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Etnik dan budaya dalam keperawatan ASPEK ETNIK DAN BUDAYA DALAM KEPERAWATAN

1. ETNIK

Etnik adalah rasa identitas diri yang berkaitan dengan kelompok kultur sosial umum dan warisan budaya. Seseorang dapat dilahirkan dalam suatu kelompok etnik tertentu tetapi dapat juga mengadopsi. karakteristik dari kelompok etnik lainnya. Karakteristik dari suatu kelompok etnik termasuk bahasa dan dialek yang sama,status perpindahan,suku bangsa,dan kepercayaan serta praktik religius. Masyarakat menggunakan bersama tradisi,nilai,simbol,literatur,cerita rakyat,musik dan makanan kesukaan. 2. BUDAYA

Budaya menggambarkan sifat non fisik, seperti nilai, keyakinan,sikap,atau adatistiadat yang disepakati oleh kelompok masyarakat dan diwariskan dari satu generasi ke generasi berikutnya. E.B. Tilor, kebudayaan merupakan suatu yg kompleks, yang didalamnya mengandung pengetahuan,kepercayaan,kesenian,moral, hukum,adat istiadat, kemampuan-kemampuan lain yang dimiliki mayarakat. 3. KONSEP ETNIK DAN BUDAYA klien mempunyai wawasan pandangan dan interprestasi mengenai penyakit dan kesehatan yang berbeda,didasarkan pada kayakinan sosial-budaya dan agama klien. Jika klien menyampaikan kepekaannya pada keunikan keyakinan dalam praktik kesehatan serta penyakit kepada perewat maka akan terbina hubungan yang baik. Kultur kumpulan dari keyakinan, praktik, kebiasaan, kesukaan, ketidak sukaan, norma, adat istiadat & ritual yang dipelajari dari keluarga selama bertahun-tahun. Etnisitas rasa identitas diri yang berkaitan dengan kelmpok sosial umum & budaya. Agama/religi keyakinan dalam suatu kekuatan sifat ketuhanan yang harus dipatuhi & diibadatkan sebagai pencipta & pengatur alam semesta 4. KETERKAITAN ETNIK DAN BUDAYA DALAM KEJADIAN PENYAKIT Setiap pasien mempunyai latar belakang budaya,etnik,keagaman ,dan sosial dari individu, keluarga atau komonitas ketika mengatisipasi atau mengalami suatu penyakit atau krisis,individu bisa saja menggunakan pendekatan modern atau tradisional untuk pncegahan dan penyembuhan, atau mungkin menggunakan

kedua

pendekatan

tersebut.

Keyakinan tradisional tentang kesehatan dan penyakit Keyakinan tradisional keyakinan rakyat didasarkan oleh kultur sering menentukan definisi kesehatan dan penyakit bagi orang yang mempunyai keyakinan tradisional. 2. Praktik tradisional Banyak praktik tradisional digunakan untuk mencegah mengatasi penyakit,praktik ini termasuk penggunaan benda,bahan,dan praktek keagamaan yang juga dikenal sebagai pengobatan rakyat. 5. Keragaman dari pengobatan tradisional

Pengobatan rakyat alamiahPengobatan yang menggunakan lingkungan alamiah dan menggunakan herbal,tumbuhan,dan subtansi hewan yang mencegah dan mengatasi penyakit Pengobatan rakyat magisoreligius Pengobatan menggunakan kata kata ramah suci, dan tindakan suci untuk mencegah dan menyembuhkan penyakit. etnik dan budaya dengan kejadian penyakik

6.

Aplikasi

Beberapa model teoritis untuk penilaian budaya yang tersedia. Model Leininger adalah pendekatan sistem luas untuk mencapai pemahaman budaya. Dia mengidentifikasi kategori isi budaya sebagai kekerabatan pendidikan, ekonomi, politik, hukum,, agama, filsafat, dan teknologi. Giger dan Davidhizer mengusulkan bahwa keperawatan mempertimbangkan fenomena berikut untuk kepentingan budaya mereka: komunikasi; ruang, waktu; pengendalian lingkungan; variasi biologis, dan organisasi sosial. Model Campinha-Bacote pandangan kesadaran budaya, pengetahuan budaya, keterampilan budaya, dan pertemuan budaya sebagai komponen kompetensi budaya dalam keperawatan pemberian perawatan

Pengkajian keperawatan Diagnosa keperawatan Masalah potensial dalam interaksi dengan sisitem perawatan kesehatan dan masalah yang melibatkan pengaruh terhadap kultur.

