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Culturally sensitive care for Native American patients

When it comes to health care, one size doesn’t fit all. Cultural sensitivity, or cultural competence, necessitates understanding that people come from different backgrounds that lend to a different interpretation of the world and people’s experiences in it. The same way that travelers who look into the customs of a country before they visit might feel less out-of-place, caregivers who are familiar with the different traditions and language of their patient group are likely to have and provide a more positive experience for those patients, ideally resulting in a higher quality of care.

How do you treat all patients equally while treating them as individuals? This is a crucial lesson for all nurses and especially those who work in settings where the patients they treat are culturally very different from the staff at the clinic or hospital–like nurses working in settings with large Indigenous populations.

What is culturally sensitive care?

Culturally competent care can be seen as one piece of the health equity puzzle. Adapting TL Cross’s original 1989 paper on a “Culturally Competent System of Care,” the CDC defines culturally competent care as “set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.”1

Expanding further, the CDC writes1:
'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

Treating patients with cultural sensitivity requires not just recognizing that people differ from one another but knowing how to treat each one with their specific beliefs and values in mind.

The shift from cultural competence to cultural safety

If cultural competence is the acquiring of knowledge, cultural safety is what you do with that knowledge, according to Lauren Vogel, a news editor for the Canadian Medical Association Journal, “Whether that means examining your own biases or challenging those of a health institution or system.”

In “Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition,” an article published in the International Journal for Equity in Health in 2019, the authors argue that to aim only for cultural competence would be limiting. According to the authors, “[competence] focuses on acquiring knowledge, skills and attitudes, [inferring] that it is a ‘static’ level of achievement,” when in fact providing culturally sensitive care is a continual process. As the authors explain, “Cultural safety is about acknowledging the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient,” and providers must recognize how this balance fluctuates depending on the patient in front of them. Providers must also learn how to avoid “othering” individuals of a larger group or making categorical assumptions or assuming homogeneity based on stereotypes. Transforming cultural competence into cultural safety requires not just continued education but conscious self-reflection, self-awareness and institutional support.2

In this article we will primarily use the terms “cultural competence” or “cultural sensitivity” with the belief that health administrators and providers are responsible for applying these practices to provide a sense of cultural safety.

Culturally sensitive care for Native American patients

Colonialism, relocation, assimilation and loss of land and tribal customs have all contributed to poor health outcomes for Native American tribes throughout the United States. Although the life expectancy for Native Americans has increased by 10 years since 1973, at 73.7 years it’s still more than 4 years less than that for the U.S. general population. Death rates are also still significantly higher in many areas for Indigenous people and include causes such as chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory disease.3

Culturally sensitive care for Native Americans includes acknowledging and understanding that the violent actions put upon this group by American settlers and the government have all contributed to a certain level of mistrust of institutions including the health care system and might prevent some Indigenous people from seeking care when they need it. Further barriers including misunderstandings over health coverage (which is guaranteed for Native Americans and Alaska Natives by the federal government), underserved reservations with minimal resources and a lack of cultural awareness by non-tribal providers all contribute to lower age expectancies and higher instances of substance abuse and behavioral health issues.

Increasingly, tribal management officials are taking over certain services in order to offer a more integrated approach to health care (especially mental health care) that brings together Native customs and modern resources.4 The Indian Health Services of the United States also notes the use of drum circles, powwows, meditations and space cleansing rituals in the care for substance abuse by some tribes.5 Although it’s not always perfect, IHS works to provide holistic options for Native American health care and its collaboration with tribal authorities illustrates the importance of community-driven solutions.

How can nurses provide culturally sensitive care?

In some places, including ten states6 and a couple cities in Canada,7 cultural competency training is mandatory but even then it’s only required for some health or dental professionals or those working in public health. The U.S. Department of Health & Human Services created a program called Think Cultural Health (TCH), which is “dedicated to advancing health equity at every point of contact.” Part of the TCH programming is centered on culturally and linguistically appropriate services, known as CLAS, and provides continuing education programming, resources and training focused on cultural competency for health providers.8 TCH’s resources include several models for culturally sensitive care such as:

The RESPECT Model:9

The RESPECT Model can help as a reminder for the types of considerations to bring to each interaction with a patient to incorporate their cultural identity.

  • Respect - Understand how respect is shown within given cultural groups.
  • Explanatory Model - Devote time in treatment to understanding how clients perceive their presenting problems. What are their views about their own substance abuse or mental symptoms? How do they explain the origin of current problems? How similar or different is your perspective?
  • Sociocultural Context - Recognize how class, race, ethnicity, gender, education, socioeconomic status, sexual and gender orientation, immigrant status, community, family, gender roles, and so forth affect care.
  • Power - Acknowledge the power differential between clients and providers.
  • Empathy - Express, verbally and nonverbally, the significance of each client’s concerns so that they feel understood.
  • Concerns and Fears - Elicit clients’ concerns and apprehensions regarding help-seeking behavior and initiation of treatment.
  • Therapeutic alliance and Trust - Commit to behaviors that enhance the therapeutic relationship; recognize that trust is not inherent but must be earned by counselors. Recognize that self-disclosure may be difficult for some patients; consciously work to establish trust.

The LEARN Model:10

This model gives a framework for working with patients to address their problems and provide potential solutions that are in line with the patient’s cultural values.

  • Listen with empathy for the patient’s perception of the problem
  • Explain your perception of the issue
  • Acknowledge and discuss differences and similarities
  • Recommend treatment. Suggest a treatment plan that is developed with the client’s involvement, including culturally appropriate aspects
  • Negotiate agreement. The final treatment plan should be determined as mutually agreeable by both the care provider and client

Examples of culturally sensitive care

While contributing to a culturally safe health practice can seem vague, read through the following examples and consider how traditional American health care practices might need to be adjusted to suit patient needs.

Culturally competent care could include:

  • Providing private space during a hospital stay to pray or meditate
  • Taking into account fasting holidays when prescribing medication schedules a
  • Asking patients how they would like to be addressed
  • Offering halal or kosher medication alternatives or interventions
  • Understanding that some cultures have certain guidelines for interactions between men and women which might influence a preference for certain staff members for care
  • Taking patients’ belief in alternative medicines seriously and considering those items interactions with prescribed medications
  • Speaking in plain language or the patient’s terms rather than medical vocabulary
  • Learning about certain birth and death customs and beliefs
  • Learning key phrases and terms in other languages

Why is culturally sensitive care important?

Culturally sensitive care has become a bigger area of focus for health systems as they aim to close gaps in health equity. According to the CDC, health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Potential disparities in health care can result from many factors including poverty, environmental threats, inadequate access to health care, individual and behavioral factors and educational inequalities.12 One barrier to receiving care can simply be individuals’ lack of comfort with or distrust of the modern American health system, like previously explained in this blog. Having these factors in mind when treating patients can help providers to understand things like resistance to treatment with an expensive drug or why a patient without reliable transportation might prefer a telehealth visit. It’s also important to understand culturally competent care as a part of health equity to continue to put pressure on systems rather than individuals to work toward a healthier future for all.

Enhance your nursing education with a curriculum that includes culturally sensitive practices

Oklahoma has the second largest Native American population in the United States,13 something the faculty of Oklahoma City University’s online nursing programs takes into serious consideration as they prepare nurses for all sorts of roles across the country. Whether you are interested in working in rural health settings or a big city, it’s becoming more important every day that your cultural competency is up-to-scratch and that you can help to provide a culturally safe environment wherever you work. Talk to an Admissions Advisor to determine which program fits your background and career goals.

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