to defining or implanting individual pieces of legislation or statute law. For example, state legislatures enact laws (statutes) establishing boards of nursing and defining terms such as registered nurse and nursing practice. Every state has a board of nursing. The board may be found either in the department of licensing boards of the health department or in an administrative agency of the governor’s office. Created by legislation known as a state nurse practice act, the board of nursing is made up of nurses and consumers. The functions of this board are described in the nurse practice act of each state and generally include licensing and examination of RNs and licensed practical nurses; licensing and/or certification of advanced practice nurses; approval of schools of nursing in the state; revocation, suspension, or denying of licenses; and writing of regulations about nursing practice and education. The state boards of nursing operationalize, implement, and enforce the statutory law by writing explicit statements (rules) on what it means to be an RN, and on the nurse’s rights and responsibilities in delegating work to others and in meeting continuing education requirements. All nurses employed in community settings are subject to legislation and regulations. For example, home health care nurses employed by private agencies must deliver care according to federal Medicare or state Medicaid legislation and regulations, so the agency can be reimbursed for those services. Private and public health care services rendered by nurses are subject to many governmental regulations for quality of care, standards of documentation, and confidentiality of client records and communications. All state health departments have a public health practice reference that governs the practice of nurses and others, and state public health laws that define the essential public health services that must be offered in the state as well as the optional services that may also be offered. Judicial and Common Law Both judicial law and common law have great impact on nursing. Judicial law is based on court or jury decisions. The opinions of the courts are referred to as case law (Birkland, 2010). The court uses other types of laws to make its decisions, including previous court decisions or cases. Precedent is one principle of common law. This means that judges are bound by previous decisions unless they are convinced that the older law is no longer relevant or valid. This process is called distinguishing, and it usually involves a demonstration of how the current situation in dispute differs from the previously decided situation. Other principles of common law such as justice, fairness, respect for individual’s autonomy, and self-determination are part of a court’s rationale and the basis upon which to make a decision. Laws Specific to Nursing Practice Despite the broad nature and varied roles of nurses in practice, two legal arenas are most applicable to nurse practice situations. The first is the statutory authority for the profession and its scope of practice, and the second is professional negligence or malpractice. Scope of Practice The issue of scope of practice involves defining nursing, setting its credentials, and then distinguishing between the practices of nurses, physicians, and other health care providers. The issue is especially important to nurses in community settings, who have traditionally practiced with much autonomy. Health care practitioners are subject to the laws of the state in which they practice, and they can practice only with a license. The states’ nurse practice acts differ somewhat, but they are the most important statutory laws affecting nurses. The nurse practice act of each state accomplishes at least four functions: defining the practice of professional nursing, identifying the scope of nursing practice, setting educational qualifications and other requirements for licensure, and determining the legal titles nurses may use to identify themselves. The usual and customary practice of nursing can be determined through a variety of sources, including the following: • Content of nursing educational programs, both general and special • Experience of other practicing nurses (peers) • Statements and standards of nursing professional organizations • Policies and procedures of agencies employing nurses • Needs and interests of the community • Updated literature, including research, books, texts, and journals • Internet sites if it can be determined that the site is a professional source of information All of these sources can describe, determine, and refine the scope of practice of a professional nurse. Every nurse should know and follow closely any proposed changes in the practice acts of nursing, medicine, pharmacy, and other related 178professions. The nurse should always examine all legislation, rules, and regulations related to nursing practice. For example, a review of the pharmacy act will let the nurse know whether to question the right to dispense medications in a family planning clinic in a local health department. Defining the scope of practice forces one to clarify independent, interdependent, and dependent nursing functions. Just as practice acts vary by state, so do the evolving issues and tensions of scopes of practice among the health professions. In past years, several state legislatures (working closely with the National Council of State Boards of Nursing) embarked on a legislative effort to develop the Interstate Nurse Licensure Compact. The compact