The New York metropolitan area traditionally has welcomed immigrants, creating a diverse population that hospice nurses must serve with cultural sensitivity.
“Culture affects our value systems and rituals, and that is so important at the end of life,” said Elaine Jones, RN, hospice program manager at the Visiting Nurse Association of Somerset Hills in Basking Ridge, N.J. “Cultural competency is important in nursing, but at end of life, these issues play a larger role.”
Small things mean a lot to people during a time of crisis, she said. Nurses must offer support, not create friction in the home.
“Our world is extremely diverse and becomes more diverse every day,” said Geri Manginello, RN, BSN, chief clinical officer of Good Shepherd Hospice in Melville, N.Y. “Without cultural competency, we are not able to ensure positive outcomes for this family.”
VNA of Somerset and other hospices serve diverse populations, so nurses must understand many cultures. “We have to be sensitive and respect cultural beliefs to provide good, effective care,” said Daughn Davis, RN, staff nurse at University Hospice in Staten Island, N.Y.
Cultural competency and respect for other people’s values go hand-in-hand with good nursing care, said Charles Meys, RN, coordinator of care at the Visiting Nurse Service of New York Hospice Care.
“During a nursing assessment, you start to see the differences,” Meys said, adding that successfully adapting to patients’ preferences requires a commitment from the nurse.
VNA of Somerset Hills is developing a cultural assessment tool to help nurses identify cultural needs on admission. When Jones hires a nurse, she incorporates cultural sensitivity questions into the interview process to ensure new hires are receptive to the cultural needs of others.
“Learning cultural sensitivity is a lifelong process, as is learning to be more human,” said Joan Alciati, RN, a nurse at the Visiting Nurse Association of Hudson Valley in Tarrytown, N.Y. “It starts with an awareness that our cultural patterns are unique.”
Alciati has cared for patients from Bangladesh, Korea and Italy and said she researches customs online before visiting someone from an unfamiliar culture. She respectfully asks families about anything that seems unfamiliar.
Many nurses learn about their patients’ cultural preferences by listening to the patient or family members, Davis said.
Meys cautions that people who are more vulnerable or alone may not have the energy to make that effort. Nurses still can learn from them by keeping their eyes open.
Jones said people do not typically say, “this is how we do it in our culture.” Understanding requires observing and processing nonverbal cues and feeling out the family.
“As long as your mind is open and caring, you cannot help but pick things up,” said Meys, who also has learned through escort/translators and fellow nurses from the patients’ community.
Interdisciplinary team meetings offer opportunities to share information about patients’ cultural preferences.
Some hospices provide a more formal education. Good Shepherd offers in-service programs and will develop new courses if the agency admits a patient from a culture not already covered in its educational offerings.
“But you can have variations,” Manginello said. “I wouldn’t want a staff member to have training in cultural diversity and think one-size-fits-all. The individuality of cultural competence needs to be factored into the care of the patient and family.”
Culture incorporates more than ethnic differences, such as sexual identity and religion, said Karen Killeen, RN, MS, at Calvary Hospital Hospice in Bronx, N.Y. Beliefs influence patients’ perceptions about hospice and death.
“There are so many levels to it,” Killeen said. “I can’t make a judgment based on a name on the referral. You have to watch, look, listen and see.”
Hospice nurses frequently provide care in patients’ homes and must honor their wishes.
“In hospice, you have been invited into the home of someone who is dying, and it’s very personal,” Meys said.
Manginello said people in some cultures believe you should remove your shoes before walking into the home, and the nurse should do so because “we are going into their sacred space.” Nurses must learn when to avoid eye contact and gain an awareness of gender issues, she said.
Nancy Salerno, RN, a nurse at Good Shepherd, recalls a Muslim male patient she was not allowed to touch because she was a woman. The family took blood pressures, and when the patient passed, the family chanted and moaned.
In other cultures, loved ones wail at the time of death. “If not sensitized to that, someone may think the people are out of perspective with their grief. But this is normal in Middle Eastern cultures,” Manginello said.
Some Buddhist families will record chants and place the recorder next to the patient’s ear, so they can listen as they die, Meys said.
In caring for a Buddhist child, Salerno learned the family believed the youngster had to experience cancer pain to live anew.
“It was difficult to discuss end of life and comfort and compassionate care when the family feels the child needs to go through torment to be born again in the next life,” Salerno said. “As challenging as that can be for the hospice staff, that family has to be supported in its belief system.”
In some cultures, Meys said the nurse must not touch the body after death.
Davis added that sometimes when an African-American patient dies, families will open the windows and doors to give the spirit freedom to move.
Whatever the customs, nurses must be nonjudgmental and respect their patients’ beliefs. “Culture is a big piece of how we care for patients,” Jones said. “The important thing is for nurses to not underestimate the power of the cultural background of patients.”