Sandra Richardson and Tracey Williams

Chapter Contents

Introduction

This chapter looks at issues of power, diversity and the role of culture in the provision of nursing care in the Emergency Department (ED) environment. Emergency nurses are faced with a diverse population group; patients are representative of the wider multicultural society and there is no clearly defined ‘best response’ that will work in all situations. While the clinical expertise and practice of nurses continues to develop, there also needs to be an awareness of the importance of developing skills in assessing and managing socio-cultural contributors to patient presentations. This impacts on the ability to establish an effective nurse–patient relationship, and within healthcare the failure to acknowledge diversity and cultural needs can adversely impact on patient outcomes. Nurses have often been described as an ‘oppressed group’, yet nurses also hold considerable power, and the exercise of this power can potentially benefit or marginalize those directly affected (Dolan 2001, Dong & Temple 2011). Understanding culture, diversity and the use of nursing power is particularly relevant in the ED as patients and families are particularly vulnerable, often feeling anxious, fearful and uncertain. For many, there is no option or alternative for seeking care, and this alone creates a sense of ‘power over’ and loss of control for the patient (Malterud 2010). If care is not provided in a respectful and responsive way, this can ultimately lead to patient disengagement from the wider health system. The role of the emergency nurse has considerable significance and impact in assisting the patient to adapt to the hospital environment and to maintain their cultural integrity.

Defining culture and acknowledging diversity

Discussing culture, whether at an academic or clinical level is both challenging and potentially threatening. For many individuals, the specifics of cultural understanding are associated with emotional and social responses, and influenced by the individual’s personal life experiences. Attempts to define culture have varied over time, between and within societies. While the concept of culture can be seen as an ‘unstable metaphorical construct more or less open to differential analysis and transformation’ (Leitch 1992), it also ‘provides a recognisable symbol of the general and identifiable traits associated with particular sub groups in society’ (Richardson 2004).

Culture is a broad term, and not limited to discussion of ethnicity. It includes elements such as individual and group values, social roles, taboos and beliefs. Clinicians therefore must understand the complexities of ethnicity and culture, its role in the life of each patient and its potential impact on one’s understanding of and ability to treat patients effectively (Hickling 2012). One framework for recognizing the range of diversity is outlined in the cultural safety model’s categories of difference (Box 41.1). Cultural diversity has been shown to impact on a patient’s involvement with the health system, including their ability to access services and the type of diagnosis and treatment offered (Celik et al. 2008). Differences in patient presentations related to age, ethnicity and gender have been linked to particular conditions, one example being the variance in signs and symptoms associated with acute coronary syndrome (Pezzin et al. 2007, Bosner et al. 2009). As well as variation in the type and range of patient-reported symptoms, differences have also been identified in the response of nursing and medical staff to individuals presenting with similar conditions (Takakuwa et al. 2006, Brown & Furyk 2009).

An individual, whether nurse or patient, may identify with more than one culture, and these can change in terms of priority and influence in response to internal and external forces. Nurses have traditionally sought to provide care ‘regardless’ of difference, assuming that the provision of a single standard of care, if set at an appropriate level, will result in ‘best practice’. Similarly, the old adage often given is to provide the treatment that ‘we would like to be given to our own relative/mother/child’. This assumes that the standard of care appropriate to one individual or within one culture is necessarily the best for all members of society. The presumption here is that, on one level, everyone is the same and that this sameness represents the ideal, which is usually the mainstream of society. For nurses, the assumption is often that the culture of healthcare is the most desirable, that patients should be compliant and responsive to directives, because they are presented in their best interests. When expressed bluntly like this, the paternalism is clear – the expert knowledge of healthcare is presumed to give the practitioner the ability to determine what is best for the patient, often overlooking the patient’s expert knowledge of ‘self’. The tendency is for nurses, and other health professionals, to integrate this approach at a subconscious level, rather than as a result of a deliberate decision-making process. Yet treating everyone the same does not guarantee an acceptable standard of practice. The care that one individual values may not be desirable or even acceptable within another culture. Rather than seeking to provide care ‘regardless’ of difference, it may be more appropriate to consider how to provide care ‘regardful’ of what makes people unique.

For emergency nurses, the benefits of recognizing and responding to cultural difference can be seen in improved ability to anticipate problems, recognize non-typical patient responses and become more responsive to individual needs. This has flow-on effects in terms of efficiency and effective use of time and the ability to defuse potential conflict. Patients who present to the ED do so for a variety of reasons, and their attitudes and expectations towards care are similarly varied. Many of these patients appear agitated, aggressive, uncooperative or actively disruptive. While physiological responses can account for some behaviours, others appear socially inappropriate and can trigger negative responses from nurses and others attempting to care for them. Many emergency nurses thrive on the excitement and adrenaline rush associated with managing trauma and other life-threatening occurrences; dealing with non-urgent patient presentations can at times seem less worthy of time and resources. Whether this is an acknowledged response, often evident in the use of pejorative terms to describe certain groups of patients, or a more subconscious reaction, this can impact on patient care.

Nurses are expected to be non-judgmental, to uphold universal standards and to do so in a calm and conscientious manner. Yet nurses are also expected to make judgements, to prioritize care and to ration the use of resources in all aspects of clinical practice. Rather than simply labelling a patient as ‘non-compliant’ or ‘difficult’, nurses can seek to identify the areas of difference between their own expectations and those of the individual receiving care. The patient who sits sullen and unresponsive may not intend to be obstructive; without knowing what their previous experiences with hospitals, the health system and figures of authority has been, it is difficult to know how this may have impacted their behaviour. It may be that a physical impairment such as deafness or difficulty with language or understanding has led to a sense of isolation and frustration. It may be that the patient is simply so focused on other things, such as the circumstances that led them to present, concern about family and friends or fear of disclosing information related to their health and personal circumstances that this has resulted in the appearance of non-cooperation or aggression. While the potential causative factors are many, the risk remains the same. Nurses need to ensure that commonly encountered factors such as workload, patient acuity and other pressures do not impact their ability to assess a given situation. Failure to do so risks introducing assumptions and treatment based on misconceptions. An effective way to understand what is happening in a given situation is by asking the patient, and doing so in a manner that encourages the individual to feel safe in sharing relevant information. In an increasingly busy workplace it is important to find the time to reflect on practice and identify the unspoken moral judgements that are made.

Stereotyping, stigma and discrimination