allows mutual recognition of generalist nursing licensure across state lines in the compact states. By 2014, 24 states had adopted the compact (NCSBN, 2014). Professional Negligence Professional negligence, or malpractice, is defined as an act (or a failure to act) that leads to injury of a client. To recover money damages in a malpractice action, the client must prove all of the following: 1. That the nurse owed a duty to the client or was responsible for the client’s care 2. That the duty to act the way a reasonable, prudent nurse would act in the same circumstances was not fulfilled 3. That the failure to act reasonably under the circumstances led to the alleged injuries 4. That the injuries provided the basis for a monetary claim from the nurse as compensation for the injury Reported cases involving negligence and population-centered nurses are rare. However, the following is an example: Home Nurse Fails to Properly Supervise Bottle Feeding of Child With Tracheal Tube for Oxygen—Death—$4.5 Million Verdict The plaintiff, a child, age sixteen months, suffered insufficiency of her lungs and required a continuous supply of oxygen via a tracheal tube. She required constant supervision by a home health nurse. In January 2008, during the day a bottle of formula was given by the nurse. The formula entered the tracheal tube and lungs. After several minutes the nurse observed that the child had stopped breathing and began cardiopulmonary resuscitation. The child did not survive. It was determined that the child had suffered asphyxiation due to ingestion of vomited material. The plaintiff claimed that the child had choked and gagged throughout the nurse’s resuscitation attempts and that CPR was not the correct method of resuscitating the child. The plaintiff claimed that the tracheal tube should have been cleared or changed. The case was initially brought against the defendant nurse’s employer, the home care agency, and the hospital which had provided the tracheal tube. The claims against the hospital were discontinued and the matter proceeded to trial against the home care agency. The defendant did not contest liability. According to a published account a $4.5 million verdict was returned for the child’s pain and suffering. A defense motion to set aside the verdict was pending. With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411,2013 1-800-298-6288. An integral part of all negligence actions is the question of who should be sued. When a nurse is employed and functioning within the scope of employment, the employer is responsible for the nurse’s negligent actions. This is referred to as the doctrine of respondeat superior. By directing a nurse to carry out a particular function, the employer becomes responsible for negligence, along with the individual nurse. Because employers are usually better able to pay for the injuries suffered by clients, they are sued more often than the nurses themselves, although an increasing number of judgments include the professional nurse by name as a co-defendant. In some instances, if the agency is found liable, the agency may in turn sue the nurse for negligence. At least, the nurse often loses the job. Thus, it is imperative that all nurses engaged in clinical practice carry their own professional liability insurance. Nurses may have personal immunity for particular practice areas, such as giving immunizations. In some states, the legislature has granted personal immunity to nurses employed by public agencies to cover all aspects of their practice under the legal theory of sovereign immunity (Cherry and Jacobs, 2013). Nursing students need to be aware that the same laws and rules that govern the professional nurse govern them. Students are expected to meet the same standard of care as that met by any licensed nurse practicing under the same or similar circumstances. Students are expected to be able to perform all tasks and make clinical decisions on the basis of the knowledge they have gained or been offered, according to their progress in their educational programs and along with adequate educational supervision. Legal Issues Affecting Health Care Practices Specific legal issues of nursing vary depending on the setting where care is delivered, the clinical arena, and the nurse’s functional role. The law, including legislation and judicial opinions, significantly affects each of the following areas of nursing practice. Nurses responsible for setting and implementing program priorities need to identify and monitor laws related to each special area of practice. School and Family Health Nurses employed by health departments or boards of education may deliver school and family health nursing. School health legislation establishes a minimum of services that must be provided to children in public and private schools. For example, most states require that children be immunized against certain communicable diseases before entering school. Children must 179have had a physical examination by that time, and most states require at least one physical at a later time in their schooling. Legislation also specifies when and what type of health screening will be conducted in schools (e.g., vision and hearing testing). These requirements are found in statutory laws of states. Some states are now requiring a simple dental examination in schools for the purpose of referring children to a dental health professional if needed. Statutes addressing child abuse and neglect make a large impact on nursing practice within schools and families. Most