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Ethics Paper

Michael Johnson

James Madison University


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Introduction

What is cultural sensitivity? According to Harkess and Kaddoura (2015) it is the complex

integration of knowledge, attitudes, and skills that enhance cross-cultural communication and

appropriate effective interactions with others, and in the health care professions, it is important to

be culturally aware when treating all patients (p. 212). The Agency for Healthcare Research and

Quality (2016) claims [delivering culturally and linguistically appropriate care] can move

organizations toward providing high quality care to vulnerable populations in a way that they can

access and understand, leading to improved health outcomes providing better overall holistic care

for patients (p. 1). The Office of Minority Health (2016) emphasizes that it is the responsibility of

the nurse to provide effective, equitable, understandable and respectful quality care and services

that are responsive to diverse cultural health beliefs and practices, preferred languages, health

literacy and other communication needs and this is a principal standard of care for all nurses

(p.1). Observing an incident of cultural insensitivity can cause ethical issues.

Background

During a womens health clinical, a nurse and I were assigned to treat a woman having an

elective C-section. The patient and her family spoke very little English, so the nurse and I worked

with an electronic translator to communicate effectively. The communication barrier between the

patient and the nurse caused some of the nurses comments to be interpreted as culturally

insensitive. The nurse made a joke during the assessment after finding bruises on the patient

asking has your husband been throwing you around the room? The patients and the familys

facial expressions changed to shock and frustration. I found I was unable to speak from

astonishment. I felt very conflicted as I did not know if I should ask to discuss the statements in

private or stay quiet. I decided not speak because there was not an opportunity where I could have

approached the nurse without undermining her authority. The nurse stated she was making a joke,
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but the sentiment did not reach the patients. Throughout the day, the nurse made more culturally

insensitive comments such as HERE in America, you will be awake during the delivery. We

dont risk harm to the mother or baby like in Iraq, and when talking to the husband she told him

You should be there for the birth of your baby. You missed your other childrens [births] so dont

miss this one. To all of these remarks, the patient became increasingly agitated and short

tempered with the nurse. The family stopped interacting with her altogether and only addressed

the doctors and myself. I attempted to establish a better relationship with the patient and her

family, as if to make up for the nurses insensitive comments. In all of these situations, the best

action I could have taken was to ensure the nurse was aware of how her statements were

perceived, and ensuring the family knew we were not trying to offend them in any way.

This entire day caused me moral distress. I felt powerless on how to address the nurse on

her comments. I did not want to come across as disrespectful to my nurse so I stopped myself from

acting. I was unsure of the most professional choice to make which would advocate for the patient

and foster a therapeutic relationship between the patient and her care team. I knew the appropriate

action was to confront the nurse about the perception of her comments and cultural differences in

Iraqi birthing processes and the nurses experiences.

Methods/Findings

The 8 Key Questions provide a great outline for analyzing this situation. These questions

guide decision making in order to produce the most ethical conclusions. These consist of fairness,

outcomes, responsibilities, character, liberty, empathy, authority, and rights, which cross-

culturally make a distinct ethical consideration (Alger, 2013, p 1.) Altogether they ensure the

decision maker is working for the best overall goal.

Fairness was not met because the nurse did not treat the patient appropriately due to the

patients nationality. She pressured the father into seeing his sons birth. In order for the
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interaction to be fair, I would need to ensure the patient receives the same polite interaction that all

other patients receive. Fairness to the patient is providing the safest, most appropriate care, free of

discrimination or bias. The next question refers to outcomes of the interaction and overall goals of

treatment. My job is to work for the best short- and long-term outcomes for the patient, family,

and myself, and the main focus for the patient was a safe delivery of her child while minimizing

pain and anxiety. We asked about the patients pain frequently and made sure she was

comfortable. We answered all her questions and reassured her of her safety. This calmed the

patient and she had a very smooth delivery free of complications. Responsibilities to the patient

involved managing her pain, addressing any and all of her concerns, communicating with the

family, receiving education in her own language, treating her appropriately, and caring for her, her

family, and her baby. The responsibility we failed to uphold was to treat the patient in a racism-

free environment. The nurse seemed to be unaware of her violations and it was my responsibility

to inform her of them. I failed as a nurse by not advocating for the patient. Should I have acted

ethically, I would have lived up to the question of character, behaving as the nurse I strive to be,

and not the nurse I was. To live up to the best of my character, I needed to stand up to the nurse

and perhaps educate her on specific cultural norms of the patients culture.

