Culturally-competent nursing
Culturalogical assessment is significant while providing nursing care to individuals, families, groups and institutions of diverse cultures and backgrounds. Leininger’s theory of culture care diversity and universality (CCDU) emphasizes on the vital role of nurses in entering the client’s world to discover cultural knowledge embedded within individual and family values. Therefore, nurses should be knowledgeable about the client’s culture and factors influencing their needs and lifeways.
In today’s era of globalization, diverse populations are disseminated in all corners of the world. Barriers exist in the healthcare practices for the diverse populations and there is widening disparity in healthcare quality and access for minority communities. Leininger’s CCDU strongly opposed the tendency of healthcare workers to impose their own belief system to other people and communities. This theory advocates the culturally congruent nursing care for all patients irrespective of their community and belief system. Thereby, it promotes cultural competence in the nurses (Sagar, 2012). Cultural competence is an integral part of transcultural nursing and involves the nursing skills demonstrating sensitivity to cultural differences in the areas of heritage, ethnicity, socioeconomic and cultural backgrounds and sexual orientation (Doostan, 2000).
The LGBT community
Most of the cultures strongly disapprove the people with sexual identities deviating from heterosexuality. Therefore, a largely unrecognized and marginalized community in terms of healthcare provision is lesbian, gay, bisexual and transgender (LGBT) population. Although these four populations are different from each other, they are often seen as one community. The discriminatory nature of present healthcare set up assumes that all patients are heterosexual and therefore, a homophobia is expressed by a significant proportion of healthcare providers (Albarran & Salmon, 2000; Eliason, 1993).
Healthcare needs of LGBT population
The gay, lesbian and bisexual adolescents face the marginalization and isolation at the time of the development of their individual and social identities. This leads to a negative self-esteem which in turn affects their self-care and health seeking behavior. This may also lead to increased risks for their physical and mental health. Studies have revealed that a leading cause of deaths in lesbian, gay and bisexual youth were suicides. Adolescents with same sex experiences are at an elevated risk of injury, disease and death because of violence, substance abuse, victimization and suicides. Overall, homosexual adolescents are at high health risks as compared to their heterosexual peers. They are harassed, threatened and assaulted because of their sexual orientation (Doostan, 2000).
Since the expression of externalized and internalized homophobia are most pronounced during adolescence, there is an increased risk of violence against gay, lesbian and bisexual adolescents. This violence may include threatening, verbal abuse, physical assaults and injury with weapons. All these experiences lead to stress and detrimental effects on the mental health of these adolescents (Doostan, 2000). The chronic stress posed by parents, teachers and peers have long-term implications in terms of physical and psychological well-being of gay and lesbian adolescents. Stress-related eating disorders, hypertension, bipolar psychiatric disorders, depression and increased incidence of physical illness such as skin cancer & infectious disease have been positively correlated with the chronic stress in these youth (Hoffman, Freeman & Swann, 2009).
All sexually active adolescents risk sexually-transmitted disease including HIV. In a study done on HIV-positive adolescents in New York city, 87% of the youth were gay males (Doostan, 2000). These men are particularly at high risk for HIV because they are likely to engage in high risk behaviors, including unprotected sex. For bisexual females, greater risks of pregnancy, sexually-transmitted disease and HIV exists because of unprotected heterosexual contacts. The risk of pregnancy of lesbian youth is severely underestimated. These females put themselves at risk of pregnancy to deny or hide their sexual orientation (Bakker & Cavender, 2003). Apart from HIV, syphilis and gonorrhea are the most common STDs seen in gay men. Antibiotic resistant gonorrhea is also more prevalent in gay men amongst LGBT community. The rate of human papilloma-virus associated anal cancer is seventeen times higher in gay men as compared to heterosexual men (Ard & Makadon, n.d.).
Since gay youth adopt a wide range of sexual practices, they have specific healthcare needs with regard to medical problems including hepatitis, HIV and other STDs. Use of condoms is not common in the monogamous gay youth during anal intercourse. Gay couples may seek healthcare for a number of psychosocial and sexual dysfunctional issues. Gay clients with HIV/AIDS may also require counseling and interventions. Therefore, nurse specialists may educate those regarding treatments, tests and HIV infection. Caring for gay men also involves counseling about relationships, safer sex and emotional issues (Taylor & Robertson, 1994).
