NURS 124 Culture & Global Health

NURS 124 Culture & Global Health • Parts borrowed with permission of Sherry Dahlke (Iceberg slides) • Objectives • 1) Discuss cultural competence, cultural safety and cultural assessment • 2) Describe and differentiate between global health, international health and public health in the context of professional nursing • 3) Define key cultural concepts related to health, illness, and diversity • 4) Discuss the benefits of seeing context and culture relationally • Cultural assessments Encourage patients to describe the values, beliefs, and practices that are significant to their care, which may be taken for granted if not revealed….. What aspects of cultural assessment help with this? What is culture? • NOT RACE: biological markers • NOT ETHNICITY: shared social and cultural heritage Culture is a social and therefore relational process Shared and Learned values and behaviors distinguishing one group from another cultural competence Culturally Congruent Care Use of sensitive and creative and meaningful care practices to fit with the general values, beliefs and lifeways of clients Cultural assessments Culturally Competent Care Ultimate Goal: Cultural safety How to Nurse, Chapter 9 & Potter and Perry p. 125 Cultural safety also requires relational inquiry as the HCP’s ‘intrapersonal doings’ or reflections Box 9.8, p. 125 38 For example: How do my own personal and cultural history, values and beliefs influence my practice? ‘Cultural sensitivity’ Why? • Cultural concepts r/t health, illness, and diversity Ethnocentrism: Stereotypes: Discrimination: Racism: Cultural imposition: • Contexts therefore are …. Linguistic/Discursive: Box 4.5, page (p. 162) Ultimate Goal: Cultural Safety • Cultural safety requires ‘relational inquiry’ at contextual level How to Nurse, Chapter 9 HCPs Safely meet people’s needs, expectations and rights given the unique context of their lives Why? • Contexts are like “intersections” History Box 4.1 ✓ Sociopolitical Box 4.2. ✓ Material/Economic Box 4.3 ✓ Physical Box 4.4 • key cultural concepts r/t health, illness, and diversity People live in and embody different contexts DoH ‘….the circumstances in which we were born, grow, live, work and age’ (HTN, p. 165) 39 • Describe and differentiate between global health, international health and public health in the context of professional nursing Global health UN Sustainable Development Goals direct our attention to SDoH (Box 9.1, p. 118, i.e. end poverty in all forms everywhere) Bringing P, M/E, SP context into the picture http://hdr.undp.org/sites/default/files/hdr_2019_overview_-_english.pdf Delving deeper: YEMEN http://hdr.undp.org/en/countries/profiles/YEM The Nursing Process And Care Planning Learning objectives • 1) Explain the relationship of critical thinking to the components of the nursing process • 2) Describe the relationships between assessment, nursing diagnosis, planning, implementation and evaluation • 3) Differentiate between nurse- initiated, physician-initiated, and collaborative interventions • 4) Explain the relationships between goals of care, expected outcomes, and evaluative measures in evaluating nursing care Basic Problem Solving • When you run into problems in your day to day life, what steps do you take to solve them, generally speaking? • How do you figure out whether you have solved a problem? 40 Critical Thinking Solves Problems • When you run into problems in your day to day life, what steps do you take to solve them, generally speaking? • How do you figure out whether you have solved a problem? • Critical thinking s a complex phenomenon that can be defined as a process and a set of skills. Most definitions emphasize the use of logic and reasoning.. Requires purposeful and reflective reasoning during which you examine ideas, assumptions and beliefs, principles, conclusions and action within the context of the situation • Clinical decision making separates professional nurses from technical personnel. • What are critical thinking requirements? • More than just cognitive skills • Ability to ask questions • Be well informed • Be honest in facing personal biases • Be willing to reconsider and think clearly about issues • Without these dispositions, sound critical thinking is unlikely to occur. Critical Thinking is a Process • Patients present with a problem of some sort (signs & symptoms of _____ ??) • The nurse knows …[specific scientific & clinical knowledge; past experiences] • The nurse hears the patient saying …[subjective] • The nurse relates all pieces of evidence Diagnostic Reasoning & Clinical Inferences • The nurse “names” the problem & solves the “why” Diagnosing: problem “X” occurred because of “A and B” 41 • The nurse ‘recommends’ solutions (actions to take) …. Clinical Decision Making (Box 12.3, p. 181 – additional considerations) • The nurse evaluates effects of actions over time AND asks: are different actions needed? Effective Problem Solving Safe, Compassionate, Competent and Ethical Care Knowledge-based