states require nurses to notify police and/or a social service agency of any situation in which they suspect a child is being abused or neglected. This is one instance in which the law mandates that a health professional breach client confidentiality to protect someone who may be in a helpless or vulnerable position. There is civil immunity for such reporting, and the nurse may be called as a witness in a court hearing of the case. Occupational health is another special area of practice that has specific legal requirements as a result of state and federal statutes. Of special concern are the state workers’ compensation statutes, which provide the legal foundation for claims of workers injured on the job. Access to records, confidentiality, and the use of standing orders are legal issues that have great practice significance to nurses employed in industries. Home Care and Hospice Home care and hospice services rendered by nurses are shaped through state statutes and have specific nursing requirements for licensure and certification. Compliance with these laws is directly linked to the method of payment for the services. For example, a service must be licensed and certified to obtain payment for services through Medicare. Federal regulations implementing Medicare/Medicaid have an enormous effect on much of nursing practice, including how nurses record details of their visits, record time spent in care activities, and document client care and the client’s status and progress. In addition, many states have passed laws requiring nurses to report elder abuse to the proper authorities, as is done with children and youth. Laws affecting home care and hospice services have focused on such issues as the right to death with dignity, rights of residents of long-term facilities and home health clients, definitions of death, and the use of living wills and advance directives. The legal and ethical dimensions of nursing practice are particularly important. Individual rights, such as the right to refuse treatment, and nursing responsibilities, such as the legal duty to render reasonable and prudent care, may appear to be in conflict in delivering home and hospice services. Much case discussion (sometimes including outside ethics consultation) may be needed to resolve such conflicts. Correctional Health Correctional health nursing practice is significantly shaped by federal and state laws and regulations and by recent Supreme Court decisions. The laws and decisions primarily relate to the type and amount of services that must be provided for incarcerated individuals. For example, physical examinations are required for all prisoners after they are sentenced. Regulations specify basic levels of care that must be provided for prisoners, and access to care during illness is a particular focus. Court decisions requiring adequate health services are based on constitutional law. If minimal services are not provided, it is a violation of a prisoner’s right to freedom from cruel and unusual punishment. Such decisions provide a framework that strongly influences the setting of nursing priorities. For example, providing care to the sick would take priority over wellness or health education classes. The Nurse’s Role in the Policy Process The number and types of laws influencing health care are increasing. Because of this, nurses need to be involved in the policy process and understand the importance of involvement of nursing to the clients they serve. For nurses to effectively care for their client populations and their communities in the complex U.S. health care system, professional advocacy for logical health policy that considers equality is essential. Professional nurses working in the community know all too well about the health care problems they and their clients encounter daily, and it is through policy and political activism that both big-picture and long-term solutions can be developed. Although the term policy may sound rather lofty, health policy is quite simply the process of turning health problems into workable action solutions. Health policy is developed on the three-legged stool of access, cost, and quality. The policy process, which is very familiar to professional nurses, includes the following: • Statement of a health care problem • Statement of policy options to address the health problem • Adoption of a particular policy option • Implementation of the policy product (e.g., a service) • Evaluation of the policy’s intended and unintended consequences in solving the original health problem Thus the policy process is very similar to the nursing process, but the focus is on the level of the larger society and the adoption strategies require political action. For most professional nurses, action in the policy arena comes most easily and naturally through participation in nursing organizations such as the ANA at the state level or the Association of Community Health Nursing Educators (ACHNE) or the Association of State and Territorial Directors of Nursing (ASTDN) at the national or state level, and in certain specialty organizations like the American Association of Specialty Nursing Organizations. Legislative Action It is often helpful to review the legislative and political processes that may have been a part of high school education. It becomes important material to remember as a professional career is embarked upon. The people within geographic jurisdictions elect their legislative representatives and senators. An important part of the legislative process is the work