Emerging Standards of Care
According to the U.S department of Health and Human services Office of Minority Health, "Integrated health care approaches must respect the whole person, work across the life span, include prevention and early intervention methods, and be person-centered, strength-based and recovery focused," (Sanchez, Chapa, Ybarra, & Martinez, Jr., 2012, p. 5 ). In this healthcare model, the patient must be treated not only according to the standards of nursing practice but integrate into the care, respect for the individual's belief system as well as their culture. "Providers that respect the cultures, languages and worldviews of the people they serve are more successful in engaging and activating individuals, families and communities to be an active participant in their own health care," (Sanchez, Chapa, Ybarra, & Martinez, Jr., 2012, p. 5) By integrating into care the individuals beliefs and needs, the professional can create rapport with the individual in such a way that encourages the individual to be active in their own health decisions based on the professional's medical knowledge and the individual's belief system. Culturally competent care is care that is respectful of and responsive to an individual's health beliefs, practices, and needs. This type of care is sensitive to the individual's ethnic and religious beliefs as well as cultural beliefs that have been shown to engage individuals into participating in their healthcare.
The skill to deliver culturally competent care is vital for all nurses. For all nurse who work in high-acuity or high-stress healthcare system environment, culturally competent care is particularly significant to patient outcomes. Nurses need to advance their cultural competency in order to be effective in developing bonds with patients, and to assess correctly, and to develop and implement nursing interventions designed to meet patients’ needs. As patient advocates, nurses are obligated to support choices made by patients or patients’ families that may reflect a cultural perspective that conflicts with conventional healthcare practices and may even conflict with the nurse’s own healthcare beliefs. In today’s society, culturally competent care cannot be accessible to all patients unless nurses have a clear understanding of diverse cultural backgrounds.
In the United States, we have observed the globalization of the planet. According to the National Center for Cultural Competence, “The make-up of the American population is changing as a result of immigration patterns and significant increases among racially, ethnically, culturally and linguistically diverse populations already residing in the United States,” (Georgetown University Center for Child and Human Development, n.d.). The United States alone has experienced a transformation that is motivated by an incursion of people from assorted ethnic and cultural groups. If the current population trends continue, it is projected that by the year 2080, the Caucasian population, which is now the majority group, will become a minority group, consisting of 48.9% of the total estimated population of the United States. The 1980 and 2000 census data show a noticeable variation in ethnic population trends among four ethnic groups: white, African American, Hispanic, and Native American. These trends are a sign for the need of culturally competent nurses for the future.
Populations served
Working for a large, globally recognized healthcare system makes it imperative that cultural competence is taught to all staff. In orientation, new staff are required to complete a four-hour training on cultural competence that involves on making the patient experience exceed the patients and families expectations. The healthcare organization makes available interpreters to facilitate communication between the healthcare staff and the patient and family. The organization as a whole is sensitive to the differing cultures and religions that enter their hospital.
The healthcare organization takes care of people from around the world on any given day. They have hospitals all over the world including the United States, Canada, and Saudi Arabia. Observing the hospital and staff in several of the hospitals in northeast Ohio, we serve many diverse populations. Muslim, Jewish, Catholic, Christian and atheist religious belief systems have been observed at the hospital as well as Hispanic, Latino, African-American, Islamic, and Asian cultures.
Population Vulnerabilities
While the healthcare entity is sensitive to the religious beliefs and cultures that come in contact with its staff every day, there are vulnerabilities to providing competent care to the many diverse patients that come for healthcare. In one of their hospitals that serves a higher than normal Hispanic population, all of the signs within the hospital are written both in English as well as Spanish. While the bilingual signage is helpful for those who cannot read English, if the individual cannot read at all, the bilingual signs are of no help. The main hospital within the organization serves a variety of cultures and religious systems. The staff has resources within the system such as bilingual staff, interpreters, and computer-based information resources to help educate staff and provide competent care for the patients.
Another issue that stands out within the system is its cafeteria and dietary departments. While all of the foods prepared for the cafeteria are health conscious choices with the nutritional content clearly stated on the menus, the cultural and religious beliefs are not. Observing the cafeteria at different hospitals all within the healthcare entity, there is not a consistent attempt at offering culturally appropriate foods on their patient menus as well as in the cafeteria.

Cultural Competence Standards
Cultural food preferences have been an issue in hospitals for many years. The food industry has capitalized on the preference for American foods and hospitals are no different. In the typical cafeteria you find a pizza, hamburgers, hot dogs, French fries, and soda pop. For some of the stricter dietary rules of some cultures, these types of foods are unsuitable for consumption. Cultural food preferences are taken into consideration when selecting cafeteria choices, however, religious food preferences are given a backseat. For instance, the physician that I work with is an Orthodox Jew, and he obeys the laws of the Torah. This means all food that he ingests has to be Kosher. Kosher means that it is suitable and pure according to Jewish law.
