Raphael E. Pascual BSN 411 ELECTIVE 2 Ms.

Lizel Pardinas
Nursing with dignity: Jehovah's Witnesses 23 April, 2009 June Simpson, RGN, SCM, ONC, is a nurse at Queen Margaret Hospital, Fife Acute Hospitals NHS Trust, Dunfermline
From a medical point of view, one of the distinguishing features of Jehovah's Witnesses is their refusal to accept blood transfusions. But is this actually true? Some nurses may have come across Jehovah's Witnesses who refuse red blood cells, but others may have encountered those who will accept blood proteins such as Factor VIII. And there are still pregnant Jehovah's Witnesses who are rhesus negative but will not accept immunoglobulins. Nurses need to keep up to date with Jehovah's Witnesses' position on blood and blood products and understand that they do have some autonomy when choosing blood fractions. Beliefs American Charles Taze Russell founded the religion in the 1870s and there are about 125,000 Jehovah's Witnesses in the UK. Acknowledging Jehovah as the only God, believers are baptised by immersion and carry their message from door to door, warning of a future vengeful battle of Armageddon. They are a law-abiding sector of the community who believe that their conduct reflects their worship of Jehovah. They also believe that Satan was

once an angel and is now an evil and powerful opponent of Jehovah. Abortion Jehovah's Witnesses see the elective termination of pregnancy as the willful taking of human life. In the rare event of a choice having to be made between the life of the mother and that of the child, the individuals concerned have freedom of choice. Birth control and reproductive technology Birth control methods that effectively terminate a pregnancy are avoided. In vitro fertilization involving eggs and sperm from unmarried people is unacceptable as it is considered adultery, as is gestational surrogacy. Organ transplants Organ transplants and organ donation are a matter of personal choice. Blood transfusion Jehovah's Witnesses refuse all blood transfusions, including stored autologous blood. They also refuse red cells, white cells, plasma and platelets. They may elect to receive fractions of these components, such as albumin, clotting factors, immunoglobulins, interferon and hemoglobin-based oxygen carriers. A group of Jehovah's Witnesses, the Associated Jehovah's Witnesses for Reform on Blood, is currently seeking to reform the organisation's position on blood and blood products Blood patch The use of this technique as a haemostatic agent is a matter of personal choice.

Blood salvage (autotransfusion) Many Jehovah's Witnesses will accept such procedures as intraoperative blood salvage and postoperative blood salvage from drains (cell saver), as well as hemodilution techniques. To make such procedures acceptable, tubing should be visible to show that the diverted blood is still in contact with the patient (tubing is seen as an extension of the circulatory system). Individual choice Members of the organization make personal decisions on treatment with blood fractions so Jehovah's Witnesses may differ in their choice of treatment. Any changes in blood product policy are conveyed to Jehovah's Witnesses through the Watchtower magazine. Patient confidentiality Jehovah's Witnesses and their relatives are taught by their faith that it is important for them to 'keep Jehovah's organisation clean'. One of the ways in which they are encouraged to do so is to inform those in positions of authority about the indiscretions of others. Because family members may also speak to those in authority in the organisation, it is important that each patient is asked in private what information may be passed on to relatives. If a patient elects to receive a 'forbidden' blood product there could be grave social implications if that decision becomes known. In such circumstances it may be necessary to make special provisions to ensure that unexpected visitors do not become aware of any treatment. Indiscreet talk between all members of hospital staff should be avoided to guarantee patient confidentiality. However, if the treatment is discovered by visitors, social services should be contacted in case the patient needs help after discharge.

Hospital policies Most hospitals have policies in place to provide Jehovah's Witnesses with the treatment they require. Most Jehovah's Witnesses are unwilling to accept the word of a nurse about the suitability of blood products for their condition. It would benefit this group of patients if hospitals investigated the possibility of holding a list of treatments endorsed by Watchtower. This could be used to help Jehovah's Witnesses make informed choices about their treatment. Baptised Jehovah's Witnesses often carry an advance medical directive/release document instructing health care professionals not to give a blood transfusion under any circumstances and releasing hospitals of the responsibility for damage caused by the refusal of blood. These documents usually state that they can be rescinded only in writing, but there may be problems if the patient is well enough to rescind it verbally but not in writing. Some patients also fill in a more detailed health care advance directive form which outlines their personal treatment choices regarding blood fractions and autologous blood procedures.

