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Moving ahead with the serialization of part of the first chapter of the CPNRE® Comprehensive Review eBook, we’re picking up from the last post about culture and cultural sensitivity. Today’s post explains how to approach challenging question scenarios about culture and choices on the CPNRE®. You can find earlier posts here: part 1, part 2, part 3, part 4, part 5, part 6, part 7, part 8, part 9, part 10 and part 11. 

Nurse-client interactions: Culture 

Given the significance of cultural influences on health, it’s important for us to talk about how to approach the concept of culture and choices on the CPNRE®.

Question scenarios about culture will most likely test your understanding of what you’re supposed to do when clients make choices about their care that you might not agree with or believe in. For example, a question might involve a client who refuses a particular treatment plan, or a client who makes a spiritual or religious request you don’t practice yourself.

When you see questions involving clients who refuse certain treatments or care, or questions involving clients who make particular requests about their care, know that the correct answer will be to advocate.

When it comes to advocating, choices and culture, there are 3 steps we need to take:

Step 1. When a client refuses a particular treatment or requests something different about their care, our 1st priority is to validate our understanding of their choice by collecting more information.

In other words, we need to assess a client’s thoughts, feelings, preferences and concerns in order to better understand what they need. This is a priority because we cannot begin to offer help to clients unless we have an understanding of what they think, feel, believe and value.

Collecting more information is the first priority whenever clients refuse aspects of their care, or make requests about their care that could be harmful.

For example, if a client tells us they:

• Want to smoke in their room
• Don’t want a male nurse to care for them
• Don’t want to take their medication
• Don’t want to walk
• Don’t want opioid analgesics
• Don’t want to be repositioned
• Don’t want to eat the meal they’ve been given

we have to prioritize an assessment in order to understand the reasons behind their choices. In my experiences as a nurse, I’ve found this step to be essential. Without understanding the reasons underlying someone’s choices and preferences, we cannot offer them the help they want and need

Let’s say a client preparing for surgery tells us, “I don’t want opioids after surgery”. We could respond by offering reassurance or information like, “Opioids are effective pain-relieving medications post-operatively” or “Opioids are not addictive when used in appropriate situations”. Or, we could start by asking, “What are your concerns about opioids?”. Unless we ask, we won’t know what clients need to hear. A client who doesn’t want to take opioids may be concerned about side effects, or they may be worried about taking them if they’ve had a reaction in the past.

On the CPNRE®, prioritizing assessment is most important whenever a client makes a request or refusal for care that could result in harm.

Remember, client choices often reflect their cultural values or beliefs, and while they may be helpful in some circumstances, when it comes to health and wellness, some values and beliefs can be harmful. In order for clients to make informed decisions about their health, we need to first understand what they know, what they believe and what they don’t know.

Step 2. After collecting more information to understand the reasons underlying clients’ requests or refusals about their care, the 2nd priority is for us to provide clients with relevant information so they can make an informed decision.

Once we understand the reasons underlying a client’s choice, then we’re able to provide them with information so they can make informed decisions about their health and their care.

It’s tempting to want to offer advice or information whenever someone makes a refusal about their care, or when someone makes a new or unusual request. But we know that prematurely offering information leads us down the slippery slope of making assumptions of what people need, instead of finding out what they actually need

Step 3. After we understand the reasons behind a client’s choice and provide them with relevant information, the 3rd priority is for us to discuss the client’s refusal for treatment or request with relevant health care team member(s).

Health care has become so complex and specialized that it’s quite normal for clients to have several different health care providers involved in their care. Through my experiences and from research, I’ve learned that it’s most appropriate to involve other health care providers when:

• We’ve collected information in order to understand the reasons why a client’s refusing care or requesting changes in their care
• We’ve provided a client with relevant information to help them make an informed choice
• The client’s problem is best addressed by another health care provider

When a client’s problem, or the solutions to their problem falls outside our scope of practice or expertise, that’s when it’s time to reach out for help.