Perkembangan dari daftar masalah yang dapat berupa pertanyaan tentang interprestasi klien mengenal masalah dan kemungkinan intervensi efektif Perencanaan dan implementasi Perawat dapat mengetahui perawatan seperti apa yang dianggap klien sesuai dgn melibatkan mereka dan keluarga mereka dalam merencanakan dan dengan menanyakan tentang harapan mereka. Mendiskusikan variabel kultural dengan klien dan keluarganya selama langkah perencanaan membantu perawat mengimplementasikan keyakinan dan praktik kesehatan pribadi. Evaluasi Mencakup evaluasi diri perawat tentang sikap dan emosi yang ditunjukkan dalam memberikan asuhan keperawatan kepada klien dari latar belakang sosio-kultural yang berbeda.

BUDAYA & SPIRITUAL DALAM KEPERAWATAN PREFACE

perawat perlu memahami dan peka tentang beragam etnik,budaya dan spiritual yg memiliki makna subyektif thd kesehatan, keadaan sakit,asuhan,& praktek penyembuhan Perspektif etnik,budaya dan spiritual visi dianggap penting bagi perawat & pelayanan kesehatan profesional lainnya dlm mengantarkan pelayanan kesehatan yg berkualitas kepada semua kliennya perawat harus mengerti bagaimana budaya dan keyakinan mereka sendiri kepercayaan rohani terkait dg keyakinan & budaya klien yg berbeda

PREFACE

pelayanan kesehatan profesional tidak diharapkan memahami semua budaya agama di dunia; ini mungkin,namun demikian diharapkan dpt mengembangkan kesadaran kebudayaan & sistem kepercayaan di daerah dimana mereka bekerja. perawat harus menyadari meskipun orang dari berbagai etnik memiliki berbagi kepercayaan, nilai, pengalaman tertentu, sering ada juga berbagai intra-ethnic yg tersebar

Having knowledge of a culture before trying to help a client and family is analogous to a nurse or a physician having basic knowledge of anatomy and physiology before doing physical assessment or attempting to meet a patients physical needs. Madeleine Leininger WHY..?

Having the skills, both academic and interpersonal, that enable a person to understand and to appreciate cultural differences and similarities within, between, and among groups. A process by which healthcare providers strive to work within the cultural context of people from diverse cultural or ethnic backgrounds.

When..?

When clients receive an overall message, conveyed both verbally and nonverbally, of personal and cultural validation. Providers integrate the clients value system, life experiences, and expectations about treatment into the therapeutic process, even when client is not fully aware that it is happening.

Despite being technically competent, a nurse can be incompetent, formulating unworkable interventions because of an unwillingness or inability to understand the culturally different patient. (West, 1994, .232)

But before trans-cultural nursing can be adequately understood, there must be a basic knowledge of key terminology such as culture, cultural values, culturally diverse nursing care, ethnocentrism, race and ethnography.

WHAT IS CULTURE ? 1. Culture: the integration of human behaviors (including thoughts, communications, actions, customs, beliefs, values, and institutions) of a racial, ethnic, religious, or social group. 2. Can greatly influence a persons perceptions of health and illness, as well as how, when, and why he or she would seek treatment. 3. Refers to norms and practices of a particular group that are learned and shared and guide thinking, decisions, and actions. 4. Keseluruhan perkembangan ide, pemikiran, kepercayaan, nilai, komunikasi, aksi-aksi, sikap, tradisi,adat, dari sekelompok orang yang menjadi pandangan/acuan bagi tindakan dlm kelompoknya

lnilai kebudayaan merup keinginan individu atau jalan pilihan dlm bertindak yg diteruskan scr turun temurun sbg suatu tindakan ataupun pengambilan keputusan. Characteristic of culture:

Culture is learned : through life experiences from birth Culture is taught: transmitted from parent to children over successive generation Culture is social: originated & develop trough interaction of people Culture is adaptive Culture is satisfying Culture is difficult to articulate Culture exist at many level

Culture Care

Refers to the values & beliefs that assist, support, or enable another person or group to maintain well-being, improve personal condition, or face death or disability Is universal, but the actions, expressions, patterns, lifestyles, and meanings of care may be different Knowledge of cultural diversity is essential for nursing to provide appropriate care to clients, families, and communities

Culture Care

Culturally diverse nursing care an optimal mode of health care delivery, refers to the variability of nursing approaches needed to provide culturally appropriate care that incorporates an individuals cultural values, beliefs, and practices including sensitivity to the environment from which the individual comes and to which the individual may ultimately return. (Leininger, 1985) TERMINOLOGY

Ethnic relates to group identification, large groups of people classified according to common traits or customs. Custom: The generally accepted way of doing things common to people who share the same culture.

Ethnocentrism the perception that ones own way is best when viewing the world (Geiger & Davidhizar, 1991). Our perspective is the

standard by which all other perspectives are measured and held to scrutiny. Ethnicity

The sense of identification that a cultural group collectively has, largely based on the groups common heritage. Race Subculture of people characterized by specific characteristics. Race Any of the different varieties of humans assumed by some people to exist, based on the discredited typological model of human variation.

Concepts of Culture and Ethnicity

Culture a set of values, beliefs & traditions that are held by a specific social group and handed down from generation to generation Subculture made up of people with a distinct identity, but who have certain ethnic, occupational or physical characteristics that are found in the larger culture Dominant group the group within the culture that has the authority to control the value system. Minority group usually has some physical or cultural characteristic that identifies the people within it as different

Cultural and Ethnic Influences on Health Care


Gender Roles It is important to know who is the dominant figure in a family Language and Communication Some clients may not be able to speak the English Language Orientation to Space and time personal space Food and Nutrition Socioeconomic

Characteristics

Feelings of despair, resignation & fatalism Day to day attitude toward life with no hope for the future Unemployment and need for financial or government aid Use of escape values such as alcohol and drugs Unstable family structure with abusiveness and abandonment Decline in self respect and retreat from community

Effects of Poverty on Health Care

Lack of affordable and adequate housing

Crowded living conditions The sick usually experience more complication Recovery time is longer Less likely to regain their preillness level of functioning Lack of access to health care insurance

Family Support

Some cultures have large extended families and are unable to share private information with anyone outside the family. Some cultures have great respect for elderly and will not consider institutional care

Physical and Mental Health

Physiologic Characteristics

Keloid formation overgrowth of connective tissue that occurs during healing process of injury, surgeryAfrican heritage Lactose intolerance lack of lactase to break down lactose during digestion Hispanic, African, Chinese, Thai. Sickle Cell Anemia sickle shaped red blood cells. Most common in African orMediterraneanethnic background. TaySacks Disease a gene for a hereditary disorder have very short life span Eastern European, Jewish descent. G6PD deficiency enzyme deficiency. Red blood cells have no cell membrane they are easily destroyed , which leads to anemia and increased billirubin levels. 10% of African American population Thalassemia genetic disorder effecting the Hgb in RBC function. Mediterranean, Asian, and African origin. Sarcoidosis formation of multiple tubercles or nodules on various parts of the body - African American population. Gout An increase of uric acid in the blood -males especially from Puerto Rican or Filipino descent. Psychological Characteristics

In most situations an individual will relate the behavior of another person to the individuals own familiar culture.

It is important to remember that what may seem perfectly reasonable & important to a client may seem ridiculous and irrelevant to a nurse. The reverse perception may also exist.

Culture Shock

Feelings an individual experiences when placed in a different and often strange culture and may result in psychological discomfort or disturbances.

