Emily Haozous, RN, PhD, FAAN
Emily Haozous, RN, PhD, FAAN

Beyond the emotional complexities of end-of-life care, a multitude of cultural nuances and differences can affect the care that oncology nurses need to provide to their patients and family members. As the face of the healthcare team, oncology nurses are often called on to navigate this delicate area within the cancer continuum.

How Do Cultural Differences Impact Care at the End of Life?

ONS member Emily Haozous, RN, PhD, FAAN, associate professor at the New Mexico College of Nursing, is working to help current and future oncology professionals understand how to offer the best possible care to patients across a wide spectrum of backgrounds and cultural identities.

“When working across cultures, the first thing to remember is that nobody fits into any one box. I teach about intersectionality when I talk about culture. Intersectionality is a term that describes the overlapping identities that all people carry with them,” Haozous says. “The concept brings together all the identities of a person to create a whole, recognizing that our full identities are a composite of our gender, age, race, social class, ethnicity, spirituality, nationality, sexual orientation, religion, mental ability or disability, physical ability, illness, and other forms of identity. Therefore, a black man with bladder cancer in room 324 may be seen as one thing, but he is actually a unified and complex whole of many identities that may have been formed throughout a lifetime of experiences of oppression, discrimination, and privilege.”

Haozous recommends that healthcare providers understand that many racial and ethnic minorities come to palliative and end-of-life care with a historical precedent of poor treatment and mistreatment within the medical systems. While some of these cases of mistreatment have occurred in the past, some are still fresh for patients, and Haozous knows it hinges on the importance of relationships.

“Good cultural care requires relationships, time, and conversations. We want to create care profiles for racial and ethnic minorities, giving ourselves rules of thumb for working with different populations similar to how we do it when working with different diseases,” Haozous says. “The best rules of thumb are to spend time with all of our patients and their families and ask their priorities for care.”

For Haozous, this includes symptom management priorities and asking patients how they want to treat side effects such as pain, nausea, fatigue, or dyspnea. Because treatments for these symptoms often leave patients feeling disconnected and groggy, Haozous notes that they may prefer a different approach—especially entering the end of life.

Barriers Preventing Culturally Sensitive Cancer Care

In a perfect world, one with infinite resources and an ideal healthcare system, each patient would receive the exact amount of time and attention they need to address their care. However, health care isn’t perfect and resources aren’t unlimited. Haozous recognizes time and attention as two of the biggest barriers to providing culturally sensitive care. Oncology professionals are faced with the difficult task of keeping cancer care efficient and affordable—while also attempting to make it individualized and tailored to the specific needs of each patient. It’s a complex maze to navigate.

“In our healthcare system, providers are spread so thin, it is difficult to do the important work of authentic dialogue with patients and families to identify their priorities for care. Without that knowledge, it is nearly impossible to provide culturally congruent care. Instead, we are triaging and treating those issues that we see as priorities without understanding their meanings and the care consequences for our patients,” Haozous says.

“Likewise, some providers may have a high degree of cultural awareness but no access to available resources. In other cases, for providers without an awareness of the importance of culture, the missed nuances of cross-cultural communication are a barrier to effective care delivery for their diverse patients.”

Having Difficult Conversations

Although Haozous recognizes the difficulty of bringing tough conversations about race, diversity, and ethnicity to the forefront, difficulty shouldn’t be a deterrent. From her own experience as an American Indian, she says she welcomes discussion about difficult subjects.

“I think a lot of people don’t realize that people from marginalized communities talk about whatever it is that makes them marginalized all the time. In my family, we are American Indian, and we talk about racism and the daily interactions that take place between white people and American Indians on a regular basis, and we do this with the same comfort you might talk about sports or current events,” Haozous notes. “When a non-American Indian approaches me to ask me a question about my culture, that person might be uncomfortable, but for me that is a regular conversation.”

In her experience, authentic conversations are the ticket to a better understanding between nurses and their diverse patients. Talking with them and their families about care priorities and their culture can close the gaps and allow for coordination of care that’s individualized according to each patient’s needs.

Learning and Incorporating Culturally Sensitive Care

The Clinical Journal of Oncology Nursing and the Oncology Nursing Forum both provide information related to cultural sensitivity and culturally competent care, and Haozous recommends them to nurses seeking more information.

Haozous notes the potential educational benefits of interacting in nurses’ communities. By attending local community events, makings friends in that community, and interacting with cultures that differ from their own, healthcare professionals can begin to understand the nuances of cultural differences and obtain different perspectives for their patients.

“Learn what people eat, how they worship, what they celebrate, how they mourn, what they think is funny, what they think is shameful, and what they believe is beautiful,” Haozous recommends. “Once a nurse has those basics, then a nuanced question asked of a patient or family member doesn’t feel as disrespectful or uninformed, and it will hopefully be seen as important to patient care.”

Most importantly, cultural conversations cannot be forced at the last minute or rushed into care conversations. “When a question is asked with respect and with the genuine intent is to improve patient care, people tend to respond with respect,” Haozous notes. “The trick is that these conversations cannot take place at the last second, without enough time to hear the response, and the nurse asking the question has to pay attention and follow through.”

One thing is certain: Cancer will continue to affect patient populations without regard to skin color, spiritual background, or country of origin. The need for culturally sensitive care will be an important aspect to ensuring successful cancer outcomes. By listening, engaging with family members, asking questions, and responding to patient priorities, oncology nurses can address the diversity and individuality of each patient’s identity while still offering the best care possible.

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