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Running head: CULTURAL COMPETENCY IN PERIPARTUM NURSING 1

April Beresford

Cultural Competency in Peripartum Nursing

Ferris State University


Abstract

Culture plays a vital role in decision-making processes and strongly influences the nurse-patient

relationship. Culture shapes the beliefs, values, perceptions and motivations of both nurses and

patients. Cultural competency is a term that describes the ability of the nurse to apply

knowledge and comprehension of a patient’s individual culture to nursing care in a way that

enhances both the safety and the efficacy of nursing care. In the peripartum setting, effective

cultural competency can take many forms. By using examples of cultural differences found in

separate cultures, this paper seeks to outline how possessing cultural knowledge can empower

nurses to make patient care a safer and more effective practice.

Key words: childbirth, culture, cultural, nursing, theory, peripartum


Cultural Competency in Peripartum Nursing

There are few realms, if any, where knowledge of a patient’s culture has little effect on

the nursing care provided. Often this is overlooked. When we form the nurse-patient

relationship, we must take into account the individuality of the patient, and understand what the

implications are of his or her values, traditions, perceptions, and beliefs on the care we are

providing.

Culture is what brings meaning to our lives. It is a shared community of people who

think and act like we do, and we learn and share behaviors and ideas. Different cultures can be

defined by religious groups, geographical location, family or tribe groups, poverty or other

resource allocation, job roles or gender, to name just a few. Cultural anthropologists spend their

entire careers in study of culture, and how it shapes individuals and populations. Culture is

learned, lived, and shared from one generation to the next. Culture is becoming a prominent

focus in nursing as relationship-based nursing models are being taught in hospitals and care

systems in order to boost not only patient satisfaction, but to provide more meaningful and

effective care.

Root Cause Analysis

A root cause analysis is a method of mapping out an issue (AHRQ, 2013). In this

instance, the issue, likely causes and solutions are simple and pretty straightforward, and explain

why cultural competency is so meaningful in the nursing profession.

Issue

Culturally sensitive or insensitive interactions between patients and nursing staff can

impact patient satisfaction and patient outcomes. Cultural competency is not an equally shared

skill among nursing staff.


Likely causes

Nurses may not fully understand the impact of culture in a healthcare setting, and may

not have a working knowledge of the culture differences between themselves and their patients

(Larsson, Sahlsten, Segesten & Plos, 2011).

Solutions

Nurses can research some of the major differences in culture in regards to their specialty,

ask basic questions when establishing rapport with patients to understand and validate the

patient’s values and expectations. By examining his or her own cultural identity and prejudices,

(s)he will be more likely to understand and respect different cultures (Larsson, Sahlsten,

Segesten & Plos, 2011).

American Nurses Association

The American Nurses Association (ANA) standards that this seminar and these learning

objectives will relate to are outcome identification, planning, and collaboration. In developing

culturally directed, quality care, the nurse identifies expected outcomes and plans individualized

care for the consumer, prescribes strategies and interventions to attain those outcomes, and

collaborates with the patient and family as well as the other members involved in the healthcare

team.

Outcome Identification

The registered nurse identifies expected outcomes for and plans individualized care for the

consumer or the situation. In the culturally competent peripartum setting, the registered nurse

will assess the cultural expectations and values related to the birthing experience and merge these

expected outcomes with current evidence based best practices.

Planning


The registered nurse develops a plan of care that prescribes strategies and interventions to

attain expected outcomes. The culturally competent nurse works with the patient to develop a

plan of care that validates the patient as part of a diverse cultural community. When appropriate,

planning will include family members who are identified by the patient as necessary support

persons.

Collaboration

The registered nurse collaborates with the health care consumer, family and others in the

conduct of nursing practice. The nurse keeps open lines of communication between the patient

and the physician, as well as any other care staff or family members that may become involved

during the childbirthing process.

Culturally Related Theories

Culture defines illness, health, and the search from distress or disease. How does a family

or a tribe or a region of people attempt to handle illness and wellness? How is that illness

percieved? Who delivers healthcare, and in what type of role? Knowing what the ‘normal’

expectations are for a patient who does not think and act the same as we do gives us valuable

insight as to how we can tailor our care and our teaching styles to meet the needs of clients from

a wide variety of backgrounds. These are questions asked by nurses and non-medical

professionals as we seek to improve relationships, and some very helpful theories have been

developed.

