Assessment: 3 Culturally Competent Ethical Decision Making
Due Date: 19/10/2010
The world is multicultural and with this comes a diversity of morals, values and beliefs. Working in regional Australia as a community mental health clinician presents many challenges one of which is working with refugees from Nepal. The following assessment will explore conflicting values and beliefs at three different levels consisting of individual, organisational, and societal levels. Some women experience post natal depression, a significant health problem after the birth of a baby. There are many factors connected to the cause including a past history of depression, past history of abuse, relationship issues and stressful life events (Beyondblue, 2010). For some cultures the stigma associated with mental health causes many problems. There has been minimal mental health and psychosocial support or mental health care in Nepal (Jordans, et al. 2010). Research has found depressive symptoms of women from Nepal after childbirth affects both the mother and child and often the symptoms are related to the woman??™s relationship with her husband (Ho-Yen, Bondevik, Ebberhard & Bjovatn, 2007).
As globilisation becomes the norm it is expected that nurses will encounter ethical dilemmas within areas of their occupations. The following ethical dilemma being discussed will identify how humans can have different beliefs and values within their varied cultures and how it can sometimes be difficult to work with these cultural beliefs. The Nepalese population have the belief that anyone who encounters a mental illness will always remain unwell and the stigma reflects badly onto the family (Krishnan & Cutler, 2005).
The inter-relationship between cultural practice and disease including identification of health and illness in their social context will be discussed whilst the goals of the discipline of nursing with the provision of meaningful humanistic and safe care to people of the many diverse cultures worldwide will be respected (Leininger, 2008). The development of health care systems around medical and nursing knowledge and practices will identify the beliefs of inequity and disadvantage in the cultural context.
The chosen framework for the analysis of the above mentioned ethical dilemma is the ???Culturally Competent Model of Ethical Decision Making??™ (Andrews & Boyle, 2008). This model was designed by (Pacquiao, 2001). There are three sections consisting of human rights, ethics and cultural competence. Every living person has the right to have input into their own care decisions while having an assessment within the paradigm of the nursing process (Andrew & Boyle, 2008). It is everyone??™s human right to receive equality care.
As a nurse there will always be cultural differences and ethical dilemmas. Ethical dilemmas are common in areas where clients are vulnerable and disenfranchised (Elders, Evans & Nizette, 2005). The dispossession and destruction of traditional lifestyles, disruption to families and communities, discrimination, cultural exclusion, poor health, lack of education and poverty are some of the barriers that inflict these dilemmas on refugees, asylum seekers and indigenous populations (Hollinsworth, 2006).
Nurses have always been identified as a professional group where ethical principles are guided by the law and expected from consumers. It is vital that nurses have an understanding of cultural differences, and respect their values and beliefs, of any decisions made by them and their family (Elders, Evans & Nizettes 2005).
Language barriers and interpreters are a common concern working in the health area. However they are a necessity that cannot be overlooked when providing quality mental health assessments to avoid clinical ethical dilemmas. It is obvious given our culturally diverse society that everyone requires multicultural training to ensure effective provision of services and equality of care is provided (Hollingsworth, 2006).
The professional practice and ethical conduct of nurses is guided by their professional bodies which is a set of nursing standards expected of all professional nurses (Australian Nursing and Midwifery Council). Anyone experiencing a mental health illness belongs to a very vulnerable group within any culture. The principle of autonomy for nurses highlights many implications especially when the nurse is to respect the patient as a chooser of care within their domain. Non-maleficence relates to the nurse ensuring no harm or potential harm comes to the patient in their care. Beneficence in clinical care is the promotion of wellbeing of the patient through affirmative action or interception. Justice relates to society??™s view of a fair and right outcome. So therefore autonomy, non-maleficence, beneficence and justice are the core principles of ethical conduct (Elders, et al., 2005).