Jehovah's Witness hospital liaison committees In response to possible misunderstandings about their specific needs in hospital, Jehovah's Witnesses have formed special committees to mediate between hospital staff and patients. It is important to gain patients' full consent to such committees' involvement as they could be counterproductive if the patient felt under pressure. Given the importance of patient confidentiality, it is vital that committee members receive no confidential information from hospital staff unless the patient has given permission for them to do so.

REFLECTION By exhibiting an empathic understanding of Jehovah's Witnesses' anxieties and beliefs about blood and blood products, nurses are in a better position to implement an appropriate care plan. As part of a multidisciplinary team they can, as patient advocates, communicate Jehovah's Witnesses' special needs and help to provide holistic patient care. As a nursing student, upon knowing the beliefs of Jehovahs Witnesses, I must observe the following measures in order to render quality care ideally while preserving their dignity whenever I encounter these patients in the clinical area. Such measures are as follows: Acknowledge the right of patients to be treated with dignity and respect in regard to their religious beliefs; Offer appropriate care, advice and education; Involve individual patients so far as is practical in making informed choices

and decisions on their care and treatment; Provide a prepared list of hematologists who can be consulted; Encourage patients identified as Jehovah's Witnesses to carry a signed and witnessed advance directive card refusing blood and stating which blood products they are not willing to receive; Provide Jehovah's Witnesses with additional identification. Some hospitals offer a colored wristband to alert staff to their needs; Make every effort to ensure that the patient understands the consequences of giving consent or refusing specific treatments; Ensure that all appropriate forms are signed when dealing with minors. There is usually another policy to deal with 'consent to procedure'; Be reviewed at regular intervals to identify changes in acceptable blood products.

Carl Vincent Skwating M. Adao N-411 ELECTIVE2

Transcultural Nursing Principles

An Application to Hospice Care Mimi Jenko, MN, RN, CHPN, Susan Raye Moffitt, MSN, ARNP-BC Providing end-of-life care that is meaningful to each family, that honors a deep appreciation for the sanctity of human life, requires nurses to develop cultural competence. It is noted that many cultural variations exist in the dying process, in what is considered culturally meaningful, and in what constitutes a good death. Using transcultural nursing concepts as a theoretical base, this article will provide an overview to the hospice practitioner who might be unfamiliar with these concepts. Additionally, a framework is provided to assist with assessments and interventions in multicultural situations. Three specific ethical areas, germane to hospice care, are also discussed: (1) sharing bad news, (2) locus of decision making, and (3) advance directives. Throughout the article, numerous clinical examples are used to underscore the presented concepts.

It was a brief yet memorable encounter. The patient, a 47-year-old MexicanAmerican migrant worker, lay dying, surrounded by numerous family members of all ages. The elderly mother clung to her profound Catholic faith, petitioning God on her son's behalf. In an effort to reposition the patient, the staff approached the bedside. The staff had worked diligently to gain the trust of the family, which was nearly crushed with one quick action. Petite and elderly, but clearly the family matriarch, the patient's mother had placed a Catholic rosary with the patient. In a task-oriented mindset, a member of staff had nearly plucked the rosary from the patient's hands and placed it unceremoniously on the bedside table. Immediately, another staff member requested permission to remove the rosary. When the treasured item of hope and faith was placed in the mother's hands, appreciation shone in her eyes. Upon the completion of the nursing task, this mother gently replaced the rosary in her son's hands. A simple act of cultural sensitivity, imperative for the healthcare providers to learn, diverted a violation of the family's heritage and beliefs.