of the legislative staff. These 180individuals do the legwork, research, paperwork, and other activities that move policy ideas into bills and then into law. In addition to the individual legislator’s office, the congressional committee staffs are also important. They are usually experts in the content of the work of a committee, such as a health and welfare committee. Frequently, developing a working relationship with key legislative staffers can be as important to achieving a policy objective as the relationship with the policy maker (i.e., the legislator). The legislative process begins with ideas (policy options) that are developed into bills. After a bill is drafted, it is introduced to the legislature, given a number, read, and assigned to a committee. Hearings, testimony, lobbying, education, research, and informal discussions follow. If the bill is passed from the legislative committee, the entire House of Representatives hears the bill, amends it as necessary, and votes on it. A majority vote moves the bill to Senate where it is read and amended, and then a vote is taken. Figure 8-2 shows the necessary formal process of the legislative pathway. image FIG 8-2 How a bill becomes a law. (From Mason DJ, Leavitt JK, Chaffee MW: Policy and politics in nursing and health care, ed 6, St Louis, 2011, Elsevier.) Nurses can be involved in the legislative process at any point. Many professional nursing associations have legislative committees made up of volunteers, governmental relations staff professionals, and sometimes political action committees (PACs), all engaged in efforts to monitor, analyze, and shape health policy. Common methods of influencing health policy outcomes include face-to-face encounters, personal letters, mailgrams, electronic mail, telephone calls, testimony, petitions, reports, position papers, fact sheets, letters to the editor, news releases, speeches, coalition building, demonstrations, and lawsuits. Depending on the issue, any of these can be effective. Although most business, including politics and the policy agendas, are dependent upon the Internet today for instant communication and quick response, all of these methods continue to be of great importance in influencing policy agendas. For example, if a face-to-face encounter is used with a legislator or a staffer, these persons can put a “face on the policy” agenda, and the reality that the policy affects real persons is an important consideration when the legislator or staff pushes the policy agenda forward. Guidelines on communication are provided in the How To box. Tips on communication and visiting legislators and their staffs, as well as general tips on political action, are presented in Boxes 8-1, 8-2, and 8-3. Political activities in which nurses can and should be involved include a wide variety of activities such as being informed voters (a must!), participating in a political party, registering others to vote, getting out the vote, fundraising for candidates, building networks or communication links for issues (e.g., a phone tree or Internet distribution list), and participating in organizations to ensure their effective involvement in health policy and politics. 182 How To Be an Effective Communicator • Use simple communications that will be readily understood. • Choose language that clearly conveys information to individuals of diverse cultures, different ages, and different educational backgrounds. • Target oral or written communication to the issue and omit jargon unique to medicine and nursing. • State your expertise on the issue first. • Briefly describe your education and experience. • Identify the relevance of the issue beyond nursing. • Provide information regarding the impact of the issue on the legislator’s constituents. • Present accurate, credible data. • Do not oversell or give inaccurate information about the problem. • Present information in an organized, thorough, concise form that is based on factual data (when available). • Give examples. Box 8-1 Tips for Visits with Legislators • Face-to-face visits are viewed as the most effective. • Call ahead and ask how much time the staff or legislator is able to give you. • When you arrive, ask if the appointment time is the same or if a scheduled vote on the House/Senate floor is going to need the legislator’s attention. • Engage in small talk at the beginning of the conversation only if the staff or legislator has time. • Structure time so that the issue can be briefly presented. The visit will probably be 15 minutes or less. • Allow an opportunity for the staff or Congress member to seek clarity or ask questions. • Offer to provide additional information or find answers to questions asked. • Do not assume that the legislator or the legislator’s staff is well informed on the issue. • Leave a one- or two-page fact sheet on the issue. • Numbers count. If the views you express are shared by a local nurses’ organization or by nurses employed at a health care facility, let the legislator know. • Invite Congress members and their staffs to conferences or meetings of nurses’ organizations, or to tour nursing facilities to meet others interested in the same policy issues. • If appropriate, invite the media and let the legislator know. • Follow up with a letter of thanks to both the legislator and the staffer. Modified from Mason D et al: Policy and politics in government, ed 5,St Louis, 2007, Elsevier. Box 8-2 Tips for Written Communication with Legislators • Communicate in writing to express opinions. • Identify