The conflicting values and beliefs of every individual, organisation and society influence the awareness and communication between clients and carers (Andrews and Boyle, 2008). Nurses practice within a wide variety of areas one of which is the community setting. Community nursing practices require a base assessment on the first meeting to identify and evaluate the cultural differences to incorporate interventions to assist the client. The assessment needs to recognise and respect the spiritual and religious beliefs and values and appreciate the influence these may have on their health (Elders, et al., 2005). The provision of quality care requires the understanding of the lived experience. There is also the need to design and organise a comprehensive care plan that is appropriate for the individual and the family and to identify what the problem is for the individual and to develop mutually shared goals (Andrews & Boyle, 2008).
Every contact with another person is culturally different. To provide culturally competent care nurses need to value cultural diversity, have the ability to formulate a cultural self assessment, have an understanding of the predictable dynamics that interaction of cultures create and an understanding of the diversities of cultures (Mays, Siantz, & Viehweg, 2002). While working with Mary there have been many hurdles to overcome. Apart from her lack of English, her husband is always present when meetings are arranged. This is not an issue except John can speak some English and has adamantly informed the team of the belief of Nepalese people that his wife can never be freed of her mental illness as mental health is caused by bad fortune (Jha, 2007). John also disagrees with any medications prescribed by the psychiatrist and does not assist in encouraging his wife to comply with medical treatments that are prescribed (Jha, 2007).
The data in the assessment is very limited. Mary was referred into the service through her case manager at the refugee centre, after conversations with an interpreter. The current standard universal assessment framework used by New South Wales Health is not appropriate for all cultures. There is no mention of values, cultural aspects, cultural values or social structural factors such as educational, religious, political or legal factors (Omeri, 2003). There is no information regarding the birth of the baby in Nepal, the length of time in Australia, past medical and mental health history, understanding of the settlement into Australia or past trauma. Showing professional interest and seeking their views on the problem will encourage empowerment of the persons involved. Being non-judgemental will also create a relaxed atmosphere that will enable clients to divulge the use of traditional medicines without feeling intimidated (Silove, 2004).
Mary??™s diagnosis is post natal depression and minimal treatment has been provided prior to her arriving in Australia. It would be of benefit to ascertain the background information of her pregnancy and the type of delivery she experienced. A better understanding of the stigma related to her diagnosis as mental health in Nepal is seen as a disease that is never cured. The cultural values and beliefs held by Nepalese people are very different to those of the clinician working with them. Our lives have all been shaped very differently. It is paramount that we all understand biocultural differences obvious in types of illness, in health care practices and in reaction to medications. Resources available in the regional area are all generic and for the best outcomes for Mary and her husband John, a specialist transcultural mental health service would be more beneficial. http://www.everyculture.com/Ma-Ni/Nepal.html.
The community mental health setting where the author works is a learning organisation. This organisation is powerful in continually encouraging education, and providing the most up to date knowledge for its staff. As it consists of a multidisciplinary team it has the added strengths of integrating the many different knowledge groups to enhance everyone??™s knowledge base. This generative organisation is performance based. The leadership is one of trust, amenable to criticism and caring. Everyone is supported in learning roles (Tapp, Edwards, Braspenning, Eriksson, Elwyn, 2008).
Nurses are well placed to be educationally trained through their organisations with continuing education and through formal education. An understanding of policies within the organisation will enlighten staff of the influences amongst the diverse populations enabling advocacy for health discrepancies and promotion in the quality of life (Douglas, et al. 2009). Culturally challenging patients will receive better care if all staff gains an understanding of cultural competence. This will alleviate discomfort and enable quality care that is culturally suitable for everyone (Christma, 2007). It will also provide staff with support from one another in identifying the required treatments.
The world is slowly progressing towards equality for everyone. The code of ethics for the Australian Nursing profession recognises the responsibility of morally suitable universal rights inclusive of respect, recognition, and protection of the many varied cultural, political, economical, and social rights afforded to everyone (Australian Nurses Federation Union).The human rights of the traditional owners of Australia, Australia??™s Aboriginal and Torres Strait Islanders people, are also respected for their viability, spirituality, emotional, physical and cultural wellbeing. Every health care setting has racism, prejudice, ethnocentrism and stereotyping. To eradicate this problem, organisations need to educate their staff to be inclusive in their workplace and utilise universal care theories. These should consist of genuine concern and respect for clients and fellow staff (Andrews & Boyle,2008).