In regards to liberty, the patient had the personal autonomy to decide to have her C-section,

and the family had the right to discuss who would witness the birth. Liberty was not upheld. The

nurse pressured the father to be present for the delivery and did not allow further discussion of the

issue. The family had planned for the patients sister to watch, but the nurse caused that to change.

For the remainder of the interactions, all other aspects of liberty were met. In order to instill

empathy, I thought of how I would want my family to be treated. I would want my family to make

a decision and have the support of the care team. I did not act to create the empathetically

reciprocated environment I would have liked to create. There were many different aspects of
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authority. There was the patients authority of her religious practices and beliefs. There was the

fathers authority as the patriarch to make decisions of the family. There was the nurses authority

as an expert to do and say what she thought was best for the patient. The combination of these

authorities conflicted and this conflict altered the patients initial birthing plans.

The last of the questions refers to rights. The patient has the right to safety, proper care,

pain relief, decision making in her own care, and so much more. The nurse and care team also

have the right to encourage treatment methods, to be safe from patient retaliation, and to consult

with other care personnel without fear of belittlement or undermining. Everyone in this interaction

had rights, which crossed over other boundaries creating tension as not all rights were met.

Provision two of the ANA Code of Ethics states the nurse is responsible for commitment to the

patient, whether an individual, family, group, community, or population and this provision goes

further to state conflict resolution is imperative to care (Brown, Lachman, and Swanson, 2015. p.

269). The nurse created a sense of conflict between herself and her patients. I too failed to abide

by this as I did not do enough to resolve the conflict presented.

Conclusion

By utilizing the 8 Key Questions and the Nursing Code of Ethics, I have learned that

making an ethical decision is more than just choosing between right and wrong. It is making the

best possible choice for the patient. Looking back, there are many different aspects I should have

considered before making my decision. I realize that the right action would have been to speak up

in some capacity. If I should experience a similar situation in the future, I would ask another nurse

to observe with me and assist in handling it. Hopefully, addressing these concerns before the nurse

continues her care will make her more aware of cultural sensitivity. In the future, I will be able to

recall this situation and ensure that I am more sensitive to my patients as well as encouraging to
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my peers. Fostering a respectful cultural understanding with patients is yet another small but

significant way for nurses to provide more holistic care and compassion.
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Reference

Agency for Healthcare Research and Quality. (2016). Honing cultural and linguistic

competence- AHRQ. Retrieved from https://innovations.ahrq.gov/topic-

collections/honing-cultural-and-linguistic-competence

Alger, J., Sternberger, L., & Goldstein, B. (2013). The madison collaborative: ethical reasoning

in action. Harrisonburg, VA: James Madison University.

Brown, J., Lachman, V., and Swanson, E.O. (2015). The new code of ethics for nurses with

interpretive statements (2015): practical clinical application, part 1. Ethics, Law, and

Policy 24(4). 268- 271. http://nursingworld.org/MainMenuCategories/EthicsStandards/

CodeofEthicsforNurses/Code-of-Ethics-2015-Part-1.pdf

Harkess, L. and Kaddoura, M. (2015). Culture and cultural competence in nursing education

and practice: the state of the art. Nursing Forum: An Independent Voice For Nursing,

51(3), 211-222. doi: 10.1111/nuf.12140

US Department of Health and Human Services Office of Minority Health. (2016). The national

CLAS standards. Retrieved from http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2

&lvlid=53