In Hebrew, “Kashrus,” which is the root for kosher (or “kasher”), means appropriate and/or “pure”, thus confirming suitability for consumption (KIR, 2014). The laws of “Kashrus” include comprehensive rules concerning permitted and forbidden foods. There are numerous aspects to these dietary rules that the devote Jew must follow.
In a kosher diet, there are certain animals that may be consumed while others may not. Animals considered kosher are bulls, cows, sheep, lambs, goats, veal, and springbok while according to Torah law pigs or camels may not be consumed due to their inability to chew cud or having split hooves which is forbidden according to the laws of the Torah (KIR, 2014). Regarding animals, when these animals are butchered for consumption, a “Schochet,"or ritual slaughterer needs to butcher the animal in accordance of Torah law (KIR, 2014). The slaughtering of the animal has to be done in such a way that there is no pain to the animal and unconsciousness/death occurs almost instantaneously (KIR, 2014). In the process of the butchering of the animal, the Torah forbids the ingestion of the sciatic nerve. In most western parts of the world that part of the animal is usually sold off to non-kosher butchers to sell. Poultry and eggs follow the same rules of slaughter and consumption as the other animals that are considered kosher. Traditionally, goose, duck, chicken, and turkey, are considered kosher and may be eaten. Eggs of only kosher animals may be consumed only if they are free of blood. This means each individual egg must be examined before consumption.
When dealing with kosher milk products this becomes much more difficult. Only kosher animals can produce kosher milk (KIR, 2014). In turn, no animal additives or non-kosher products can be added to kosher milk otherwise the milk is no longer kosher. According to the Torah: "You may not cook a young animal in the milk of its mother" (Ex.23:19). Since the Torah forbids the combination of mixing meat and milk together for consumption, it renders the food non-kosher (KIR, 2014). In some strict religious Jewish sects, they require the separation of meat and milk during preparation to the extent of having to have separate pans and utensils that must be washed separately (KIR, 2014). Also, the consumption of milk and meat must be timed correctly so that at the time consumption the meat and milk avoid being mixed in an individual’s stomach. It is not uncommon for an individual to eat meat and then wait several hours before consuming dairy as to honor kosher law.
In a kosher diet, only fish with fins and scales may be consumed such as tuna, herring and salmon (KIR, 2014). Shellfish such as shrimp, lobster, crabs or crawfish are forbidden (KIR, 2014). For all plants that are grown in the soil, trees or plants their fruits and vegetables are kosher. Consuming fruits or vegetables, according to the kosher diet, all must be carefully inspected for insects since insects are not kosher (KIR, 2014). Other laws apply specifically to the planting and sowing of vegetables, fruits, and grains. For instance, any fruits from trees may not be consumed if the tree has been planted within the past three years (KIR, 2014). Biblically, no new grain may be eaten, or bread baked from it, before one brings an "omer" of the first fruits of the harvest on the second day of Passover (Lev.23:14).
Lastly, beverages must be kosher as well to be consumed. Beverages produced from grape or grape-based derivatives may only be drunk if the grapes come from a kosher winery, prepared under strict Rabbinical Supervision (KIR, 2014). As for kosher wine, gelatin, casein, and bull blood are prohibited in the wine-making process. Only bacteria or kosher enzymes from the bowl may be used for fermentation (KIR, 2014). All devices and utensils used for the harvest and processing of the grapes must be cleansed under supervision (KIR, 2014).
Another population that is effected by dietary restrictions is the Muslim community. According to the Qur'an, to the Muslims, eating is a matter of faith for those who follow the dietary laws called Halal, or permitted foods ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). Those foods that are forbidden, such as pork and birds of prey, are known as Haram ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). While the foods that are uncertain for ingesting are known as Mashbooh ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). Muslims eat to preserve and maintain their good health. Overindulgence or the use of stimulants such as tea, coffee, or alcohol are strongly discouraged. Fasting is regularly practiced on Mondays and Thursdays, and more often for other sacred holidays ( "Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). Fasting on these occasions includes abstention from all food and drink from sunrise to sunset ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). Fasting can increase the risk of a number of health complications especially if liquids as well as solids are included in the fast. When symptoms arise, it is vital to end the fast or add water to the fast to preserve health. Depending on the amount of symptoms, ending the fast may be the only alternative. In severe cases of dehydration, medical care should be pursued as soon as possible to restore proper health. In a modern day western hospital setting, being able to abide by these dietary restrictions can be difficult if not nearly impossible.
In the Muslim faith, the holy month of Ramadan is in the ninth month of the Islamic year. Ramadan is a time devoted to prayer, fasting, and charity ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). Most Muslims are required to abstain from food and drink during daylight hours for the entire month. The fast is broken each evening after sunset by a meal called the iftar, which traditionally includes dates and water or sweet drinks and is resumed again at sunrise ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). Fasting during Ramadan is one of the five Pillars of Faith, which are the most crucial religious duties in Islam ("Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating," 2014). In a hospital setting, to honor the fast during the time of Ramadan may be difficult as well as not in the best interest of the patient health. The practice is to remind Muslims of the poor, to cleanse the body, and to foster serenity and spiritual devotion.
