Perinatal Loss and Palliative Care — A Women’s Health Conference 2008 Multicultural Issues in Perinatal Grief and Loss Shannon Mulligan BSW Social Worker NICU /FAU St. Boniface General Hospital

Demographics  Canada is a richly pluralistic society.  1996, 17% of the Canadian population were immigrants. Canadian Institute for Health Information, 1999  Many new immigrants consider or settle in Manitoba based on the ‘point’ system bonuses within the Canadian Immigration System.  As of 2006, the foreign-born population numbered 121,300, or 17.7% of the total population of Winnipeg. Statistics Canada Census 2006

Demographics  Manitoba’s immigration rate is relatively high and ranked third among the provinces behind Alberta and Ontario.  According to the 2006 Statistics Canada report, an estimated 31,200 newcomers settled in Manitoba, about 2.8% of the total recent immigrants.  The foreign-born population in Winnipeg grew by 10.5% between 2001 and 2006.

Demographics  About 1 in 5 foreign-born residents of Winnipeg were recent immigrants, predominantly born in Asia and the Middle East. The Philippines was the leading source country, with nearly 3 out of every 10 newcomers, while India and the People's Republic of China were also among the leading source countries of recent immigrants. Statistics Canada Census 2006

Manitoba Immigration Top 10 countries of origin, 2004  Philippines: 1,529  Germany: 952  India: 535  South Korea: 398  Israel: 329  Ethiopia: 305  China: 290  Sudan: 225  Ukraine: 213  England: 170

What is Culture?  Culture may be considered an “invisible blueprint for living” (Jones, 1999, p.395), the essence of one’s being.  Capers (1992) defines culture as the “ pattern of learned behaviors, values, beliefs and customs which are shared by members of a group and are usually transmitted to other group members through time.

Definitions  It is essential to recognize that the term ‘culture’ goes beyond racial, ethnic, and linguistic differences Andrews and Boyle, 1999; Castillo,  Culture evolves and develops when families immigrate to new places and become influenced by the dominant culture.

What is Culture? “You sure look nice tonight Ginger… and what you rolled in sure does stink!”

Cultural Values  A preferred way of acting or knowing something that has been reinforced by ones social structure, and ultimately, governs one’s actions and decisions. Leininger, M. Transcultural Care, Diversity and Universality; A Theory of Nursing. Nursing and Health Care :

Cultural Values  Values can be reflected in a person’s cultural perception of time, personal space, communication style, role of gender and family practices in aspects of daily living. Prenatal Neonatal Nursing, June, 1999; 13(1):15-26.

Cultural Values “This is your side of the family, you realize.”

Cultural Values  Understanding different cultural beliefs as they pertain to loss and grief is critical because “lack of cultural understanding, language barriers, and internal bias or prejudice creates visible and invisible barriers for our clients.” (1999, p. 3) Journal of Cultural Diversity.Vol. 9, No. 3

Cultural Values  It should be noted that every belief system ranges from the most orthodox to the least conventional in practice or observance.  Therefore, cultural, professional and spiritual competency should be considered an evolutionary process.  A universal theme of almost all cultures is the creation of rites and rituals around important life events. Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide. National Perinatal Association; 2004.

 All cultures have developed methods for adaptive coping, grief, and mourning.  Hence, a lack of cultural awareness and sensitivity may interfere with a family’s ability to cope effectively with loss and grief.

Developing Core Competencies  Becoming culturally sensitive involves self awareness and learning to appreciate the differences of cultural practices.  It requires the health care provider to engage in a mutually respectful relationship with patients/clients and their families.

Developing Core Competencies  Cultural competence entails a willingness to allow ourselves to experience and learn others’ practices and to approach our patients and their families from a position of respect and openness.  We must first recognize our own cultural beliefs and acknowledge them as our unique and individual interpretations.

Developing Core Competencies  While becoming culturally sensitized, however, it is important to resist stereotyping people of any particular national origin or religion, recognizing that within any group, individuals, families, communities and other sub groups can differ substantially from one another in their beliefs and practices. Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide. National Perinatal Association; 2004.

4 Core Competencies  Cultural Competence  Linguistic Competence  Professional Competence  Spiritual Competence

Cultural Competence  “ The awareness and respect for cultural/ religious practices, beliefs, and differences, enabling practitioners to adapt health care in accordance with ethno cultural/religious heritage of the individual, family, and community.” Spector, R. E. Cultural Care: Guidelines to Heritage. Assessment and Health Traditions, 2 nd. Ed. Upper Saddle River, NJ: Prentice Hall Health; 2000

Linguistic Competence  The provision of bilingual staff or interpretation services for all clients without English Language proficiency. US Department of Health and Human Services Office of Minority Health. Assuring Cultural Competence in Health Care: Recommendations for National Statistics and an Outcomes- Focused Research Agenda. Washington, DC.

Professional Competence  The accrual of scientific knowledge and skills and the application of the best evidence available in the rendering of health care that is congruent with the traditions and beliefs of members of diverse ethno cultural/religious groups. Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide. National Perinatal Association; 2004.

Spiritual Competence  The ability to identify and understand one’s own values and spiritual beliefs in the context of a pluralistic society, recognizing how interactions with patients and families may be affected by religious differences. Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide. National Perinatal Association; 2004

 Culture evolves and develops when families immigrate to new places and become influenced by the dominant culture.  Culture is, therefore, not static and is an ever evolving, individualistic viewpoint or experience.  Culturally sensitive questions should be asked of patients and families who are faced with coping with the loss of a loved one.

 Clements, Vigil et al. in the Journal of Psychosocial Nursing, identify four sets of Culturally Sensitive Questions. Culturally Sensitive Questions

 What are the family’s cultural traditions and rituals for coping with dying, the deceased’s body, and honoring the deceased?  What are the family’s beliefs about what happens after death?

Culturally Sensitive Questions  What does the family consider to be the roles for each member in coping with the death?  What does the family feel to be a normal expression of grief and acceptance of the loss? Clements, Paul T., Vigil, Gloria J., et al. Cultural Perspectives of Death, Grief, and Bereavement. Journal of Psychosocial Nursing, Vol. 41, No. 7; July, 2003.

What can we do as Professionals?  Promote and support the attitudes, behaviors, knowledge and skills necessary for staff to work respectfully and effectively with patients and each other in a culturally diverse work environment.  Utilize formal mechanisms for community and consumer involvement in the design and execution of service delivery, including planning, service delivery and evaluation.

What can we do as professionals?  Require and arrange for ongoing education and training for all staff in culturally and linguistically competent service delivery.  Provide all clients, with limited English language proficiency, access to bilingual staff or interpretation services.  Undertake ongoing organizational assessments of cultural and linguistic competence and institute performance improvement programs. Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide. National Perinatal Association; 2004.

Questions? Thoughts? Comments? Thank You!