Inuit Culture and Multicultural Competency

When I think of multicultural competence I think of ice patterns on a window...multifaceted, layer upon layer and intricate.

We are called as nurses to consider three aspects in the quest for multicultural competency….

1.     Awareness of own assumptions, values, biases

2.     Knowledge about the culture.  Separation from the client’s community may be especially difficult in this client population.

3.     Skills.  It seems to me that with individuals from an Inuit cultural background that attention to non-verbal communication would be particularly important.  The 3 V’s and B

·      Visual: patterns of eye contact

·      Vocal Qualities:  tone and speech rate

·      Verbal Tracking: following the client

·      Body Language:  attentive authentic and mirroring would be important.  Caution with physical contact.

Other communication strategies??

·      Minimize direct questions.  I am cringing at my memories of past interactions with members of this culture when I think back to how many direct questions I asked.

·      Translation services

·      Be conscious of the power dynamic with the nurse-client relationship

·      Be aware of own expressions of emotions and sensitive with eliciting information about the patient’s emotions and feelings.

·      Be aware that the client may visually express an emotion but is actually feeling a very different emotion. i.e. incongruence between verbal and non-verbal is more of a possibility with this client population

·       The use of silence may be helpful in eliciting communication.

Please feel free to share any strategies you have found helpful in communicating to individuals from this cultural background.

Bibliography

Ivey, A. & Ivey, M.  (2010).  Intentional interviewing and counselling.  California; Brooks/Cole.

Inuit Culture

Inuit Culture

I have read some very interesting information about Inuit culture and would like to share this with you.  As always however we are cautioned as nurses  to treat all as individuals and not to automatically attribute cultural traits to all members of a given culture…

In traditional Inuit culture children are taught to be non-competitive and not to ask direct questions.  Direct questions are considered impolite.

In Inuit society the traits of independence, innovation, patience and perseverance are valued. In traditional society these traits would greatly increase the chance of survival for the individual and the group.

The ability to accept realities that are beyond one’s control is also a valued character trait. There can exist a dichotomy here however.  The Inuit admire people who manage to work out a solution to an identified problem. However, submission in the face of a problem one can do nothing about is acceptable also.  It should be noted that this cultural characteristic can equate to resignation and fatalism when dealing with a public servant or nurse as in some instances in dealing with these sectors of society, the Inuit may feel their input is unwelcome or irrelevant.  They may also feel they are at the mercy of the “authority figure” and respond this way.  The result of this response is that they may not volunteer necessary information or ask questions needed to clarify the situation.

In Inuit culture, displays of anger or frustration are considered childish.  Tact and humility are desirable qualities.

There exists a tradition of not displaying emotions.  Public display of emotions is considered immature.  Emotions are expressed more freely in smaller, intimate groups and if an Inuk feels he/she must express emotion, it is believed that this expression should only involve those people that he/she feels are responsible for his/her emotional state.  Emotions are displayed in a very subtle way e.g. with a different tone of voice or the lifting of eyebrows.  These subtle emotional cues are usually almost imperceptible to those from a different culture but the Inuit are adept at recognizing slight vocal intonations and facial expressions that reflect emotional states.

Although Inuit culture respects autonomy, community is also valued.   Desirable adult behaviour is considered to be maintaining one’s independence while also being a fully responsible member of society.

Physical contact also differs from North American culture. Public displays of affection are reserved for children.  Display of affection between adults is considered improper adult behaviour.

Inuit tend to withdraw in unfamiliar situations.  With health professionals they may seem withdrawn or uncommunicative if this is a new situation for them because they are unsure of what is expected.

Some Inuit feel that non-Inuit are aggressive, prying, domineering and opiniated. However, the Inuit cultural value of non-interference may prevent Inuit from telling others how they really feel about the situation.  It apparently can be very difficult for non-Inuit to detect the subtle signs of Inuit disapproval.  This may result in some Inuit withdrawing from close contact with non-Inuit for a period of time as they may experience too much strain in their dealings with non-Inuit.

Thought I would end with a video of a beautiful Inuit woman who explains the intricacies of throat singing

Embrace Life - always wear your seat belt. I'm thinking of my communication prof who is an ER Nurse also. This video says SO much with non-verbal communication. Very powerful video

Picking Up the Pieces: Communication Strategies

The Shock of a Cancer Diagnosis

Setting the Scene

Gyne-oncology patients are counselled pre-operatively about the high probability of a cancer diagnosis.  However the shock experienced postoperatively is challenging for patients and for the staff caring for them.

Case Study

It is your patient’s first day after surgery and morning rounds have just finished. You enter your patient’s room after rounds and find her either crying or on the verge of tears.  She has just found out that the growth in her abdomen is cancerous and she will need to have chemotherapy.  She heard she has 3 years left to live.  What do you say?  What do you do?   You literally feel like your task is to “pick up the pieces”.  You have 4 patients in your assignment, you need to give 0800 meds, answer call bells, do assessments and hopefully get at least one bed bath started before 0900.

On weekdays you can rely upon your multidisciplinary team (e.g. our liaison nurse or social worker) to follow-up and help. However, on the weekend it is the nurse who becomes frontline psychosocial support.  This newsletter focuses on some communication strategies to use when patients have just been given “bad news”.  