practice, Professional Responsibility Assessment Primary : client • Secondary: medical records, team, family • Tertiary: literature (specific knowledge), past work experience • Interviews: what do you know going in right now? • Interviews: gather a nursing health history [Box 13-1, p. 189-190] developmental, psychological, social, spiritual, sociocultural physiological (meds, physical exam, diagnostics and labs) • Interviews: gather a nursing family history Critical thinking is an attitude and maintaining standards Using critical thinking in your assessment if you saw a patient grimacing – you would ask questions such as are you having pain? Sources of data are the patient, the family, healthcare team, medical records, literature, nurses’ experience How do you conduct an assessment: interview, observation of behavior, diagnostic and laboratory data, interpreting data and making nursing judgements Interview Orientation phase Working phase 42 Termination phase Nursing health history Components Physical examination Observation of client behaviour Diagnostic and laboratory data Step 1:Validate Nursing health and family history: client Physical exam and observed behaviors: medical records & team Clarification: is my information correct, did I miss anything? Careful judgements: professional responsibility Step 2: analysis and Interpretation • Organizing information into meaningful clusters (patterns or trends) • Comparing with standards (specific knowledge – professional standards; past experiences) Cues (signs, symptoms, other findings) most worrisome? What is the priority problem or concern? Are there multiple problems? What problems can wait? • Drawing conclusions (subjective & objective; all-source evidence) 43 Critical Thinking Solves Problems Nursing Diagnosis 3 Pieces of Nursing Diagnosis Samantha, Damien, Shelly 44 WEEK 7: YOUNG TO ADULTHOOD WEEK 8: OLDER PERSONS OLDER PERSONS Learning objectives: 1) Identify common myths/stereotypes re: older adults 2) Discuss common developmental tasks of older adults 3) Describe common physio changes with aging 4) Describe selected health concerns of older adults 45 Statistics Canada -65+ outnumber <15 -Life expectancy for males: 78.8, females: 83.3 -By 2025, 25% are 65+ and 80+ population is quadrupling -2015-2050, proportion of the worlds population over 60, from 12% to 22% -by 2020, percentage aged 60 and older wil outnumber children younger than 5 -2050, 80% will be living in low and middle income countries -the pace of population aging is much faster in the past -all countries: how to ensure that health and social systems are ready Erikson’s theory • Integrity vs. despair -adjusting to decreasing health and physical strength - adjusting to retirement -Adjusting to death of a spouse -*accepting one’s self as an aging person finding ways to maintain quality of life redefining relationships with adult children -Self reflection: has my life been worthwhile? -growth and wisdom! Age-related changes… • Fibrosis of pancreas and lowered sensitivity to insulin • Degenerating nerve cells • Diminished sensory perceptions • Thickening of blood vessels, lower peripheral circulation, calcified heart valves • Lesser cough reflex & fewer alveoli & chest wall rigidity 46 • Decreased muscle mass & strength • Drying of skin and lost elasticity (hyaluronic acid) • Lower core temperature elevation & T-cell functioning; decreased stress responses Forgetfulness is not a normal consequence, nor is cognitive impairment! However, ARCs can lead to …… Atypical Presentations • Infectious disease with out fever. • Mass without symptoms. • Heart attack without chest pain. • Pulmonary edema without shortness of breath. • Abdominal pain is absent or vague • Dehydration from acute illnesses • Depression without sadness. Complex health assessments ….. Prevention & Health Promotion 1. Exercise: 30 mins a day 2. Nutrition: Fx limiations, dentition, $, meds, isolation 3. Immunizations: pneumonia, flu 4. Others: smoking, weight, watch BP, sunscreens and seatbelts 5. Secondary: stool, mammograms, ECGs, vision, pap and pelvic, prostate blood or urine and rectal; blood glucose, thyroid, cholesterol, bone density 6. Secondary: DDD, functioning, meds falls, alcohol intake 7. Psychosocial: reminisce, cognitive, stimulates, body image Common myths 47 • • • • • • old people are ill and disabled old people are not interested in and are not having sex old people are draining the health care system old people are technophobic old people are senile Therefore, old people are all the same …. https://www.who.int/ageing/features/misconceptions/en/ Ageism “[a] process of systematic stereotyping or discrimination against people because they are old, just as racism and sexism accomplish with skin colour and gender. Ageism allows the younger generations to see older people as different than themselves; thus they subtly cease to identify with their elders as human beings” (Butler 1969) Physical and psychosocial characteristics and lifestyles (p. 412 P & P) Slow, sick, senile, dependent, ugly: death’s doorstep, no will to life, grumpy, stubborn: VS Active, capable, healthy, sharp, attractive, well-groomed, warm, open-minded Act your age (identity): you had your turn (succession): those limited resources are ours, not yours (consumption) Most socially perpetuated forms of prejudice in Canadian society (Canadian Network for the Prevention of Elder Abuse 2015; Revera 2014) Did you know? Becca Levy’s work: a self-fulfilling prophecy? • • • • • Poorer recovery from cardiac illness and increased risk of hospitalization Hearing loss and memory impairment Shorter life expectancies Altered physical functioning and memory tests in lab settings Seeing own process of aging in a negative light 48 Other evidence • • • • Causes depression and negative affect Predicts having experienced public age discrimination Associated with age-related anxiety, dismissed work opportunities vamping up resumes Worry over physical functioning associated with lower self-esteem (women especially!) • (WHO 2019) Agism is recognized as the common source of the justification for, and the driving force behind age discrimination • (Levy and MacDonald 2016) Any age groups can experience age discrimination, but people 65+ are the main targets in westen society • • • (AHRC 2018) In 2018, age discrimination was added to the alberta human rights act (23) goods, services, accommodations or facilities that are customarily available to the public and tenancy (Department of Justice Canada 2013) Unlawful to discriminate by age (Government of Canada 2018) Advancing knowledge about systemic issues that affect older Canadian’s mental health and wellness is a priority Dementia is… • A gradual and progressive decline in mental processing ability that affects short-term memory, communication, language, judgement, reasoning, and abstract thinking Dementias Alzheimer’s- most common - Global deterioration - Slow onset - Personality disintegration - Loss of insight Vascular Dementia- common - symptoms vary with the area of the brain affected - relatively abrupt and rapid onset - good preservation of personality - have insight Frontal Temporal -common 49 - Onset often 50s-60s - slow onset - early personality disintegration- disinhibition - early loss of insight - language changes - takes away common sense Lewy Body cells in cortex - variable onset - fluctuations in cognition - fluctuations in personality - fluctuating insight - visual hallucinations - Parkinsonian features - takes a long time to diagnose Global Deterioration Scale 1 -no cognitive decline 2 -very mild cognitive decline 3 -mild cognitive decline 4- moderate cognitive decline 5- moderately severe cognitive decline 6- severe cognitive decline 7- very severe cognitive decline Depression is… Biologically based illness that affects a person’s thoughts, feelings, behaviour, and even physical health -onset often insidious, can be chronic -early morning waking-worse in morning Delirium is… -a medical emergency! -characterized by an acute and fluctuating onset of confusion, disturbances in attention, disorganized thinking and/or decline in level of consciousness. -SUDDEN ONSET 3 Types of Delirium Hypoactive Delirium- often unrecognized, sleepy 50 Hyperactive Delirium- hitting, punching Mixed Delirium- mix of both Confusion Assessment Model Feature 1- Acute Onset or Fluctuating Course Feature 2- Inattention Feature 3- Disorganized Thinking Feature 4- Altered Level of Consciousness *The diagnosis of Delirium by CAM requires the presence of features 1 and 2 and either 3 and 4* Delirium Prevention - determine the risks - hydration - nutrition - limiting tubes (IV and catheters) - hearing aides and glasses on - white orientation boards and clocks - introduce yourself Causes of Delirium - medications- 40%, (benzos) - infectious processes, respiratory and urinary tract infections - dehydration and electrolyte imbalance - metabolic imbalances - hypoxia Responsive Behaviours (Delirium) -gestures, words, or actions used, often unintentionally to communicate personal meanings, needs or concerns related to the individual’s personal, social or physical environment. Psychotic Features -illusions -delusions/paranoia -hallucinations -psychotic features are not responsive behaviours! 51 Strategies Assessment- recognizing anxious behaviours and potential causes. Look for cause of behaviours: -individuals’ physical issues -individuals’ psychological issues -individuals’ cognitive issues -individuals’ environmental issues= multiple distractions, unfamiliar routine, inconsistency of tasks/staff. Person-Centered Approach -focusing on the person’s abilities and skills. -reassuring the individual and being positive. -adapting the environment, communication, intervention for the individual. Plan and implement- nonpharmacological interventions first. Evaluate, adapt, & communicate- doing more of an ineffective intervention is not helpful. Prevention- structuring the environment and activities to reduce stressors. WEEK 9: ETHICS Learning objectives 1) Discuss