Exam tactic 

On the CPNRE®, questions about culture and client-choice may involve clients:

1. Refusing a particular treatment or intervention (i.e. refusing to take narcotic analgesia, refusing to eat, or refusing to participate in physiotherapy)
2. Making a request (i.e. to wear particular clothing, to eat a particular kind of food, to have a spiritual ceremony)

When you see a question scenario that sounds like these scenarios above, it’s important for you to choose the answer that best represents one these 3 steps of advocating in sequential order, from 1-2-3.

As you get ready to write your exam, keep in mind that although the culture of nursing values empathy, autonomy, empowerment, honesty and respect for choices, not every culture or client will share these values. As nurses, we don’t necessarily have to agree with clients’ choices or practices, but we are obligated to respect the choices they do make. Clients have the right to make informed choices and decisions about their health, and as long as they don’t cause harm to other people, and they’re are aware of the potential consequences and risks, the choice is theirs to make.

Today’s post in the serialization of the first chapter of the CPNRE® Comprehensive Review eBook takes a look at culture and the ways in which we can be sensitive to the cultural influences and choices our clients make. You can find the previous posts here: part 1, part 2, part 3, part 4, part 5, part 6, part 7, part 8, part 9 and part 10. 

Nurse-client interactions: Culture

The process of writing this book taught me so much about nursing. This couldn’t be any more true than when it comes to the topic of culture. When I first started learning more about culture and cultural sensitivity, initially I cringed. Here’s another wishy-washy topic, I thought. But of course, it didn’t take long for me to learn that most client behaviours and choices are inextricably connected to cultural values and beliefs.

For years I was frustrated whenever clients would continue to make unhealthy choices or decisions despite my attempts to provide health education.

• Clients with uncontrolled diabetes wouldn’t take their medications as I instructed
• Clients on Coumadin wouldn’t get their INR done when I asked them to
• Clients with advanced COPD would continue to smoke despite knowing the risks
• Clients with asthma would not use their inhalers despite my efforts to teach them why they’re important

It was as if my information always went in one ear and out the other.

For most of my career I believed that the best and only way we can help clients make better decisions about their health was through education. But after learning more about culture, I’ve realized that we cannot truly help clients achieve better health unless we acknowledge and respect their cultural values and practices. And, that we can only support clients to get to where they want to go by gently helping them to see when their values and beliefs and behaviours – their culture – isn’t serving them well.

The simplest definition of culture that I could find is that it’s “a learned way of thinking and behaving – for better or for worse – amongst a certain group of individuals”. From this definition, culture is considered a group of people who are connected to one another through shared characteristics, customs, values, behaviours, beliefs, traditions and language.

Although we may not think that culture is all that significant, it’s important to understand that it impacts everything we do, from:

• What we eat
• When we eat
• How we dress
• How we behave
• How we spend our time
• How we treat other people
• How we parent
• How we work, &
• How we live

There are no areas of our life immune to cultural influences.

Here’s the thing: most of us are so influenced by our culture that we often don’t recognize that it exists. Without being aware of our own cultural influences, it’s hard to see how culture impacts the thoughts and behaviours of the clients we care for, especially when it comes to health.

As I think about my own cultural influences on health, I’ve learned about one belief in particular that isn’t all that helpful – and is actually harmful to me.

When I’m sick, I believe that I have to continue fulfilling my obligations at work and at home. I do this because this is how my family raised me. I was taught that you don’t get a free pass to relax when you’re sick. As I’ve grown older I’ve realized that this belief is not healthy. As a consequence, I have to work really hard to be kind to myself and take time to rest when I need to, because it’s not my first instinct. This might seem ridiculous to some of you who were brought up in a culture that values self-care. I certainly wasn’t.

When I think about positive influences of my culture on my health, I’ve learned that my belief in physical wellness is a good thing.

