Term Paper: Personal Advanced Nursing Practice Framework

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Personal Advanced Nursing Practice Framework

Nursing paradigm of cultural dialogue and change

Like so many nurses today, I find myself practicing in a culturally diverse environment. Earlier theories of nursing tended to view the patient in the abstract, as an autonomous individual to be helped by the nurse. However, some models, such as Dorothy Orem's, gradually took a broader view of the nursing process as a way to correct patient's self-care deficits. Gradually, systems theories such as that of Betty Neuman's began to incorporate a more expansive view of the patient's environment into the concept of nursing. Nursing theories also came to include how to address the client's family and social context, particularly in systems-based framework like Neuman's. But only Madeline Leininger's philosophy of transcultural nursing, a philosophy of culturally specific care, fully addresses the needs of contemporary society. Leininger defined her ideal as "a humanistic and scientific area of formal study and practice in nursing which is focused upon differences and similarities among cultures with respect to human care, health, and illness based upon the people's cultural values, beliefs, and practices" and nursing is required "to use this knowledge to provide cultural specific or culturally congruent nursing care to people" (Leininger 1991).

As useful as Leininger's idea has proved in my practice, however, I have not incorporated it without some modifications. In my view, culture is a personal, economic, and social schema as well as a product of the patient's ethnicity. In terms of culture, for example, many families from Asia, Latin America, or Southern Europe have a strong extended family network. Accepting grandchildren as part of the circle of caregivers is essential, as well as keeping multiple family members notified of an elder's health. But a personal 'culture' can also be more immediately related to one's social or economic status: in many families, I see how a long-standing culture of poverty has lead to a low level of health literacy. Healthcare, healthy food and exercise is not given a priority. Costs of living rather than long-term health-related consequences are the focus of the family. The emphasis is on the here and now, rather than on the long-term amongst many poor families. Even the high-achieving, high-stress culture of America can be problematic, in terms of facilitating patient health.

Cultural sensitivity is important, but culture must be a dialogue between nurse and patient. When the culture of the patient promotes physical and mental health, the nurse should interact with the culture in a respectful and positive fashion. However, when the patient's culture is creating environmental stressors or impeding health-related knowledge (such as a Somali parent who insists it is impossible for his or her child to be autistic or have ADHD because 'we don't have such diseases in our community' or a Greek immigrant continues to smoke because in Greece, everyone smokes) the nurse must engage with a positive dialogue of change with that culture.

The four paradigms of nursing: environment, nursing, health, and client or recipient of care

Environment

Ever since nursing began as a unique profession, with a theoretical basis, the impact of the environment upon patient care has been chronicled. Florence Nightingale stressed the need to create a health-promoting environment that was sanitary and well-ventilated, based upon her experience as a wartime nurse. The environment where the nurse provides care, whether in a busy emergency room or the patient's home, will impact and shape the way care is given. A leisurely, friendly pace may be appropriate at home or a doctor's office, but not in a place where many are clamoring for medical attention from the nurse.

The patient's environment includes not just the immediate physical environment, but also the environment that the patient inhabited previously, before the patient met the nurse, and the environment into which the patient will enter after nursing care is given. For example, if a child is being treated for asthma, the nurse might very sensibly recommend that the child be housed in an allergy-free environment with no dust or mold. But if the parent lives in low-income housing and cannot remove the child from such an environment in the near future, the nurse must craft a realistic solution, based upon the economic culture of the patient.

As noted by Dorothy Orem, "physical, chemical, and biologic features" of the environment "include things such as atmosphere, pollutants, weather conditions, pets, infectious organisms and the like. Socioeconomic features of the environment focus on the family and the community and include such things as gender and age roles, cultural roles, and cultural prescriptions of authority" (Bridge et al. 2010, p. 5). Central to my cultural dialogue paradigm of nursing is the idea that the nurse must have a realistic apprehension of what he or she should and can change regarding the physical and cultural environment. Patients who are accustomed to going to faith healers for care, or who are not accustomed to going to the doctor at all may need to be engaged in a 'change promotion' health-related dialogue and negotiation. However, other aspects of the patient's culture and environment can and must be respected, such as the desire to treat older relatives within a home-based context.

Nursing

When asked to 'free associate' what nursing entails, the first response that popped into my head was that nursing is -- hard (but very rewarding) work! The reason nursing is such hard work is because it taxes every aspect of the nurse's and the patient's being and sense of self. Both individuals must communicate with one another as much as they are capable. Nursing is not something done 'to' someone, as stressed by theorist Imogene King -- instead, it is an active process of the nurse helping the patient achieve a goal, a common health-related goal set by the nurse and patient (Williams 2001).

Health

The notion of what constitutes health is culturally controversial, although to the novice nurse it might seem like a 'no brainer.' For a patient facing the end of life, a nurse may be confronted with a family that insists no heroic measures must be allowed -- or a devoutly Catholic family who believes that every measure must be exhausted, even in defiance of a patient's living will. Health for an athletic adolescent may require finding a nutrition program that optimizes his or her athletic performance, even if the young person is already physically fit, while for a patient with a mental illness, tolerating some physical side effects might be acceptable if a psychotropic drug can relieve his or her anxiety. Health is a negotiation of physical, mental, and social factors. Regarding the social, even an illness that might not be physically damaging (such as acne) may require some treatment, because of the social needs of the adolescent sufferer. The 'culture' of adolescence, or a life stage such as pregnancy, may have its own demands.

Client

While some culturally-focused theories of nursing may stress the idea that the 'client' is the entire social network of the individual known as the 'patient,' in my view the patient's health always comes first. Environmental aspects such as family and society must be addressed, and treated with respect. However, the nurse must act as an advocate for the patient, to avoid well-meaning family members obscuring the client's needs with their own needs. For example, the child of Christian Scientist parents who believe in the power of prayer to cure illness may require conventional medicine to cure his or her illness. As part of the patient's environment, the parents must be treated with respect, and in terms of the definition of 'health' the seriousness of the illness and the psychological distress of conventional treatment and care must be weighed against one another. But the child as a 'client' is the nurse's ultimate responsibility, not keeping a state of harmony within the Christian Science community as a whole.

Define and describe other concepts and constructs

Dialogue is thus a key component of effectively integrating cultural sensitivity into nursing: there must be a continual flow of dialogue between patient and care providers, and between the cultures of medicine and the personal, social, and religious worldviews of the client. Effective cultural integration is about negotiation and balance, not winners and losers.

Discuss how the components of your framework interrelate

Culture affects a patient's health: an individual who has grown up poor, where 'comfort foods' are defined as high-sugar foods, will need to renegotiate his or her relationship to food to avoid obesity and diabetes. A family and neighborhood environment that normalizes rather than pathologizes such a high-carbohydrate diet will impact the client's receptivity to nursing interventions. The nurse must place the client's self-interest at the forefront of the purpose of care, rather than the hurt feelings of the patient's grandmother or friends, but in prescribing a course of nursing treatment, the patient's budget, cultural pressures not to comply, and economic and logistical challenges must be kept in mind. The nurse must negotiate with all aspects of the patient's life that impact… [END OF PREVIEW]

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