Effective Communication Strategies

Attending Behavior

Visuals: eye contact

Vocals: vocal quality

Verbals: verbal tracking

Body language: attentive, authentic and congruent

Also known as unconditional positive regard.  Body language is an important aspect of communication and needs to be congruent with verbal communication.  You are in action mode with an already prioritized set of tasks.  SLOW DOWN, take a deep breath and sit beside the patient, use touch and eye contact if culturally appropriate.  “Mirror” your patient’s body language.

Buckman’s research with medical students has shown that empathic communication takes less time than anticipated.  Silence may be effective if the patient is crying.  Tears can be therapeutic and a great release of tension.

Acknowledge Feelings

Using both verbal and non-verbal communication, acknowledge the feelings.  Saying something like,  “You look upset” may be all you need to say to encourage the patient to share. Avoid premature reassurances such as “Don’t worry.  It will be okay.”

Patient’s Perception

It is important to find out what the patient knows/has understood about his/her condition.  Find out from the physician what was discussed and hopefully the physician can return to clarify information.  If not, call the physician and let him/her know that follow-up and clarification is needed.  For example, with the patient who thought she had 3 years left to live, misinterpretation of what was said was the case.  The patient had asked the physician about treatment options and in the course of the discussion he had mentioned that the effectiveness of chemotherapy decreased after 3 years.  

Re-prioritize

Attempt to stay with the physician while he/she clarifies and communicates with the patient.  This allows you to know what has been discussed.

 SPIKES is an acronym for delivering bad news.  Delivering a diagnosis is not a nursing act, however nurses can use aspects of the SPIKES method for communicating bad news.

SPIKES: a physician aid for breaking bad news

Setting

Patient perception

Invitation

Knowledge

Empathy/exploring

Strategy/summary

Re-prioritizing your workday at this stage may help or perhaps other nurses can cover for you for a short period.  If not, let the patient know her needs are important to you and set a time when you can return.  Offer to phone a family member or friend.

Summary Points

·      Build trust.  Follow-up on your promise to check back.

·      Encourage and strengthen past coping strategies

·      Listen more.  Talk less.  The patient is the focus.

·      Elicit feedback (paraphrasing, summarizing are effective strategies)

·      The relationship between patient and nurses/physicians has a power differential that can inhibit communication. Try to remove barriers.

·      Use open-ended questions to encourage patient communication.

·      Be culturally sensitive.

·      Be genuine.

“The art of communication is an important part of therapy: occasionally it is the only constituent.  It usually requires greater thought and planning than a drug prescription and unfortunately it is commonly administered in sub-therapeutic doses.”                                    R. Buckman

Bibliography

Anderson, I.  (2000).  Continuing education program on end-of-life care.

                     Retrieved from   http://www.cme.utoronto.ca/endoflife/Modules.htm

Baile, F., Buckman, R., Lenzi, R., Glober, G., Beale, E. & Kudelka, A.  (2000).  SPIKES- a six step protocol for delivering bad news.  The Oncologist, 5: 303-311

Ivey, E., Ivey, M. & Zalaquett, C.  (2010).  Intentional interviewing & counselling.  (7^th Ed.) Brooks/Cole: Belmont, CA.

Malloy, P., Virani, R., Kelly K. & Munevar, C.  Beyond bad news-communication skills of nurses in palliative care.  Journal of Hospice and Palliative Nursing 12(3): 166-174

Pereira, J.  (2008).   The Pallium Palliative Pocketbook.  Canada.  The Pallium Project.  For more information go to http://www.palliativetool.info

The Kiss

The Kiss by Gustav Klimt

Learning goals #1, 3 & 5.  As Valentine's Day approaches  I'm pondering the kiss (the act, not the painting) and the power of non-verbal communication.  It all started with a quote from renowned actress, Ingrid Bergman in our local paper who is purported to have said,  " A kiss is a lovely trick designed by nature to stop speech when words become superfluous.”  Fans of the movie Casablanca might disagree.  The kiss between Humphrey Bogart and Ingrid Bergman in that movie was memorable but not nearly as memorable as Bogie's classic line " Here's looking at you kid."  I digress.  Klimt's painting on the other hand speaks to the power of the non-verbal.  The couple are enveloped   in a transcendent-like oneness of being.  The only representation of their individualism within the act being the differing patterns of the beautiful gold object covering them.  The couple's body language is totally congruent with romantic love.  For those of you who may wish to read more about this beautiful painting follow this link:http://ezinearticles.com/?Gustav-Klimt---The-Kiss&id=4138409   


Yesterday, I started googling "kiss as communication".  Well, there are kisses for every occasion and for very different reasons according to which culture you belong.  I learned that kissing between couples in some African and Asian cultures was unheard of before colonialization. 