Madeleine Leininger

Madeleine Leininger developed strong transcultural nursing theories, the best known being

her Culture Care Diversity and Universality (1991). Her theory is based on cultural competency

in the nurse-patient relationship, and how this relates to better outcomes for the patient. Cultural


competence is an important component of nursing. Culture defines illness, health, and the search

from distress or disease. The use of traditional or alternate models of healthcare is widely varied

and may conflict with Western medicine. For a nurse to successfully provide care for a client of

a different culture or ethnic background, effective intercultural communication must take place

(Leininger & MacFarland, 2005).

Jean Watson

As was also reflected previously in Leininger’s theory, cultural competency can have a

positive effect on the type of relationship we build with our patients. Jean Watson’s Theory of

Human Caring (1979) also applies, and describes the patient as a whole: composed of the mind,

the body, and the spirit, and if we fail to address one of those three facets we are failing to fulfill

our capacity as nurses.

Kevin MacDonald

Culture is evolutionary over the span of generations, and thus culturally competent care

will evolve as well. This belief is supported in Kevin MacDonald’s evolution of culture, in which

he explores the adaptations of culture from a psychological perspective. Because culture

influences everything that we do, from how we construct our family dynamics, to the foods we

eat, to our health-seeking behaviors, to how we interact with the natural world around us, it is

important to note that nursing is not the only profession that touches on culture (MacDonald,

2009).

Peripartum Nursing as a Cultural Experience

Childbirth is one of the most common biological experiences of the human race. Chances

are good that most adults have heard a few birthing stories from others, and possibly have one of

their own. It is an area of nursing that can have so many patient preferences, and patients often


present to the hospital in a state of health, rather than illness. But the act of childbirth, even in

absence of complications, is one that is perceived differently from patient to patient, and from

family to family. This is largely based on the cultural knowledge of childbirth that the patient

and her family share. As an example, formal childbirthing classes are quite common throughout

the United States. Patients later present to the hospital to deliver after being given the same

information in class about childbirth, and yet preferences and perceptions, fears and desires vary

from one patient to the next. Some of the common distinguishing factors in the way that women

view the perinatal and postpartum periods are based on the view of the pregnancy as either a

healthy state or a vulnerable period, the perception of pain during contractions and the delivery

of the infant, the participation of (or absence of) family members and their expected roles, and

the religious implications that one may or may not attribute to reproduction.

In many parts of the world, hospitals are only utilized for complicated deliveries.

Midwives around the world are sometimes trained professionally, and are sometimes just close

relatives with no formal training. The perceptions of some foreigners or those of cultures who

do not routinely deliver at hospitals are that western-type hospitals have a higher likelihood for

imposing epidurals or cesarean deliveries and for disregarding some of the cultural practices that

should surround the birthing process. This author believes that the current trend of our own

United States citizens to perform more home deliveries now than a decade ago is a reflection of

this. So how do we amend this?

Relationship Based Care

The application of the relationship-based care model, referred to as RBC, is one way to

effectively integrate patient culture into the peripartum nursing areas. At Spectrum Health,

where this author saw firsthand how this model was applied, patients were very receptive to the


changes. As nursing is both an art and a science, the art becomes the balance between safe

obstetrical practices and the individual wants and needs of the family. And statistics have shown

us that delivery of an infant in an acute care setting, such as a hospital, has a significant decrease

in infant and maternal morbidity and mortality. So the bottom line is that if we can deliver

quality, safe healthcare to the patient, in a way that is meaningful and validating to the patient

and her family, delivery in a hospital setting will be a more preferable choice than the

alternative: delivering at home.

Nurses as Champions of Change

The nurse-patient role is very different from that of the physician, and nurses ultimately

serve as an advocate for the patient, as well as educator, comforter, and coach. The ability of

nurses to develop true cultural competency first starts with his or her own reflection on personal

culture and a desire to understand how other cultures are both similar and different than her own.

Basic knowledge of some of the more prominent cultures in the area is important, but cannot

replace a non-judgmental attitude in the presence of cultural differences (Spector, 2009).