I was fortunate to grow up in a family that taught me about the importance of regular physical activity early in life. As a young girl I remember regularly going to aerobics classes at the YMCA with my mom, because ‘that’s just what we did’. As an adult I continue to live an active life. Physical activity has become so engrained in my life that it almost doesn’t feel like a choice, even though it is. Thankfully, it’s a choice and a value that keeps me well.

When we are aware of cultural ‘norms’ and expectations, it’s easier to acknowledge when our values, beliefs and practices are harmful to us.

This idea that culture influences how we think and act is important because in order for us to help clients achieve better health, we have to do two things:

1. We have to understand and respect clients’ culture beliefs and practices (the choices they make) when they’re not harmful.
2. We have to help clients learn about other ways of thinking and being in the world when their cultural beliefs and practices (the choices they make) are putting them at risk for harm.

If a client wants us to arrange a religious ceremony or respect their traditions and they aren’t putting other people at risk for harm, it’s our job to support their needs.

If a client wants to smoke in their hospital room, or refuses to receive medically necessary care, it’s our job to understand the reasons underlying their choices and help them understand the implications of their decisions.

One of the biggest reasons why clients often feel disrespected by us has nothing to do with our nursing skills or competence, and everything to do with our sensitivity towards their values, beliefs, and choices. We know from research that people are more likely to feel worthless, disconnected, disrespected and unaccepted when we pass judgment about their choices, when we force people to make different decisions, and when we use shame as motivation to help them change their behaviour. In her book ‘I thought it was just me’, Brene Brown says that “we cannot force people to make positive changes by putting them down, threatening them, humiliating them in front of other people or belittling them”.

So if we tell a client enough times:

• “You should exercise more because you’re gaining weight and it’s raising your blood sugars.”
• “You should really take chemotherapy because without it you’ll die.”
• “You shouldn’t take homeopathic remedies.”
• “We can’t allow you to practice your religious beliefs.”

We’ll likely see a swift change in their behaviour, but it probably won’t be a lasting change, and it certainly won’t be a positive change. When we use shame or pass judgment about someone’s choices as a means to help them change, when we attack someone’s cultural beliefs and practices – it leads them to be silenced and secretive and feel unworthy of connection. The effects on health are disastrous.

Instead of telling clients what to do or forcing clients to make different decisions, it’s really important for us to seek an understanding of their values, goals, beliefs and preferences, and advocate for their needs to be met in a way that’s meaningful to them.

Here are a few lessons about culture:

• Capable clients know what’s best for them
• Capable clients have the right to make choices and decisions about their health (as long as their choices don’t hurt other people)
• People in the same culture group have different values and beliefs
• We have an obligation to commit to integrating clients’ cultural preferences into their care when there’s no risk of harm to other people
• Culturally-sensitive care is client-centered care

Picking up from yesterday’s post about the role of the environment in nursing, today’s post looks at language barriers and ways we can overcome them. Today’s the 10th instalment of the CPNRE® Comprehensive Review eBook. To see the previous posts – click here: part 1, part 2, part 3, part 4, part 5, part 6, part 7, part 8 and part 9.

Nurse-client interactions: Language barriers

Clear language is needed for clients or their substitute decision-makers (SDMs) to make informed decisions about their health and their care. But what happens when clients or their SDMs speak different languages than us? Or when clients speak English as a second language? Is clear language still necessary? The short answer: yes.

Situations involving language barriers deserve special attention, especially for the CPNRE®. When it comes to language, there are things we need to do in order to develop a mutual understanding of what a person wants or needs.

Here’s what you need to know about language barriers for the CPNRE®:

1. Ninety-nine percent of the time when clients or their SDMs have difficulty communicating or understanding us because of a language barrier, it’s best to use trained interpreters. Trained interpreters have specialized knowledge and skills in language and culture, and can be trusted to be more objective, to maintain confidentiality and understand health care terminology better than a client’s family and friends.

