Service Learning Project
Case Study #1
Carol, a 35-year-old woman of African descent, comes to the clinic for a follow-up visit after having an HIV test. Upon receiving her results through the post-counseling interview, it is discovered that Carol is really Carl, a 35-year-old man who has recently been released from prison.
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Further discussion reveals that Carl participated in receptive anal sex while he was incarcerated. When asked about his sexual orientation, he insists he is heterosexual and goes on to explain that now that he is HIV positive he can never return to his native country in the Caribbean because of the stigma attached to HIV/AIDS.
He gives a series of expressions in Patois (dialect of English) that would be used to describe a person like him and what would be done to such a person. Clearly, Carol is dealing with a series of issues that may pose a challenge to the health care professional.
1. As a health care professional, what can you do to increase your understanding of this patient’s culture so that you can get this patient into treatment?
2. How can you find out the meaning of the Patois expressions to better understand this patient’s issues and provide appropriate medical care?
3. Discuss other Cultural Competence issues that may impact retention into care and treatment.
Case Study #2
Carmen, a 17-year-old Latina, shows up at a clinic for a gynecological exam. Carmen has been sexually active for over a year, and because she does not use condoms consistently, she is afraid that she may have contracted HIV or another STI.
Carmen’s mother has insisted on accompanying her to the exam, which she believes, is only to discuss an irregular menstrual cycle that Carmen has been complaining about. When the provider asks Carmen if she would like her mother to stay for the exam, her mother says, “Of course she would, she has nothing to hide from me.”
As the provider begins to ask Carmen questions related to her sexual health, it becomes obvious that Carmen is uncomfortable answering the questions in front of her mother.
When the provider asks if Carmen has ever engaged in sexual intercourse, Carmen glances over at her mother and then responds, “No, of course not.” Carmen desperately wants to voice her concerns about the possible contraction of HIV or another disease but she is ashamed to admit to her mother that she has been sexually active, and therefore does not request the appropriate medical screenings.
1. What cultural beliefs and values contribute to Carmen’s unwillingness to admit her sexual behavior in front of her mother?
2. How could the health care provider request that Carmen’s mother leaves the exam room without offending her or implying that Carmen is hiding something from her?
3. How could the provider successfully address Carmen’s health concerns and provide Carmen with sexual health information without causing a great amount of family discord between Carmen and her mother?
4. Discuss other Cultural Competence issues that may impact retention into care and treatment.
Case Study # 3
· A Vietnamese woman was rushed to the hospital by her adult children. The emergency room personnel discovered dark red welts running up her arms, shoulders and chest, yet the only presenting complaint was dizziness. When questioned, her son explained that he had rubbed her body with a quarter. A nurse becomes concerned when she finds an elderly Chinese patient rubbing himself with a quarter (she thought he was trying to hurt himself). When she took the coin away from the patient, he became very upset, grabbed it back from her and continued to rub his arms and legs, leaving dark red scratches.
· A Vietnamese girl in her first year at an American elementary school was not feeling well one morning, so her mother rubbed the back of her neck with a coin. When the school staff discovered the welts on the girl’s neck, they immediately assumed they were seeing a case of child abuse and reported the family to the authorities.
In each case the patient was practicing a traditional form of healing known as coin rubbing. There are several variations, including heating the coin, but they all involve vigorously rubbing the body with a coin. This produces red welts, which can distract medical staff from the real problem of treatment or be mistaken for child abuse. It is important to recognize and become familiar with this practice, and not to be distracted from the real problem or mistakenly make accusations of child abuse.
· Discuss other Cultural Competence issues that may impact retention into care and treatment.
· Examine and identify the gaps of care/treatment
· From a “big picture” perspective (administration) what could be implemented to ensure cultural competency is being implemented?
· How could this be handled better using cultural humility and sensitivity?
Case Study #4
Kerry, a 32-year-old Native American woman from a small reservation in Montana presented to a large urban clinic in the Northwest for care. She was married at age 17 and had contracted HIV from prior IVDU (intravenous drug use). She has been unemployed for the past 10 years. Her husband, Carlos, a Central American immigrant, had been HIV tested and was negative, although Kerry admitted they occasionally had unprotected intercourse.
Her medical history was complicated by periodic alcohol and crack binges, and a history of abnormal Pap smears. Her family and social history revealed childhood physical and sexual abuse, and chemical dependency.
Although she had a brother living nearby in the city, she was adamant that he and family in Montana know nothing about her diagnosis or treatment as she feared family revenge.
She did not want her family to try to take her back to the reservation – a place she escaped from and she made it clear she didn’t want to return, even after death. Her husband agreed with her decision not to return to the reservation, and noted that her family did not like him, as he was an “outsider.”
Kerry knew that her brother Mike often called the primary care doctor for updates on her condition. The patient reminded her physician that she wanted her diagnosis kept confidential, even if that seemed harmful to others.
She was initially started on antiretroviral therapy, but frequently missed appointments for medical and gynecological care. She occasionally spoke of wanting to see a medicine person through the clinic, but did not follow through on this because the healer was male, and because she occasionally needs drugs.
Her CD4(a type of cell to help with immunity) counts continued to decline, with rising viral load, and she was admitted to the hospital’s intensive care unit with opportunistic infection and cardiomyopathy.
She had previously expressed a strong desire to be a “no code,” but suddenly changed her mind in the ICU(intensive care unit) just prior to her death. After her death, her brother and elder aunt demanded to know her diagnosis. Then they told her husband that “they were her blood family, and she
needed to be buried at home,” regardless of her wishes, and that he had no legal or other rights to make any decisions.
1. What are the barriers to care in this case?
2. What ethical decisions must the health care providers make concerning her diagnosis and treatment
3. What course of action could the health care providers have taken for more culturally competent care?
4. How can the issue of her burial be resolved?
5. Discuss other Cultural Competence issues that may impact retention into care and treatment.
Case Study #5
A middle-aged Chinese patient refused pain medication following cataract surgery. When asked, he replied his discomfort was bearable and he could survive without any medication. Later the nurse found him restless and uncomfortable. Again the nurse offered pain medication. Again he refused, explaining that her responsibilities at the hospital were far more important than his comfort and he did not want to impose. Only after she firmly insisted that the patients comfort was one of her most important responsibilities did the patient finally agree to take the medication.
Things to Consider
· Chinese are taught self-restraint. The needs of the group are more important than those of the individual.
· Another factor that may be involved in Asian’s refusal of pain medication is courtesy. They generally consider it impolite to accept something the first time it is offered.
· The safest approach for the nurse is to anticipate the needs of an Asian patient for pain medication without waiting for requests – Nurses should be aware of Asian rules of etiquette when offering pain medication, food or other services.
· If the patient continues to refuse medication, their wish should be respected.
1. Discuss other Cultural Competence issues that may impact retention into care and treatment.
2. Identify the gaps of caring for the patient in a culturally sensitive manner.
3. As a healthcare provider how would you have handled this situation in using cultural humility?