yourself as a nurse. • Acknowledge the Congress member’s work as positive or negative, but be courteous. • Follow up on meetings or phone calls with a letter or e-mail. • Share knowledge about a particular problem. • Recommend policy solutions so the legislator or staff will know why you are writing. • The letter should be typed, a maximum of two pages, and focused on one or two issues at most. • The purpose of the letter should be stated at the beginning. • Present clear and compelling rationales for your concern or position on an issue. • If the purpose of the letter is to express disappointment regarding a stance on an issue or a vote that has been cast, the letter should be as positive as possible. • Write letters thanking a Congress member for taking a particular position on an issue. • A letter to the editor of the local newspaper or a nursing newsletter praising a legislator’s position (with a copy forwarded to the legislator) is welcome publicity, especially during an election year. • If you visited with the legislator or a staffer, review the major points covered in person and answer any questions that were raised during conversation. • Have personal business cards and include them with letters. • Address written correspondence as follows (the same general format applies to state and local officials): U.S. Senator U.S. Representative Honorable Jane Doe Honorable Jane Doe United States Senate House of Representatives Washington, DC 20510 Washington, DC 20515 Dear Senator Doe: Dear Representative Doe: Modified from Mason D et al: Policy and politics in government, ed 5,St Louis, 2007, Elsevier. Box 8-3 Tips for Action • Become informed. • Become acquainted with elected officials. • Become involved in the state nurses’ association. • Build communication and leadership skills. • Increase your knowledge about a range of professional issues. • Expand and strengthen your professional network. • Build relationships within the profession and with representatives of public and private sector organizations with an interest in health care. • Be aware of what is taking place in health care beyond the environment and the practice in which you work. • Communicate with legislators regularly and share expertise and perspective on issues related to health care and nursing. • Offer your expertise to assist in developing new legislation, modifying existing legislation or regulations. • Identify yourself as a nurse with associated education and expertise. • Let people know that nurses are capable of functioning in many different roles and making substantial contributions. • Be confident. • Do not burn bridges. • Be friendly. • Lend a hand to other nurses. It benefits all of us. • Find an experienced mentor to work with you if you are new to the policy arena. • Volunteer, seek appointments, or participate in elections in campaigns. • Explore opportunities for involvement through internships, fellowships, and volunteer work at all levels (local, state, and national). Modified from Mason D, Keavitt JK, Chaffee MW: Policy and politics ingovernment, ed 5, St Louis, 2007, Elsevier. The direct reimbursement of advanced practice nurses (APNs) in the Medicare program is one example of how nurses can use their influence. The inclusion of amendments to Medicare that authorized APN reimbursement regardless of specialty or client location in the Balanced Budget Act of 1997 required the sustained efforts of the ANA and other national nursing organizations over a long period (Nursing World, 2000; USDHHS, CMS, 2011. During that time, individual nurses provided testimony to Congress and to MEDPAC (the physicians’ political action committee) on the importance of direct reimbursement to APNs. Many APNs worked closely and vigorously with their congressional representatives to lobby for this Medicare amendment. Even more wrote letters and provided position papers and fact sheets to help legislators understand the value of APNs. Although the process took more than 10 years to achieve fully, APN reimbursement in Medicare became a reality. Both the nursing profession and Medicare beneficiaries will benefit from the enhanced access of Medicare clients to APNs. The ANA was likewise a strong supporter for the Patient Safety Act of 1997 (ANA, 1997). This law requires health care agencies to make public some information on nurse staff levels, staff mix, and outcomes, and it requires the USDHHS to review and approve all health care acquisitions and mergers. All of these requirements are to determine any long-term effect on the health and safety of clients, communities, and staff. On the state legislative level, all 50 states have passed title protection for APNs; this was achieved by individual nurses, state nurses associations, and various nursing specialty groups participating in the legislative process with the 50 state legislators. Title protection means that only certain nurses who meet state criteria can call themselves advanced practice nurses. Regulatory Action The regulatory process, although it may not be as visible a process as legislation, can also be used to shape laws and dramatically affect health policy. This process should be on the radar screen of professional nurses who wish to successfully participate in policy activity. At each level of government, the executive branch can and, in most cases, must prepare regulations for implementing policy for new laws and new programs. These regulations are detailed, and they establish, fix, and control standards and criteria for carrying out