2. If a capable client cannot communicate or understand information because of a language barrier, and they cannot provide informed consent for routine, non-urgent interventions, the proposed interventions should be postponed until someone is available to assist in communicating with the client. What this means is, if a client requires routine blood work or diagnostic testing and we cannot communicate information they need to know to make informed consent, it’s best for us to wait until someone can facilitate communication. Imagine yourself in a walk-in-clinic in another country and you don’t speak the language used by health care providers. How would you feel if they didn’t find an interpreter to explain the plan of care and insisted on providing care they thought was necessary? If it were me, I’d lose my mind.

3. If a client is capable of making decisions, but cannot communicate and efforts to overcome a language barrier are unsuccessful, treatments or procedures may be provided without their consent if it is clear the client would not refuse treatment and delaying treatment will increase their risk for harm.

4. If a capable client turns away, shakes their head, pushes back, yells or says ‘no’ when offered care or treatment, these actions imply the client is refusing treatment – regardless of whether a language barrier exists.

We can help overcome language barriers by:

• Speaking slowly and clearly
• Avoiding slang and complex medical terminology
• Avoiding assumptions about what clients are saying
• Clarifying what we’re hearing or seeing, especially when things are unclear
• Understanding client preferences, opinions, beliefs, and values
• Orienting clients who are unfamiliar with a particular health care situation or setting

Exam tactic

You may see questions on the CPNRE® testing your understanding of how practical nurses should handle language barriers.

It’s a sign you’re being tested about language barriers when you see a question referring to a client who is an immigrant, or a client who speaks English as a second language. As you read the answer options to questions like this, keep in mind clients’ rights to informed decision-making and the various ways to overcome communication challenges listed above.

Generally speaking, if there’s a non-urgent clinical situation and a language barrier exists, it’s best to use a trained interpreter to explain the nature of a proposed treatment or procedure in order to obtain informed consent.

Continuing where we left off last week with the serialization of the CPNRE® Comprehensive Review eBook, today’s post is all about the environment in which we work – and how we can make it psychologically safe for the people we care for. To bring you up to speed, here’s part 1, part 2, part 3, part 4, part 5, part 6, part 7 and part 8.

Nurse-client interactions: Environment

When we’re busy and overwhelmed, it’s easy to overlook the decisions we make about the environment surrounding our clients and their families.

But before we talk about how we can make the environment safe, I think it’s important to examine the potential consequences when we fail to consider the environment in which we work.

The best teachable moments are the ones where people screw up, so I’m going to share a few examples of how the environment can help or harm the psychological safety of the people we care for.

A few years ago, I started seeing a new physician. The first few times I saw her, I noticed that she left the exam room door wide open during our visits. At first, I remember thinking to myself, “this is weird, but maybe there’s a reason”. But after several months of seeing her, I realized this is what she does. Regardless of the reasons why she leaves the exam room door open during client visits, it’s important to recognize that this lack of regard for privacy and dignity undoubtedly makes people feel uneasy about sharing personal information when they know other people can easily listen. I know it makes me feel uncomfortable and far more hesitant to open up knowing that someone is across the hall, listening to what I say. It seems as though this physician doesn’t understand the perspective of her clients and how the environment is influencing her interactions and care.

Here’s a different example – an example of what happens when we pay close attention to the needs of the people we care for, and how the environment plays a role in meeting their needs.

A few years ago, my father underwent a liver resection for metastatic colorectal cancer. After his surgery, the surgeon brought my family into a quiet, private space to talk. At first I thought the surgeon did this because he was about to share bad news, but I quickly understood that he did this so my family could have a place to talk without spectators. There were lots of tears and emotions felt during that discussion, and I cannot imagine what it would have been like to do that in the hallway or a busy waiting room where other people could watch and listen. It was clear that this physician appreciated that the environment in which we communicated had a tremendous impact on our psychological safety.