In a web-based survey conducted on 788 LGBT youths, it was found that this community sought healthcare in a wide range of arenas. These youth sought help for mental health problems like depression, suicidal feelings, drug & alcohol use, smoking, etc. The physical health issues faced by them included nutrition, holistic and complementary treatments, tattooing and body piercing. They also had reproductive health challenges like testicular problems, pregnancy prevention, menstrual and other gynecological problems. Transgender youth specifically faced gender issues like taking masculinizing or feminizing hormones and talking to parents about being transgender (Hoffman, Freeman & Swann, 2009). These populations are at a higher risk of developing cancer, have higher rates of cigarette smoking & alcohol use and have more issues with body image (Neville & Henrickson, 2006). Lesbians are more likely to be obese as compared to heterosexual women. Lesbian and gay adolescents more commonly engage in unhealthy eating behaviors than heterosexual youth (Ard & Makadon, n.d.).
Creating culturally-competent nursing interventions
The key questions here are “What do nurses need to know about LGBT community in order to provide a quality healthcare? And should the knowledge of homosexuality be a part of culturally-competent or transcultural nursing care?” The lack of understanding and judgmental attitudes by the nurses may lead to alienating experiences for lesbians, gay men and their families. Studies have shown that lesbian, gay and bisexual people experience social isolation, neglect and inadequate healthcare provision by nurses. These experiences are manifested by reduced contact with the nurses, avoidance, abandonment, and less professional interactions. Owing to the indignity, insecurity and negative reactions of the healthcare providers, LGBT community delays the decision of seeking treatment which may have serious consequences (Albarran & Salmon, 2000).
The most important thing that the nurses should do is to contemplate on their own feelings about lesbian, gay and bisexual people. If a nurse feels uncomfortable working with these clients, she may convey the message of discomfort with non-verbal communication including absence of eye contact, physical distance, avoiding touch, etc. Hence, the client may feel discriminated (Eliason, 1993). In the critical care setups, patient’s sexuality of not much of an issue because the nurse focus on keeping the patient alive. However, owing to their judgmental views, critical care nurses may also label the HIV/AIDS patients of LGBT community as undeserving of care and are referred to as ‘bed blockers’ (Albarran & Salmon, 2000).
In order to help nurses in the delivery of culturally-competent care, various theories and assessment models have been proposed. Leininger’s Sunrise model links the nursing care practices with individuals, families, groups and communities and the factor affecting them such as technology, philosophy, society culture, politics, economics and education. Similarly, several other tools relating to culturally-competent nursing care have been proposed. However, these tools do not include sexual orientation as one of the factors affecting individuality of a person. Therefore, it is necessary to consider cultural differences in sexual behavior in nursing assessment and nursing intervention (Doostan, 2000).
In order to be able to provide a culturally-competent care, the nurse should talk about her discomfort with her supervisor, attend workshops/classes on the issue, and read about gay, lesbian & bisexual cultures and role play with other nurses. Overall, nurses should be aware of the unique healthcare needs of LGBT community and examine their own cultural belief systems about same-sex relationships. Negative and un-informed attitude may lead to poor quality of care provided and therefore, disrupts the nurse-client relationships (Eliason, 1993).
Culturally competent care can only be provided to LGBT community if the nurses remain sensitive and aware. Undoubtedly, the nurse will not realize the sexual identity or orientation of these individuals until they disclose it to her. However, in any healthcare setup, especially schools, the nurses need to create a comfortable setting where the youth may seek support and help for their concerns. At the same time, the adolescents must not be forced to reveal their sexual identity before they are ready to do so.