Hospital culture also comes into play. Have you ever heard the phrase “This is how we do it

here”? Having a questioning attitude is Okay. Is the reason behind it a hospital policy based on

patient safety and research-based nursing practice, of a simple convenience or preference on

behalf of the hospital staff? Is there a way to alter certain practices so that safety is maintained

while fulfilling a need for the patient?

Knowing how to ask questions and when to ask questions is more important than

remembering all of the individual facets of each defined culture. Within most broad cultures are

several subcultures. For example, if you are Caucasian, you are still different than other

Caucasians because you are part of a nursing culture, may be part of a religious culture, and


belong to a regional culture as well. If you are a nurse, you participate in a different culture than

those who are not part of the healthcare system. Understanding some of the general preferences

of some of the prominent cultures in your area may give you an advantage but should never take

precedence over asking the questions and forming a trusting relationship with each patient.

Although these questions are framed for peripartum nursing, they can easily be adapted for other

specialties.

“How can I be helpful to you to keep your traditions while in the hospital?”

“Who will be present for the birth?”

“What are your goals for a healthy delivery?”

“What are you afraid of?”

“What would an ideal birth look like?”

Grand Rapids, Michigan

Here in Grand Rapids, Michigan, we have quite a melting pot of different cultures. Part of

this is due to a handful of refugee groups in our area, and part of it is due to a strong

demographic presence of a variety of socioeconomic and religious cultures. According to the

year 2000 US census, Grand Rapids leads the state of Michigan in the percentage of foreign-born

people residing in the area with 10.5%, compared to a state of Michigan percentage of 5.3 who

reported being born in another country (US Census, 2010).

Somali (Bantu) Culture

Somalia is a country in East Africa, on the coastline of the Indian Ocean. Many Somalians

immigrated to the USA because of civil war and genocide and a large population settled in the

greater Grand Rapids area in response to refugee efforts by local groups. Many of the people of

Somalia are part of separate tribes, each with their own subcultures. As a general overview, I


will cover Somalian Bantu customs, as the Bantu are a prominent subculture. Many Bantu

practice Islam, and many of the traditions are based on these teachings. As a general preference,

large families are encouraged. Childbirth is not viewed as an illness but is seen as rite of passage

by women. Often times a woman is more highly esteemed by her peers if she has birthed many

children, as this is a sign of wealth and favor from Allah. Because of this, there may be several

family members who wish to be present for the birth, and any medical procedure or birth

complication that are perceived to potentially cause infertility are not well accepted. The general

opinion of cesarean delivery is that it results in infertility or loss of function within the family or

tribe, and because of this many Bantu also associate cesarean deliveries with maternal or fetal

death. Most Bantu women will avoid cesarean delivery, even going so far as to fast prior to

delivery in hopes of delivering a small infant. The risks of this are malnutrition, a small for

gestational age infant, and oligiohydraminios (low amniotic fluid). Consumption of herbs or flax

seed mixed with water and made into a porridge are thought to encourage strong contractions

and vaginal stretching to allow passage of the infant. Pain is sometimes controlled using heated

needles and prayer, and epidural use in in the hospital setting is not common. Decision-making

is not addressed by just the patient but the consensus of her family. Men are typically not

present during delivery, and midwifery is very common for home births (Hill, Hunt & Hyrkas,

2012; Narruhn, 2008).

Female circumcision, which involves blunt removal of the clitoris, most of the labia

minora and a portion of the labia majora, is practiced by up to 98% of Bantu. Negative opinions

by Western practitioners is often a source of high anxiety and a barrier to Somali women seeking

formal healthcare in our society. Because of the scarring involved, a band of tight skin often

impedes fetal expulsion in third stage labor. As a result, anterior episiotomy is often necessary to


avoid serious perineal tears. Many births means many episiotomies, and most Bantu prefer to

have perineal repair in such a way as to restore the small introital vaginal opening in between

births. The postpartum period is referred to by the Somali word ‘afantanbah’, and lasts for about

40 days. During this period there is large family member involvement, women will typically

breastfeed but other family members will feed her and take care of the other children as she

convalesces in bed. Mother and baby remain at home, often wearing herb-infused bracelets or

garlic to ward off the ‘evil eye’. Some families will choose not to name their child formally until

this period is over and the risk has been decreased, and will refer to the new infant by nicknames

until then. This is not an extremely common practice, but is still utilized in some subcultures.