certain laws. Figure 8-3 shows the steps in the typical process of writing regulations. When the legislature passes a law and delegates its oversight to an agency, it gives that agency the power to make regulations. Because regulations flow from legislation, they have the force of law. image FIG 8-3 The process of writing regulations. The Process of Regulation After a law is passed, the appropriate executive department begins the process of regulation by studying the topic or issue. Advisory groups or special task forces are sometimes formed to provide the content for the regulations. Nurses can influence these regulations by writing letters to the regulatory agency in charge or by speaking at open public hearings. Many letters are now accepted by Internet. After rewriting, the proposed regulations are put into final draft form and printed in the legally required publication (e.g., at the federal level, the Federal Register). Similar registers exist in most states, where regulations from state executive 183departments, including state health departments, are published. Public comment is called for in written form or oral presentation within a given period. Revisions made to proposed regulations are based on public comment and public hearing. Depending on the amount and content of the public reaction, final regulations are prepared or more study of the area and issues is conducted. Final published regulations carry the force of law. When regulations become effective, health care practice is changed to conform to the new regulations. Monitoring administrative regulations is essential for the professional nurse, who can influence regulations by attending the hearings, providing comments, testifying, and engaging in lobbying aimed at individuals involved in the writing of the regulations. Concrete written suggestions for revision submitted to these individuals are frequently persuasive and must be acknowledged by government in publishing the final rules. An excellent example of how nurses must continue to influence health policy outcomes, even after positive legislation has passed, occurred after the passage of the Balanced Budget Act of 1997 (PL 105-33, 1997). The HCFA began to implement the BBA ’97 through the publication of draft regulations seeking to define APN practice and Medicare reimbursement. The nursing community responded vigorously with negative opinions about the initial restrictive definitions and requirement. Their reactions were effective and reshaped the final regulations to recognize the state definitions for APN practice autonomy. Final regulations, published in a Code of Regulations (both federal and state), usually lead to changes in practice. For example, Medicare regulations setting standards for nursing homes and home health are incorporated into these agencies’ manuals. In the case of APN reimbursement, some Medicare fiscal intermediaries have had difficulty in recognizing APNs as appropriate providers, but professional nursing organization advocates have forcefully addressed these implementation barriers. Nursing Advocacy Advocacy begins with the art of influencing others (politics) to adopt a specific course of action (policy) to solve a societal problem. This is accomplished by building relationships with the appropriate policy makers—the individuals or groups that determine a specific course of action to be followed by a government or institution to achieve a desired end (policy outcome). Relationships for effective advocacy can be built in a number of ways. In January 2006, Medicare Part D—the prescription drug benefits policy—became effective. Public health professionals need to continue to assist many vulnerable persons to understand the value of enrolling in Part D, to educate them on how to use the benefits, and to ensure that the populations who are 184“dually” enrolled in both Medicare and Medicaid are registered. Coordinating efforts between civic, religious, and health care agencies to provide health education is a necessity. A letter or visit to the district, state, or national office of a legislator to discuss a particular policy or health care issue can be interesting, educational, and effective. Contributions of money, labor, expertise, or influence may also be welcomed by the policy makers involved in setting a course of action to obtain a desired health outcome for an individual, a family, a group, a community, or society (health policy). In addition, one may develop a grassroots network of community and professional friends with a mutual interest in health policy advocacy. The network may be able to promote health policy initiatives for the community. During the Obama presidential campaign, many advocacy networks were established via the Internet and monies were solicited using this process. Many special-interest groups in health care have the potential, desire, and resources to influence the health policy process. A tremendous advantage that nursing has in advocating for issues and in influencing policy makers is the force of its numbers, since nursing is the largest of the health professions. However, nursing must organize its numbers in such a way that each nurse joins with others to speak with one voice. The greatest effect will be had when all nurses make similar demands for policy outcomes. During 2002, the nursing profession spoke clearly, distinctly, and together on a serious problem for the health arena and for the profession: the nursing shortage. Health care facilities and employers were having ever-increasing