 Cultural misinformation continues despite all our efforts to move away from  an ethnocentric world-view.  I viewed a youtube video about "Eskimo kissing".  Yes, I'm ashamed to say that  the Inuit are still being referred to as "Eskimos", a term the Inuit find offensive.  In fact, I was amazed at the LACK of information about Inuit culture on the web...so yet another reason to continue with my blog.  I'm going to try hard to find some accurate, first-hand info about this very rich culture.  In any case the Inuit "kiss" is a form of greeting that truly uses the senses as communication.  Touch, smell and the visual are used.  Please watch the youtube video with apologies for the "eskimo" reference.  http://www.youtube.com/watch?v=gB4P0B5gT0U


Does anyone have information about reliable websites on Inuit culture?  Please share if you do and as for  learning goal #5  (self help strategies to prevent compassion fatigue and therefore facilitate empathic communication), well, contemplating the positive aspects of the human species like love is a good start and I've joined a gym.  Hooray for me!  


Speaking of the positive aspects of the human species check out this link about "survival of the kindness", an American social psychologist, Dacher Keltner gives us good news about our species.   He talks about compassion triumphing over self-interest and "the sympathy breakthrough".     http://www.cbc.ca/tapestry/episode/2011/01/30/survival-of-the-kindest-3

Adolescent and Young Adult Cancer, 1: Delayed Diagnosis

What's new on this topic in the media this week?

So we have 2 articles in the media directly concerning communication.  One is on the Power of Listening...something I've heard before but hard to do just as Susan Schwartz relates.  Most powerful message from this article?  SLOW DOWN, STOP COMPETING FOR 'AIR TIME'  Here's the link and the capitalization is for my benefit (trying to be conscious of online etiquette).
http://www.ottawacitizen.com/news/todays-paper/power+listening/4189198/story.html

The second article is about a report from CMAJ (Journal of the Canadian Medical Association)  about doctors needing more training in empathy.  Also interesting reading. I would just like to comment however that I have worked with physicians who are very good communicators.   The article leaves you with the impression that most aren't.  To read more go to:

http://www.canada.com/Doctors+need+more+training+empathy+CMAJ+report/4156797/story.html

mastering blogger

Okay so I just learned a few blogger communication strategies

1. There is a youtube video on how to create a blog...you can follow it @http://www.youtube.com/watch?v=ryb4VPSmKuo
2. I couldn't add an attachment so I had to cut and paste my learning goals

Assignment #1 Learning Goals

Please bear in mind folks that I've never written a blog before so probably my learning goals should include mastering that as well but I am going to try to attach the 5 learning goals we were asked to write at the beginning of this course.

Learning Objectives

1. Increase congruence between non-verbal and verbal communication

Benefit to Practice:  I have a tendency to continue or commence tasks while I am interacting with patients.  My words may convey positive regard but my non-verbal behaviour does not.

Success Indicators:  I will reflect on my daily interactions with patients and will rate a decrease in this behaviour

Strategies:  I will make a notation on my worksheet as a daily reminder and elicit feedback from my peers.  Review CNO Practice Standard: Therapeutic Nurse-Client Relationship.

2. Explore strategies to improve patient information capture while maintaining therapeutic communication

Benefit to Practice:  One of my positions as an RN involves postoperative pain assessments.  Time restraints are a daily occurrence with this position and I would like to improve the efficiency of my data collection but maintain effective communication

Success Indicators:  Patients will continue to express satisfaction with pain assessment visits and I will see a decrease in the number of repeat visits to capture missed information

Strategies: Make a template of all the information I wish to capture and review this with each patient before termination of the visit.  Review CNO Practice: Standard Therapeutic Nurse-Client Relationship.

3. Increase knowledge of communication strategies for patients from Inuit cultural background

Benefit to Practice: Our hospital receives many Inuit patients for care and I would like to become more culturally competent with this patient population

Success Indicators:  I will become more knowledgeable of cultural traditions of this population and document and share communication strategies with my peers.

Strategies:  Review CNO Practice Guideline: Culturally Sensitive Care and RNAO BPG: Embracing Cultural Diversity.  Research articles on communication with this patient population, search hospital database for communication strategies and presentations on this topic. 

4. Explore strategies of effective communication for patients receiving “bad news” in the postoperative period.

Benefit to Practice: One of my nursing positions is on a surgical oncology floor and it is not unusual to arrive in a patient’s room after rounds to find them in a state of distress regarding operative findings.

Success Indicators:  Patient satisfaction if possible before end of course, positive feedback from peers regarding applicability of information and strategies.

Strategies: Review CNO Practice Standard: Therapeutic Nurse-Client Relationship and Practice Guideline: Guiding Decisions About End-of-Life Care.  Research articles, review attending behaviours and active listening skills and reflect on daily practice.  Share findings with peers.

5. Increase practice of reflective/meditative strategies

Benefit to Practice: I am finding that the end of life issues facing the patients for whom I care increasingly impacts me emotionally.  I know that I need to devote more time to self-health to maintain therapeutic relationships.  

Success Indicators:  I will be able to leave at the end of a shift feeling I have delivered compassionate care and communicated therapeutically and not feel burdened by issues facing my patients. 

Strategies:  Decrease number of weekly shifts.  No overtime hours.  Review self- help strategies.  Devote minimum of one hour daily to self-help strategies.  Review RNAO BPG: Healthy Work Environment.