Fetal loss is an unfortunate outcome of some pregnancies, and Somali Bantu are not excluded.

The loss of a pregnancy or the loss of an infant or child is seen as the will of Allah (Hill, Hunt &

Hyrkas, 2012; Narruhn, 2008).

This basic knowledge of the Somalian Bantu culture can positively impact nursing care.

Each situation will differ, but there are some basic considerations. Be prepared for large

families, including many female relatives. Do not assume that if the father of the baby is not

present that the patient is in a bad relationship. Be prepared to research herbal remedies if the

patient brings herbs or traditional medicines to the hospital to assist with labor. While Western

medicine is highly research based, there are some situations where home remedies really work.

Even if there is no physiological merit to their aid in the laboring process, do not underestimate

the impact of comfort and familiarity. Asking questions such as “when was your last meal?” or

“Have you had a change in your food intake in the past few weeks?” is appropriate, and explain

the rationale for your inquiry. Preparing for a SGA or oligohydraminos birth may mean an

alteration in APGAR scoring or require frequent blood glucose checks. Have a basic


understanding of the unique physiological differences in women who have undergone female

circumcision, including the possibility of an anterior rather than posterior episiotomy. Reflect on

your own opinions but be prepared to leave those emotions out of your care of the patient. The

postpartum period is a time of intense maternal bonding, but do not undervalue the participation

of supportive and closely connected family members, whom are going to be a distinct part of this

child’s upbringing into that culture.

Orthodox Judiasm

Judiasm is a monotheistic religion, and with 12 to 14 million Jews in the world, the

largest populations are concentrated in Israel and the United States. The Jewish culture has

many laws regarding how they regard the people and things around them, which can aid in a

better defined expectation of the birthing process. Niddah is the law that defines how a man and

his wife handle bleeding situations, including childbirth. It prevents physical contact between a

husband and his wife when the wife is bleeding from the uterus, and extends for seven days after

the bleeding stops. This includes childbirth, surgery, and menses. Anita Diamant, author of the

fictional book called The Red Tent (1997), describes niddah not as a time of separation but as a

time of connection between women. The red tent was historically a place where women would

go during menses to isolate themselves away from the men, but it became a time of joyful

bonding between those women, and they looked forward to it. Niddah, thus, is not received

negatively buy those who practice it.

Kosher meal preparation prohibits combining meat and dairy together, even if combined

in the intestinal tract. Kosher foods are plentiful in Israel but are harder to come by in the United

States, and kosher foods must never come into contact with non-kosher foods. While most

Israeli hospitals have separate kitchens to prepare these meals, most acute care facilities in the


USA do not. As a result, many Kosher meals will come in double wrapping to prevent any form

of contamination. Prior to opening the inner package, Jewish custom advocates for a washing of

the hands with a cup in addition to washing hands under running water (Noble, Rom, Newsome-

Wicks, Englehardt, & Woloski-Wruble, 2009).

The Sabbath is anticipated and strictly observed by Orthodox Jews, celebrated weekly

from sundown on Friday through one hour past sundown on Saturday. During this time, Jews

are absolutely prevented from doing any work, or anything perceived as causing work. Although

it is a happy time with family involvement, it drastically alters how Jewish followers can handle

certain situations. The concept of work is not just punching a time card, but also includes

writing, riding in a car, operating a microwave or other electronic appliance, using telephones or

preparing food. This author had a patient once who came to the hospital by ambulance on a

Friday evening, and her family walked for four hours to be by her side, in the middle of the

night. When they arrived at the hospital, they were prevented from coming inside because the

automatic door opener kept swinging open as they approached. They had to wait outside until

another guest left, and while the door was still open they were able to enter. Although they did

use the telephone to call 9-1-1 and the patient was allowed to be transported to the hospital by

ambulance and receive care by the paramedics, they tried diligently to reduce the number of

times that the Sabbath laws were broken. The woman that came to the hospital had a wig on that

was exactly the same color and length of her own hair, but because it is considered to be indecent

to bare such a personal trait, she had a wig on. Most women will also wear dresses that are long

and cover the elbows. Bare arms are considered very inappropriate. Men wear a specific

hairstyle and a small cap on the crown of the head, mostly in dark colors. Men who are

conversing with a woman who is not a relative will often look away, and a married man may


look directly at his wife while speaking about her to a care practitioner. Men may also refuse to

shake hands with a woman as a sign of respect to his married wife. Personal affection is often

disguised while in public (Noble, Rom, Newsome-Wicks, Englehardt, & Woloski-Wruble,

2009).