difficulty finding experienced nurses to employ. In addition, the need for RNs was predicted to balloon in the next 20 years because of the aging of the U.S. population, technological advances, and economic factors. Demand for RNs was anticipated to increase by 22% by the year 2008. This increased demand for professional nurses, coupled with the expected retirement of a rapidly aging nursing workforce, placed a tremendous stress on the health care system. The workforce shortage resulted from a complex set of factors such as fewer young people entering the profession, declining nursing school enrollment, the aging of the current nurse workforce, and uncomfortable working conditions in which nurses felt pressured to “do more with less.” On December 4, 2009, the BLS (2009) reported that the health care sector of the economy was continuing to grow, despite significant job losses in nearly all major industries. During the same time period a shortage of registered nurses was projected to spread across the country between 2009 and 2030 (AJMQ, 2012). The American Association of Colleges of Nursing (AACN) remained concerned about the shortage of RNs and worked with schools, policy makers, other organizations, and the media to bring attention to this health care crisis. AACN worked to enact legislation, identify strategies, and form collaborations to address the nursing shortage (AACN, 2010). However, in June 2011 it was reported that employers and staffing agencies posted more than 121,000 new job ads for Registered Nurses in May, up 46% from May 2010 (AACN, 2014). Advocacy by expert and committed health professionals can bring about positive change for the profession, the community, and the clients that nurses serve. Keeping up to date on issues within government, professional organizations, law, and public policy is vitally important. Informed activism directed toward a professional role, image, and value for professional nurses, and toward a health care system in the United States that provides high quality and affordable universal access to health care, should be a life-long commitment for all professional nurses. image Linking Content to Practice An example of how the policy process works follows, involving a nursing organization and individual members. Whether you are a member of a group as described below, or working on your own to influence health policy, the steps described here apply. Over a 15-month time frame, the American Nurses Association was involved in advocating for health care reform. During the presidential campaign, candidates were educated about the nursing profession and ANA’s Agenda for Health System Reform. ANA and its members participated in national media interviews and local media events. The message was that the association and its members believed that health care is a basic right. ANA collaborated with the nursing community to outline the profession’s priorities as proposals were developed in Congress. Testimony was given before three key congressional committees. ANA representatives met with White House and congressional health care reform staff, and took part in two presidential press conferences at the White House. As reported by ANA, thousands of nurses joined ANA’s health care reform team, sending letters to representatives of Congress, sharing their stories, and meeting with members of Congress. They also participated in rallies and events. For more information on ANA’s health care reform work, visit http://www.rnaction.org/toolkit. image Focus on Quality and Safety Education for Nurses • Targeted competency: Quality improvement • Knowledge: Describe strategies for learning about the outcomes of care in the public setting • Skills: Seek information about outcomes of care for populations served in care settings • Attitudes: Appreciate that continuous quality improvement is an essential part of the daily work of all professionals QI Question The Quad Council competency of policy development and program planning skills indicates that the beginning PHN collects information that will inform policy decisions. Also the PHN describes the legislative policy development process and identifies outcomes of current health policy relevant to PHN practice. The 2014 outbreak of the Ebola virus in the United States brought quick recognition that there was a need for improvement in policies related to infectious disease control. What were the indicators that the infection control policies in place were not sufficient to prevent the spread of disease? Describe the CQI data collection processes that determined the need for policy change. What role did nurses and organized nursing play in improving the infection control policy and guidelines nationally? What has been the outcome of the new policy and how were populations affected both locally and nationally? 