Concepts of transcultural nursing were developed by Leininger in the mid-1950s. "Transcultural nursing" has become an accepted phrase, a formal concept, and a field of study extending across cultural lines in search of the "essence of nursing." The implications of these definitions are vast. An increase in migration of people between countries has occurred and gender issues continue to add complex layers to one's world view. As cited by Andrews and Boyle, numerous authors have identified transcultural nursing as the blending of anthropology and nursing in both theory and practice. Anthropology refers to the study of humans: their origins, behavior, customs, social relationships, and development over time. The use of transcultural nursing principles provides a venue to examine many aspects of the delivery of care. Cultural factors were not formally integrated into the nursing curricula until the 1960s and 1970s.Many changes were prompted by the seminal work, Nursing and Anthropology: Two Worlds to Blend(1970), in which Leininger urged the two professions to share knowledge and experiences. Leininger, the first graduate-prepared nurse to hold a PhD in cultural and social anthropology, continued her work with Transcultural Nursing: Concepts, Theories, Research, and Practice (1978). This publication is widely considered the first definitive work on the practice of transcultural nursing. In a single day, a hospice nurse may care for a foreign-born corporate executive, or a rural family on a country dirt road. Each environment, each person, embodies a different culture. Providing end-of-life care that honors an appreciation for the sanctity of human life requires nurses to develop cultural competence. This article will review the transcultural nursing literature and apply these concepts to hospice practice.

Galanti acknowledges that nurses face "this monumental task on a daily basis; interacting with patients and family members who are ill, scared and generally not at their best" and strives to make various cultural practices seem "interesting rather than annoying." Healthcare providers strive for successful outcomes. Understanding specific factors that shape behaviors is an essential beginning. "Learning about, understanding, and respecting the values and beliefs of others" is a basic definition of cultural competence.It is not a stagnant entity, but a dynamic process. As cultures interact with each other, inevitable conflicts and clashes ensue, often with impacts on healthcare outcomes. Yet developing cultural competence should be a

constant learning process, versus an end point. By first understanding their own culture, nurses should acquire knowledge and understanding of the values and beliefs of other cultures. Then, the knowledge can be incorporated and applied to professional nursing practice. Bigby states that understanding one's self is fundamental in understanding how to relate to others; that "personal self-reflection and self-critique are required to explore how different life experiences influence interactions with patients." An equally critical step in developing cultural competence is acknowledging that different expectations may exist between providers and patients. Each will experience similar situations from different perspectives. The beginning of cultural competence, asserts Bigby, is the desire to better one's relations with other groups of people. Values, or standards that a group of people hold in common, provide a framework to govern one's life, including attitudes and behaviors. Personal decisions and actions are guided by these standards, thus revealing a person's identity. How one perceives and reacts to others is affected by one's values. Further exploration of one's personal culture may include awareness into one's heritage. The concept of heritage includes cultural, ethnic, and religious backgrounds. Each component contributes to the creation of a culturally unique individual. Culture is a concept that "encompasses beliefs and behaviors that are learned and shared by a group." Luckmann refers to the "common lifestyle, languages, behavior patterns, traditions and beliefs that are learned and passed from one generation to the next." Spector emphasizes culture as a metacommunication system in which the spoken and the nonspoken have significance. Additionally, Tripp-Reimer makes the following point: some habits and behaviors are open to change, but some are acquired early and are much more stable. Ethnicity is a complex term and may indicate some characteristics that a group shares in common, such as race; a common geographic origin; or a shared set of literature, music, or folk traditions. Shared food preferences, such as eating a kosher diet, might also characterize a certain ethnic group. Religion is defined by the Office of Minority Health as "a set of beliefs, values and practices based on the teachings of a spiritual leader." Many mysteries-life and death, pain and suffering-are derived from and respond to religious concerns. When framing a health crisis in meaning and purpose, often a religious component is involved.

REFLECTION: It seems that nursing practice becomes more challenging as life becomes more "increasingly multilingual, multicultural, and multi-faith," Hence I have to learn more about the values and history of countless cultural beliefs. Anthropological studies "support evidence that there is no one universally applicable view of grief." Yet, despite numerous variations in practices, death is still a fundamental human experience. According to Brody and Hunt who adopted a straightforward, seemingly simple approach: applying an "attitude of humility and curiosity is a willingness to learn patient preferences." In making the effort to explore and discover mutually acceptable outcomes, the art of caring and nurturing others is enhanced.