Cultural Imposition and Ethnocentrism

Cultural Imposition. the tendency for health personnel to impose their beliefs practices and values of other cultures, because they believe that their ideas are superior. Ethnocentrism the belief that ones own ideas, beliefs and practices are the best and superior.

Spirituality & Religion

Spirituality refers to a subjective experience of the sacred, whereas religion involves subscribing to a set of beliefs or doctrines that are institutionalized. Spiritual Health

Caring for the whole person Accepting beliefs and experiences Helping with issues surrounding meaning and hope Spirituality- refers to that which gives life to, animates, or gives meaning to an individual Caring for a clients spiritual health means caring for the whole person and once again it means taking a look at yourself and evaluating where you stand recognizing your own spirituality and incorporating that into your care NOT forcing that into the care you provide There is an association between meaning and hope, and prayer and meditation, and health

Religion & spirituality in healing.

Prayer (doa), Chants (nyanyian gereja)

Pilgrimages (Ziarah) Fasting Amulets or talismans (jimat) Healing rituals Anointing with oil Sacraments Laying on of hands

Religion, Health & Culture


Research demonstrates positive health outcomes for people with strong spiritual and religious beliefs Congruent with holistic philosophical beliefs about human nature Dietary & lifestyle practices often promote health & prevent disease (e.g., lower incidence of heart disease among Mormons & Seventh-day Adventists) Guides moral & ethical decision making

Symbols of Ethnoreligious Identity


Shrines with Buddha, candles, incense, and various artifacts (Buddhist) Presence of prayer beads (Muslim) Amulets and talismans (charms) to ward off illness or bring good health (Mexican, Puerto Rican, & many African groups) Rosaries, religious medals, statues, votive candles (Catholics) Presence of mezuzza (small case containing torah passages on parchment usually hung in doorway)

Include Religious & Spiritual Factors in Cultural Assessment


Health-related beliefs & practices, e.g., diet, medications, medical & surgical procedures Religious calendar & holy days Healing practices Religious network for providing spiritual & emotional support for sick & dying members. Spiritual & religious healers

Religious, Cultural & Civic Holidays


Avoid scheduling medical appointments during holidays Avoid disruption to holy days (such as fasting during Ramadan)

Promoting Effective

Cross-Cultural Communication.. What do Limited-English Speakers Want? Speaking ones native language is.

Easier when feeling ill More comfortable More accurate

What is unsafe practice with Limited-English speakers?


Using family members as interpreters Recruiting ad hoc (or untrained) interpreters Writing instructions in English

Interpreter errors cause medical errors (Levine, JAMA, 2006) Why not use a family member as an interpreter?

Office for Civil Rights (OCR) Policy Guidance (2000) states that untrained ginterpretersh: May not understand the concepts or official terminology they are asked to interpret or translate Obstruct the flow of confidential information to the provider. Fail to disclose intimate details of personal and family life; Clinicians, too, refrain from candid discussions with untrained interpreters present.

Requirements in Using a Translator

Use approved Interpreter Services

OR

Use the Interpreter Telephone Using Appropriate Interpreter Services in Clinical Care Speak with Charge Nurse for assistance Call Operator to place call 1-800 number Client code/ID Request language

Directness in Clinical Encounters

Americans value directness:

Spit it out Say whats on your mind

Languages that depend on subtle contextual cues:

Infer meaning Imply, but do not state, the point (Japanese, Arabic) Directness and Subtlety

Maybe or That would be difficult is probably a polite no Avoid yes/no questions Phrase your inquiry as a multiple choice question

Nonverbal Communication

Facial expressions, body language, & tone of voice play a much greater role in cultures where people prefer indirect communication & talking around the issue.

Gestures and Facial Expressions


Another culturally influenced aspect of communication is the demonstration of emotion, such as joy, affection, anger, or upset. Most Koreans, for instance, are taught that laughter & frequent smiling make a person appear unintelligent, so they prefer to wear a serious expression. While Americans widen their eyes to show anger, Chinese people narrow theirs. Vietnamese, conversely, consider anger a personal thing, not to be demonstrated publicly. Smiling & laughter may be signs of embarrassment & confusion on the part of some Asians. Talking with ones hands is more common in southern Europe than in northernEurope. A direct stare by an African American or Arab is not meant as a challenge to your authority, while dropped eyes may be a sign of respect from Latino or Asian patients & coworkers.