185 Practice Application Larry was in his final rotation in the Bachelor of Science in nursing program at State University. He was anxious to complete his final nursing course, because upon graduation he would begin a position as a staff nurse specializing in school health at the local health department. His wife was expecting their first child, and she had been receiving prenatal care at the health department. Larry was aware that a few years ago the federal government had, by law, provided block grants to states for primary care, maternal–child health programs, and other health care needs of states. He had read the Federal Register and knew that the regulations for these grants had been written through USDHHS departments. He was aware that these regulations did not require states to fund specific programs. Larry read in the local newspaper that the health department was closing its prenatal clinic at the end of the month. When his state had received its block grant, it decided to spend the money for programs other than prenatal care. Larry found that a 3-year study in his own state showed improved pregnancy outcomes as a result of prenatal care. The results were further improved when the care was delivered by population-centered nurses. After Larry’s daughter was born, he read in the Federal Register that states could apply for federal stimulus funds and receive a grant for home visiting services to support mothers and new babies. Larry was concerned that, as a student, he would have little influence on how such grant dollars would be spent. However, he decided to call his classmates together to plan a course of action. What would such an action plan include? Answers can be found on the Evolve site. Key Points • The legal basis for most congressional action in health care can be found in Article I, Section 8, of the U.S. Constitution. • The five major health care functions of the federal government are direct service, financing, information, policy setting, and public protection. • The goal of the World Health Organization is the attainment by all people of the highest possible level of health. • Many federal agencies are involved in government health care functions. The agency most directly involved with the health and welfare of Americans is the U.S. Department of Health and Human Services (USDHHS). • Most state and local governments have activities that affect nursing practice. • The variety and range of functions of governmental agencies have had a major impact on nursing. Funding, in particular, has shaped the role and tasks of nurses. • The private sector (of which nurses are a part) can influence legislation in many ways, especially through the process of writing regulations. • The number and types of laws influencing health care are increasing. Because of this, involvement in the political process is important to nurses. • Professional negligence and the scope of practice are two legal aspects particularly relevant to nursing practice. • Nurses must consider the legal implications of their own practice in each clinical encounter. • The federal and most state governments are composed of three branches: the executive, the legislative, and the judicial. • Each branch of government plays a significant role in health policy. • The U.S. Public Health Service was created in 1798. • The first national health insurance legislation was challenged in the Supreme Court in 1937. • Health: United States (NCHS, 2013) is an important source of data about the nation’s health care problems. • In 1921 the Sheppard-Towner Act was passed, and it had an important influence on child health programs and population-centered nursing practice. • The Division of Nursing, the National Institute of Nursing Research, and the Agency for Healthcare Policy and Research are governmental agencies important to nursing. • Nurses, through state and local health departments, function as consultants, policy advocates, population level and direct care providers, researchers, teachers, supervisors, and program managers. • The state governments are responsible for regulating nursing practice within the state. • Federal and state social welfare programs have been developed to provide monetary benefits to the poor, older adults, the disabled, and the unemployed. • Social welfare programs affect nursing practice. These programs improve the quality of life for special populations, thus making the nurse’s job easier in assisting the client with health needs. • The nurse’s scope of practice is defined by legislation and by standards of practice within a specialty. 186 Clinical Decision—Making Activities 1. Conduct an interview with a local health officer. Ask for information from a 10-year period. Try to see trends in population size, health needs and corresponding roles, and activities of government that were implemented to meet these changes. What were some of the problems you identified? 2. Examine a current health department budget and compare it with a budget from previous years. Has there been any impact on health care because of changes in government spending (especially before and after the passing of the Patient Protection and Affordable Care Act)? Give an example. 3. Locate your state register or other documents, such as newspapers, that publish proposed regulations. Select one set of proposed regulations and critique them. Submit your opinion in writing as public comment, or attend the hearing and testify on the regulations. Be sure to submit something in writing. Evaluate your participation by stating what you learned and whether the proposed regulations were changed in your favor. 4. Find and review your state nurse practice act and define your scope of practice. Give examples of your practice boundaries. 5. Contact your local public health agency to discuss the state’s official powers in regulating epidemics, such as the measles outbreak in Orange County, California, (HCA, 2014) and anthrax exposures related to bioterrorism. 6. Explore the state’s right to protect the health, safety, and welfare of its citizens. 7. Ask about the conflict between the state’s rights and individual rights and how such issues are resolved. 8. 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