Nurses should examine their own feelings, values and stereotypes regarding homosexuality. But they need not change their personal beliefs on the issue. However, if they face intrapersonal conflict and discomfort, they can use four cross-cultural communication skills to meet their professional and legal responsibilities while serving LGBT adolescents. The first skill involves recognizing one’s own personal behavior that causes insecurity and resistance in others. If the nurse assumes that everyone is heterosexual and refuses to understand the health damaging effects of stigma of LGBT adolescents, it will create defensiveness in the youth. To reduce the intrapersonal challenges and obstacles, nurses may attend workshops or read about LGBT cultures. Nurses may promote their understanding of the community by contacting the other members of this community. This may also reduce prejudice, discrimination and negative stereotyping.
The second cross-cultural communication skill involves taking actions to decrease the resistant and defensive behavior in the LGBT adolescents. The nurses should explain and practice confidentiality of health interactions. This helps the youth to feel safe and seek healthcare or information. The nurses should demonstrate non-judgmental caring and display gay inclusive posters & educational material in the school settings.
The third communication skill makes the nurse able to describe and explain the issue from a third person’s perspective. Nurse may have readily available resources for LGBT adolescents to help them deal with their parents, teachers and peers. Nurses may also support families having difficulty in understanding their children. The nurses working in school setups must ensure that the school provides a safe learning environment and prohibits discrimination on the basis of sexual orientation (Bakker & Cavender, 2003).
The fourth communication skill involves acknowledging that mistakes will be made. The most common mistake made during an open conversation is the assumption that everyone is heterosexual. Therefore, a nurse should have a communication error recovery skill to accomplish positive outcomes in case of healthcare provision and consultation. These communication skills serve as the strategies for being more culturally-competent and help address the unique health needs of LGBT adolescents (Bakker & Cavender, 2003). Healthcare providers including nurses who work with adolescents should be prepared to provide quality care and support to the LGBT community. Unless the healthcare providers are aware of their own bias and inadequate knowledge of LGBT community, they will not be able to provide the necessary referrals and resources (Doostan, 2000). Since nurse are the first point of contact in the primary healthcare, they should ensure that they give opportunities for the disclosure of sexual identity of the patient and also seek permission from him/her to pass their information to other healthcare professionals involved in their care (Neville & Henrickson, 2006).
In the present healthcare setups, the registration forms require the people to state whether they are single, married, divorced or widowed. This contributes to the feeling that a member of LGBT community is ‘invisible and unwelcome’ (Doostan, 2000). Therefore, intake forms should be revised to be inclusive of LGBT identities. The information about the sexual identity of a person may also be added in the electronic health records. Nurses need to reconsider their approach that all healthcare users are heterosexual. They should create an environment inclusive of LGBT community.
References
Albarran, J. W. & Salmon, D. (2000). Lesbian, gay and bisexual experiences within critical care nursing, 1988-1998: A survey of the literature. International Journal of Nursing Studies, 37, 445-455.
Ard, K. K. & Makadon, H. J. (n.d.). Improving the healthcare of lesbian, gay, bisexual and transgender people: Understanding and eliminating health disparities. The Fenway Institute. Retrieved from http://www.lgbthealtheducation.org/wp-content/uploads/12-054_LGBTHealtharticle_v3_07-09-12.pdf.
Bakker, L. J. & Cavender, A. (2003). Promoting culturally competent care for gay youth. The Journal of School Nursing, 19(2), 65-72.
Doostan, L. G. (2000). Adolescent homosexuality and culturally competent nursing. Nursing Forum, 35(3), 13-20.
Eliason, M. J. (1993). Cultural diversity in nursing care: The lesbian, gay or bisexual client. Journal of Transcultural Nursing, 5(1), 14-20.
Hoffman, N. D., Freeman, K. & Swann, S. (2009). Healthcare preferences of lesbian, gay, bisexual, transgender and questioning youth. Journal of Adolescent Health, 45, 222-229.
Neville, S. & Henrickson, M. (2006). Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing, 55(4), 407-415.
Sagar, P. (2012). Transcultural nursing theory and models: Application in nursing education, practice and administration. New York: Springer.
Taylor, I. & Robertson, A. (1994). The health needs of gay men: A discussion of the literature and implications or nursing. Journal of Advanced Nursing, 20, 560-566.