The best thing healthcare professionals can do for any culturally challenging situation is

to provide a non-judgemental environment (Spector, 2009). Using knowledge of some of the

basic practices of that culture can assist in providing a comfortable environment and validating

birth experience for the patient and family. For Orthodox Jews, a cup placed near the sink, or

bringing a basin of water and a cup to a laboring or postpartum mother is an appropriate way to

support customs regarding sanitation. If the laboring mother needs to be moved into, say, the

operating room or into a postpartum area, assure that her head is properly covered and her hair is

contained, and allow her the option to cover bare arms. Unless there is a viable reason that you

need to speak to a praying person, wait until a more appropriate time. Avoid looking directly at

a husband, and a good way to do this is to look at the patient when speaking to him. Ask the

husband how he would prefer to participate in the birthing process, and be prepared for either

scenario. Jewish women expect this type of separation during the birthing process, and most will

deny a feeling of being disregarded or not cared for by their spouses as these circumstances are

expected.

African American

The structure and culture of African American families can sometimes be slightly

different than other American family models. The tendency is for a family to be matriarchal, or

headed by a female figure who is often the grandmother. Participation by father figures is often

below that of other cultures, and as a result the socioeconomic status of many families forces


them to join multigenerational homes to share resources. African American families often

identify themselves as being Christian, although there are some who are Islamic or have other

affiliations. The tendency to use vocalizations such as shouting or moaning during labor and

during childbirth is not uncommon (Moore, 2004). Most females are accustomed to childbirth in

a hospital setting. While some African American women choose to breastfeed, others utilize

bottle feeing quite successfully. Although there are some African Americans who are socially

and financially disadvantaged, access to a variety of healthcare options is provided through

government assistance.

Caucasian American

It’s hard to describe the Caucasian experience, as Caucasian Americans compose the

majority of the population in the United States. Often times this means that their culture and

expectations are used as a comparative ‘normal’. Like most other Americans, there is a wide

variety of healthcare options available even to those that are socially or financially

disadvantaged. In spite of this, more Caucasian Americans are choosing to experience a home

birth. Some of the reasons cited in a 2010 study were a preference toward a low-intervention

birth in a familiar setting. Lack of transportation in rural settings was also mentioned, but was

comparatively small in number compared to maternal preference (MacDorman, Menacker, &

Declerq, 2010). Those that do deliver in the hospital setting are often more accepting of epidural

use, labor inductions, and cesarean delivery (Moore, 2004).

Summary

So what does this all mean? Why do we care? We care because we, as nurses, care for

our patients as a whole. As mentioned previously in Leininger’s theory, and demonstrated using

different cultural models from the Grand Rapids area, cultural competency can have a positive


effect on the type of relationship we build with our patients. Jean Watson’s theory of nursing

also applies, and describes the patient as a whole: composed of the mind, the body, and the spirit,

and if we fail to address one of those three facets we are failing to fulfill our capacity as nurses.

Lack of concern or complacency in this issue decreases the effectiveness of any nursing care we

deliver.

Culture is evolutionary over the span of generations, and thus culturally competent care

will evolve as well. This belief is supported in several theories, both nursing and non-nursing in

origin. By implementing more of the principles of relationship based care, and considering

cultural differences as opportunities to better serve our patients, we are on track to become a

more accepted and effective provider of quality healthcare.


References

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phenomenographic study based on patient experiences. International Emergency

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http://www.psnet.ahrq.gov/primer.aspx?primerID=10


Narruhn, R.A. (2008). Perinatal profile for patients from Somalia. Ethnomed, University of

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Noble, A., Rom, M., Newsome-Wicks, M., Englehardt, K., Woloski-Wruble, A. (2009). Jewish

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http://quickfacts.census.gov/qfd/states/26/

2634000.html

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