While our ability to create quiet, safe, respectful and private environments depends on the setting and situation, there are simple things we can do to improve the influence of the physical space for our clients and their families.

Practical nurses can create a respectful, safe and private environment by:

• Drawing curtains to create privacy in a hospital room
• Knocking before entering through a closed door
• Finding a private space, free of noise and distraction especially in sensitive situations
• Paying attention to lighting in a room
• Using neutral spaces
• Limiting the use of chapels or religious spaces unless a client or family specifically requests it

Here’s an example of a question about the environment:

 Correct answer:  4.

The conference room is the most appropriate environment in this situation for the simple reason that it’s the most quiet, private and neutral space amongst these answer options.

Nursing stations don’t offer a lot of confidentiality and they can be noisy. Chapels aren’t appropriate spaces to hold meetings for a few reasons. One reason is that other people may want to use the chapel for prayer and the other reason is that not everyone is comfortable in a chapel. Client rooms also aren’t the most appropriate environments to hold meetings because there may be other clients sharing the room, and some meetings are held about clients – without them.

Exam tactic

You may see questions on the CPNRE® asking you to choose ‘Which environment is the most appropriate?’ or ‘Where should the practical nurse arrange a meeting?’ When answering these kinds of questions, try to think about the above ways in which we can provide a dignified space for clients and their families. Ask yourself: what kind of environment would provide this client or family the most privacy and respect for their beliefs, values and preferences?

In yesterday’s post, we talked about the elusive concept of empathy. Today, we’re introducing the concept of power in nursing and what it means to give power away. It’s part 8 in the serialization of the CPNRE Comprehensive Review eBook. If you want a re-fresher, here’s part 1, part 2, part 3, part 4, part 5, part 6 and part 7.

Nurse-client interactions: Power

Power is a challenging concept for a lot of us, especially women. There’s a part in each of us who wants to be told what to do and be cared for by others – but there’s also a part of us that is afraid of being powerless.

When we talk about power in health care, we often think about ‘power-over’. Power-over is defined as the ability of a person or group of people to exert control over others. In health care, this means that nurses and physicians and other professionals have more authority, more knowledge, more skills, more influence and more leverage than clients do.

One of the greatest problems with power-over in our health care system is that ‘health’ has been defined in our society so often that people usually believe we – as in health care professionals – are the experts of their health and they should do what we say.

The truth is, clients are the experts of their health because they know what’s best for them. We just don’t often realize that – or help clients realize it themselves.

To overcome the inherent asymmetrical power in health care, and in nursing, we have to create and give away power. Instead of telling clients what to do, we can partner with them – and help them make decisions if they want to change something.

In order for clients to make changes in their health and manage the problems they face, we have to empower them with the skills and knowledge they need to change their behaviours if they want to. We know that when clients are involved in their care and making decisions affecting their health, the better off they are.

Question: Which column of statements below is the most empowering?  

Answer: the right column

By helping clients identify and build upon their preferences, strengths, and weaknesses, we’re empowering them to take responsibility and become more independent in managing their health.

We can empower clients by:

• Providing them  with the relevant information they need to manage their health
• Including them in planning their care
• Supporting them to evaluate their care and give feedback
• Listening to their concerns, questions, preferences, values and beliefs
• Giving choices and allowing capable people to make their own decisions

Exam tactic

It’s a sign you’re being tested about the concept of power on the CPNRE® if you see a question asking you to choose something like:

• How can the practical nurse encourage the client to take responsibility for his/her health?
• How can the practical nurse promote the client’s independence?
• How can the practical nurse involve the client in planning his/her care?
• How can the practical nurse implement a plan of care the client will agree with?
• How can the practical nurse understand the client’s health care needs?

When you see questions like these on the CPNRE®, you should think about the above ways in which practical nurses could give people power. Choose the one answer option involving the practical nurse empowering someone to have more control over his or her health or care. Although hard to do, it’s always better to let capable people decide for themselves than for us to make decisions for them.