how values are developed * shape our perspectives 2) Discuss the role of values in the study of ethics 3) Describe some basic ethical philosophies relevant to healthcare 4) Explain the relationship b/w ethics & professional nursing practice Intermingled Day 1 & Day 2 Applications 52 1) Discuss how values influence patient care 2) Explain the relationship between ethics and professional nursing practice 3) Apply a method of ethical analysis to a clinical situation Values Right vs. wrong - Rights vs. Duties Kohlberg What is in it for me? There’s me and sometimes you Shift - How will my actions affect others I know? Society at large? Shift - Balance; I don’t have to conform – my values and principles are Social contracts - constant improving in society BUT basic rights Self-chosen ethical principles – universal and consistent and rounded Beyond the basics Values Clarification Describe a personal or professional experience in which you felt uncomfortable, in which you believe your beliefs and values were being challenged, or in which you believe your beliefs and values were different from others… 1. How did you feel? 53 2. What values of yours? *Where did they come from* 3. How were the other person’s values different? 4. How did you react? 5. Would you change anything for the next time? Practice Standards for Regulated Members 1. Responsibility and Accountability 2. Knowledge-Based Practice 3. Ethical Practice 4. Service to the Public 5. Self-Regulation Carries the weight of law. Five practice standards, the third one requires nurses to adhere to the Code of Ethics Notice that all of the standards have an ethical underpinning 54 Ethics • Study of good conduct, character, and motives • Philosophical ideals of right and wrong • What matters most to people or professions Deontology • Free to act – it seems good for most of us Utilitarianism • Free to act - it seems good for most of us • What will the outcome be? Feminist ethics • Decisions/actions benefiting men > women? Bioethics: at the bedside Beneficence 55 • Autonomy • Justice • Non-maleficence Page 38, Code of Ethics (CNA, 2017) Code of Ethics (CNA, 2017, p. 14-23) • Providing safe, compassionate, competent, ethical care • Promoting health and well-being • Promoting and respecting informed decision making [autonomy] • Honouring dignity • Maintaining privacy and confidentiality • Promoting justice [justice] [Beneficence and non-maleficence] • Being accountable https://www.cna-aiic.ca/html/en/Code-of-Ethics-2017-Edition/files/assets/basic-html/page18.html Guiding principles accepted by all members Settling questions about all members actions at work What we are responsible for – duty to perform action thoughtfully and adequately; {COE} 56 How we can be accountable – answer to your actions (patient, profession, employer and society) – keep up with standards {SOP}, laws and regulations, competence to provide these practices, healthy or fit enough to do so, share knowledge What we advocate for* (intervene on behalf of another to minimize suffering, protect privacy and confidentiality, promote health and social conditions for living and dying with dignity advocate for mental health services) 57 In Alberta and across Canada, HPA The college must establish, maintain and enforce a code of ethics, Schedule 24 of the HPA - In their practice, registered nurses do one or more of the following: (a) based on an ethic of caring and the goals and circumstances of those receiving nursing services, registered nurses apply nursing knowledge, skill and judgment to assist individuals, families, groups and communities to achieve their optimal physical, emotional, mental and spiritual health and well-being, (ii) assess, diagnose and provide treatment and interventions and make referrals, (iii) prevent or treat injury and illness, (iv) teach, counsel and advocate to enhance health and well-being, (v) co-ordinate, supervise, monitor and evaluate the provision of health services, (vi) teach nursing theory and practice, (vii) manage, administer and allocate resources related to health services, and (viii) engage in research related to health and the practice of nursing, and (b) provide restricted activities authorized by the regulations. Relational Ethics is….. A way of ‘being’ with others, families, communities or colleagues. Environment & Embodiment Mutuality (Mutual Respect) *being accountable, i.e. fit to practice, and sharing knowledge *promoting and respecting informed decision making Engagement Autonomy: What does the person want? How well has the person been informed and/or supported? What explicit or implicit promises have been made to the person? (CNA, 2017, p. 38) 58 Relational autonomy: What relationships or structures are affecting various individuals involved in the situation? How can these relationships and structures be used to enable support of the person, family members, and health-care providers? (CNA, 2017, p. 38) Fidelity: Are you fostering trust in the person/family/team relationships? (CNA, 2017, p. 38) Relational ethics; focuses on the role of relational context or the experience of the relationship in shaping moral choices. A relational inquiry approach offers inquiry processes to assist in deciding how to “do good” Four themes 1. Environment; health care system affects the nature of relationships 2. Embodiment; healing cannot occur unless the scientific knowledge and human compassion are given equal weight. 