With these religious dietary beliefs, it illustrates the difficulty that the common hospital culture would have in obeying each religion, culture and ethnic beliefs in a large organization. Although those who observe differing beliefs, it would be practical for patients and families if the healthcare organization would be specially equipped to modify a diet or another another need to honor the patient's belief system and culture. From a patient's point of view, being able to have some control of their lives while being a patient in the hospital is important. By understanding and obeying cultural and religious beliefs of the patient, nurses are individualizing the care as well as providing culturally competent care for them.
Nursing Care
Nursing care for the most part is exceptionally provided in regards to nursing standards of practice as well as cultural competence. The nurses that provide direct patient care are some of the most compassionate and hardest working nurses I have so far met in my nursing career. The healthcare organization provides a full orientation to the nursing floor as a new hire as well as a skills competency check. For those nurses that have been with the system for any length of time over one year, a yearly skills competency day is mandatory. The yearly skills competency also includes a portion on cultural diversity in the workplace. The healthcare entity also gives employees one day per calendar year for an education day so that they can attend other education such as a seminar in order to meet the CEU requirements for licensure. So, the organization gives employees many opportunities for educating themselves about cultural diversity.
In the patient care arena, the nursing staff take extraordinary care to sensitive to the cultural beliefs and religious practices that care part of their patient's care. For instance, if there are certain bathing requirements such as required in Islamic culture, the staff does their best to uphold the patient's practices. The Islamic culture strongly believes in physical as well as spiritual purity. The Qur'an outlines in its verses how to maintain purity and achieve ritual cleanliness. Taking care of an individual that is Islamic the nurse would need to be aware of these rules and abide by them as well. For instance, the Qur'an goes into great detail on the step by step instructions on how to perform "Wudu" which is the act of physically purifying oneself and when "Wudu" is no longer binding. Keeping the patient and family at ease by abiding by their customs during a difficult time can bring them a sense of comfort and peace.
Solutions
In the observation of how the healthcare entity attempts to be mindful of the diverse population that enters doors, their plans are not fool proof. One big issue I have observed and have spoken at length about deals with dietary selections for patients as well as families in the cafeteria. We must not forget that family is just as important in the care of the patient as the patient is. For the religious practices that limit diets or have strict rules to abide by such as Jewish, Catholic or Islamic religions, the standard for selections leave little for patients and families to choose from that honors their traditional beliefs. The solution to the issue would be to implement changes to the cafeteria menu as well as increasing selections of food that would honor each belief system.
Conclusion
As with all efforts at cultural competence, it is difficult for any clinician to enter a patient room fully armed with a comprehensive knowledge and awareness of the expected cultural appropriate experience. In that light, it is extremely difficult for a nurse to be thoroughly versed in every religious facet and even the most culturally component nurse cannot comprehend what experience the patient and families are coping with. Even the most culturally knowledgeable practitioner cannot fully comprehend the client's experience, and should not presume to do so. Regardless of the professional’s background or knowledge, their job is to remain inquisitive and open to the distinctions and complexities that make up the clients' lives and define their reality. There lies the beauty of our work; a great honor we are given each time our clients invite us into their lives, and give us an opportunity to see the world from their eyes, a new and different perspective. References:
Georgetown University Center for Child and Human Development. (n.d.). The Compelling Need for Cultural and Linguistic Competence: National Center for Cultural Competence. Retrieved November 9, 2014, from http://nccc.georgetown.edu/foundations/need.html
KIR. (2014). What is Kosher Food, Kosher Rules, Products, Definition, What Does Kosher Mean. Retrieved November 8, 2014, from http://www.koshercertification.org.uk/whatdoe.html
Naumburg, C. G., L.I.C.S.W. (2007). Judaism: A hidden diversity. Smith College Studies in Social Work, 77(2), 79-K. Retrieved from http://search.proquest.com/docview/216186520?accountid=458
Religion and Dietary Practices - effects, food, nutrition, body, health, fat, nutrients, eating. (2014). Retrieved November 9, 2014, from http://www.faqs.org/nutrition/Pre-Sma/Religion-and-Dietary-Practices.html
Sanchez, K., Chapa, T., Ybarra, R., & Martinez, Jr., O. (2012). Enhancing the delivery of health care: Eliminating health disparities through a culturally & linguistically centered integrated health care approach: consensus statements and recommendations. Retrieved from United States website: http://www.hogg.utexas.edu/uploads/documents/FinalReport%20-ConsensusStatementsRecommendations.pdf
U.S. Department of Health and Human Services. (214, June 18). Cultural Competency - The Office of Minority Health. Retrieved from http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6