Everyone is responsible for culturally competent care. Globilisation has huge impacts on everyone. As barriers are broken, access for all cultures is becoming more accessible to health care services. The interaction and integration of all humans from all countries ensure the increased availability and accessibility of all information. Culturally competent care is everyone??™s responsibility. With the high movement of globilsation everyone needs to have a better understanding of cultural differences (Papadapolous & Omeri, 2008).
Transcultural theories and models of care require education, research and practice. These crucial elements form the basis of providing appropriate care needs to all diverse cultures whilst assisting in the removal of health inequalities provided to vulnerable and marginalised populations (Papadapolous & Omeri, 2008). Flexibility and adaptability is required. As Nurses are bound by a professional code of ethics it is important that nurses provide culturally competent, culturally responsive, compassionate care to everyone (Australian Nursing Federation).
Ethical dilemmas will always be experienced by individuals worldwide. It is, however, important and obvious given our culturally diverse society, that everyone requires multicultural training to ensure effective provision of services and equality of care (Hollingsworth, 2006). Conflicting values and beliefs have been discussed when working with people from other cultures and the power members of family units possess.
Education for cultural competency requires the promotion of social, cultural, linguistic, religious and spiritual backgrounds. A supportive management to engage other staff members in understanding the requirements of culturally appropriate care for consumers is essential. An understanding of the many diverse groups being serviced by a health sector will enable a better understanding of the implications derived from the lack of cultural competence (Australian Government, 2005). Self reflection of our own practices is necessary to identify discrepancies in our practices.
Andrews, M. M.,& Boyle, J. S., (2008). Transcultural concepts in nursing care (5th ed.).
Philadelphia: Wolters Kluwer Health / Lippincot Williams and Wilkins.
Beyondblue.org.au (2010). What is post natal depression retrieved October 10th, 2010,
Chrisman, N. (2007). Extending cultural competence through systems change: Academic,
hospital and community partnerships. Journal of Transcultural Nursing, 18, 68S
Douglas, M., Pierce, J., Rosenkoetter, M., Callister, L., Hattar-Pollara, M., Lauderdale, J.,
Miller,J. Milstead, J., Nardi, D., Pacquiao, D. (2009). Standards of practice for culturally competent care: A request for comments. Journal of Transcultural Nursing, 20, 257-269.
Elders, R., Evans, K., & Nizette, D. (2005). Psychiatric and mental health nursing.
Sydney, Mosby Elsevier.
Hollinsworth, D. (2006). Race and racism in Australia (3rd ed.). Australia, Thomson Social
Ho-Yen, S., Bondevik, G., Eberhard, M., & Bjorvatn, B. (2007). Factors associated with
depressive symptoms among postnatal women in Nepal. Acta Obstetricia et Gynecologica, 86, 291-297.
Jha, A., (2007). Nepalese psychiatrists??™ struggle for evolution. Psychiatric Bulletin,
Jordans, M., Upadhaya, N., Tol, W., Shrestha, P., Doucet, J., Gurung, R., Aguettant, J.,
et al. (2010). Introducing the IASC mental health and psychosocial support guidelines in emergencies in Nepal, Intervention, 8(1), 52-63.
Krishnan, M., & Cutler, D. (2005). A Resident??™s experience in cross cultural/community
psychiatry, Community Mental Health Journal, 41(5), 599-611.
National Health and Medical Research Council (2005). Cultural competency in health: A
guide for policy partnership and participation. Australian Government.
Omeri, A. (2003). Meeting diversity challenges: Pathway of ???Advanced??™ Transcultural
Nursing practice in Australia. Contemporary Nurse, 15, 175-187.
Pacquiao, D. (2001). Addressing cultural incongruities of advance directives. Bioethics
Forum, 17(1), 27-31.
Silove, D. (2004). How to treat mental health problems in migrants and refugees. Australian
Doctor, 16, 33-38.
Tapp, L., Edwards, A. Braspenning, J., Eriksson, T., Elwyn, G. (2008). Developing
Organisational maturity: considering the role of culture typologies for primary care
Practices. Education for Primary Care, 19, 1-12