Gestures

Use gestures with care, as they can have negative meanings in other cultures. Thumbs-up and the OK sign are obscene gestures in parts of South America & theMediterranean. Pointing with the index finger and beckoning with the hand as a come here sign are seen as rude in some cultures much as snapping ones fingers at someone would be viewed in the United States. American culture generally expects people to stand about an arms length apart when talking in a business situation. Any closer is reserved for more intimate contact or seen as aggression. In theMiddle East, however, it is normal for people to stand close enough to feel each others breath on their faces.

Touch

Different rules about who can be touched & where. A handshake is generally accepted as a standard greeting in business, yet the kind of handshake differs.

North America= hearty grasp Mexico= softer hold Asia= soft handshake with the second hand brought up under the first is a sign of friendship & warmth Touch

Religious rules may apply to appropriate touch.

Touching between men & women in public is not permitted by some orthodox religions, so a handshake would not be appropriate.

Ideas about respect are conveyed through touch

Touching the head, even tousling a childs hair as an affectionate gesture, would be considered offensive by many Asians. If you need to touch someone for purposes of an examination, explain the purpose & procedure before you begin. Topics Appropriate for Discussion

What is acceptable for nurse and patient to discuss?

Many Asian groups regard feelings as too private to be shared.

Latinos generally appreciate inquiries about family members, while most Arabs & Asians regard feelings as too personal to discuss in business situations. In social conversations, Filipinos, Arabs, & Vietnamese might find it completely acceptable to ask the price you have paid for something or how much you earn, while most Americans would consider that behavior rude. Inappropriate Conversation Topics

Even a seemingly innocuous comment on the weather is off limits in the Muslim world, where natural phenomena are viewed as Allahs will, not to be judged by humans. This points to another aspect that relates to privacy. To many newcomers, Americans seem naively open. Discretion and purposeful communication help us judge when to converse and when to be silent.

Privacy

Discussing personal matters outside the family is seen as embarrassing by many cultures. Thoughts, feelings, & problems are kept to oneself in most groups outside the dominant American culture. Privacy boundaries may have implications when medical problems are exacerbated by personal or family problems.

Saving face.

In Asia, the Middle East, & to some extentLatin America, ones dignity must be preserved at all costs. Death is preferred to loss of face in traditional Japanese culture, hence the suicide ritual, hara-kiri, as a final way to restore honor. Any embarrassment can lead to loss of face, even in the dominant American culture. To be criticized in front of others, publicly snubbed, or fired, would be humiliating in most any culture. Seemingly harmless behaviors can be demeaning to some patients.

The Culturally Competent Clinician

Attitudes of the Culturally Competent Clinician Understanding: Acknowledging that there can be differences between our Western and other cultures healthcare values and practices. Empathy: Being sensitive to the feeling of being different.

Patience: Understanding the potential differences between our Western and other cultures concept of time and immediacy. Ability: To laugh with oneself and others. Trust: Investment in building a relationship with patients, which conveys a commitment to safeguard their well-being. Non-Verbal Communication All cultures have rules, often unspoken, about who touches whom, when & where. Nonverbal Communication (~65% of all communication)

Touch Facial expressions Eye movements Body posture

Cultural Perspectives on Modesty (kerendahan hati) Patients may prefer clinicians of the same gender May be taboo for males to examine or treat females (e.g., Middle Eastern groups) In some Asian & Hispanic cultures, older adults may believe that hospital gowns cause disease by exposing them to cold drafts (related to yin/yang & hot/cold theories of disease) Pain and Cultural Competence : Reaction to Pain

Reactions are culturally prescribed Lets discuss

..

Pain and Culture

Pain is an abstract concept which can be referred to as:

A personal private sensation A stimulus that signals harm

A pattern of behavior to protect from harm Pain Experience

Pain is a universal human experience, but pain reactions are unique to the individual and includes thoughts, feelings, reactions, expectations and past experiences associated with pain. The experience of pain can also be described in physiologic, psychosocial, economic and spiritual contexts.