3. Mutuality; a relationship that benefits both you and the patient and harms neither. (non-judgmental) Mutual respect is person-focused and its vision encompasses oneself equally with others (Dillon 1992: 129 note 30). Mutual respect for difference and what it means to be a person--some of the ethics literature has explored personhood from a perspective of cognitive ability, etc. but the disability community and the non western cultures have awakened us to the limitations of that perspective Mutualism is not sacrificing the well-being of one for the sake of another (Dillon 1992: 129 note 30). This means, of course, that mutual respect expects one to care for oneself, and caring for oneself includes continually growing in self-understanding 4. Engagement; connecting with another person in an open trusting and responsive manner. (therapeutic professional relationship not a social relationship) 59 Issues are relational in nature • Patient care issues, i.e. Informed consent • Issues of safety in the work environment • End of Life: futile care, ACP, MAID* *Bill C14 1. https://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent 2. https://www.albertahealthservices.ca/info/Page16124.aspx 3. Nurse does not legally assume the duty of obtaining informed consent but witnessing the consent and ensures that the following has been done by the physician and that the patient’s signature authentic and that the patient appears to be competent to give consent. Refusal of treatment or medication must be documented in full. Creates a legal duty for the physician and other healthcare providers to disclose material facts in terms that the patient can reasonably understand. Describes treatment alternatives, risks, benefits. 4. Professional Boundaries (“territory”) 5. a professional relationship 6. moral disengagement 7. Informed consent 8. Competence; surrogates 9. Presumed consent for organ donation 10. Truth-telling (e.g., placebos) 11. Beginning of Life 12. Genetic testing, Eugenics 60 13. Moral status of fetus 14. End of Life 15. Futile care 16. Active euthanasia (MAID) 17. Withdrawal of food and hydration 18. Resource allocation 19. Funding health care Next Class Ethical issues & dilemmas Case study • Ethical issues You have been assigned to care for a `98-year-old woman who was recently admitted with a diagnosis of pneumonia. She has a history of cardiac disease and takes a number of medications. She has been fairly active until the past few days, when her cough worsened and a fever developed. You note her pulse has become weak and threadlike and that her respirations are increasingly labored. When you mention to the family that you may need to call the physician and even take heroic life-saving measures, the patient’s son and daughter become distraught, saying that they do not want their mother to be kept alive on ‘machines’. The report that they have discussed this situation with their mother. You find that her wishes have not been documented in her chart. The family members have not discussed this situation with the patient’s primary physician. 1. What actions would you consider taking at this moment? Think of why, in relation to autonomy and beneficence, and futile care. 2. What are your personal values at the end of life? • Ethical dilemma A conflict between two sets of human values both of which are judged to be “good” but neither of which can be fully served (p. 92) • Ethical Dilemmas (conflict) • Determine whether the issue is an ethical dilemma 61 • Gather all relevant information • Examine and determine you own values on the issue *Page 35 COE Verbalizing the problem: agreement is important • Consider possible courses of action: options, values? • Reflect on the outcome (delicate – ethics meeting? Decision?) *page 35 & 36 COE Choose an action – constant reflection (p. 36, COE) • Evaluate action and outcome (INTD meeting with patient) *Page 36 COE • Dilemma Analysis You have received into care a 35-year-old female, who has been in a coma since her MVA 4 hours ago. She has an abdominal bleed and requires surgery. She is married. Her husband does not share her religious beliefs. There is no personal medical directive. You have been informed by him that her religious beliefs state she cannot receive any blood products. Due to the loss of blood your patient has experienced thus far she may require the administration of blood products during surgery or post operatively. While witnessing the physician trying to obtain informed consent from the husband to proceed with the surgery, the husband turns to you and says; “What would you do in my position?” 62