What is Included in a Pain Assessment Cross-Culturally?

Pain Expression: Verbal and non-verbal behaviors, including gestures and tone of voice. Pain Language: Word(s) used to describe pain. Language or other communication techniques such as pointing to site of pain. Religious Beliefs: Meaning of pain or suffering. Rituals and taboos associated with pain or pain treatment.

Pain Assessment and Cultural Factors


Social Roles: Ethnic identity and degree of acculturation: such as primary language used, identification of social support networks. Family relationships, consider the role(s) the individual has within the family, extended family presence and role in community (such as employment). Gender and Age Influences. Perception of the healthcare system: Trust vs. suspicion. remedies. Past experience with the healthcare system. Use of traditional/lay

Pain Treatment and Cultural Factors

Attitudes and fears about pain medications or other interventions may impact the patient and/or family compliance with a pain treatment plan. Physiologic response to medications has race and age variations. For example, body composition of fat and serum protein in the elderly may alter distribution and absorption of medications. Also elicit patient beliefs about: Meaning of pain or illness. Expectations of healthcare providers. Therapeutic goals.

Barriers

Typical barriers to a cultural sensitive pain assessment and treatment by healthcare providers include:

Stereotyping. Lack of empathy. Ethnocentrism. Language. Experience or expertise of practitioner and time constraints. National Institutes of Health

Facilitates research and evaluation of complementary and alternative practices Provides information about a variety of methods

What is complementary and alternative medicine?


Includes a broad range of healing philosophies, approaches & therapies A therapy is called complementary when it is used in addition to conventional biomedical/scientific treatments An alternative therapy is used instead of conventional biomedical/scientific treatments. Conventional refers to those widely accepted & practiced by the mainstream medical community

Complementary &

Alternative Therapies Complementary Therapies: What is the Clinical Goal?

Gain the patients trust so he/she will tell you the truth about alternative and complementary practices used to treat pain or other symptoms.

What Does the Clinician do with a Patient Using Complementary Therapies?


Check for drug interactions with prescription or over-the-counter medications Assess for harmful side effects Discourage over-reliance on traditional healing if it delays necessary biomedical treatment (for example, conditions for which an antibiotic is needed)

Meta-Communicative Cultural Competence


Pay attention to body language, facial expressions & other behavioral cues; much information may be found in what is not said Avoid yes/no questions; ask open ended questions or ones that give multiple choices; remember that a nod or yes may mean: Yes, I heard rather than Yes, I understand or Yes, I agree

Meta-Communicative Cultural Competence

Consider that smiles & laughter may indicate discomfort or embarrassment; investigate to identify what is causing the difficulty or confusion Make formal introductions using titles (Mr., Mrs., Ms., Dr.) & surnames; let the individual take the lead in getting more familiar

Meta-Communicative Cultural Competence


Greet patients with Good Morning or Good Afternoon and when possible, in their language If there is a language barrier, assume confusion; watch for tangible signs of understanding, such as taking out a drivers license or social security card to get a required number

Meta-Communicative Cultural Competence

Take your cue from the other person regarding formality, distance, and touch

Question your assumptions about the other persons behavior; expressions & gestures may not mean what you think; consider what a particular behavior may mean from the other persons point of view Explain the reasons for all information you request or directions you give.

Meta-Communicative Cultural Competence


Use a soft, gentle tone and maintain an even temperament Spend time cultivating relationships by getting to know patients & coworkers Be open to including patients family members in discussions & meetings with patients Consider the best way to show respect, perhaps by addressing the head of the family or group first

Meta-Communicative Cultural Competence


Use pictures & diagrams where appropriate; Pay attention to subtle cues that may tell you an individuals dignity has been wounded Recognize that differences in time consciousness may be cultural & not a sign of laziness or resistance

ESSENTIAL SKILLS FOR CULTURALLY COMPETENT NURSING CARE


Cross-cultural Understanding Intercultural Communication Facilitation Skills Flexibility