Congestive heart failure is a cardiac disease that causes many complications and affects many individuals in multiple ways. Aspects of one’s life that are impacted by CHF are: activities of daily living, including social, family, and spiritual involvement. It can be very difficult for someone with heart failure to manage the disease and deal with the complications both physically and emotionally. However, there are some preventative measures that can be taken to avoid such extremes. Nurses play a huge roll when caring for a patient suffering from heart failure. It is important that they understand how this disease is affecting their patient beyond the cardiovascular system, and to be aware of interventions that will improve the outcome of their patient’s health.

A patient presents to the clinic complaining of dyspnea, fatigue, weakness, swelling in his feet so bad that he is unable to put his shoes and he has a persistent cough. The nurse quickly assesses the patient and expresses her concerns of the probability of heart failure to the physician. The physician further assesses the patient and begins to get a history of the patient’s onset of symptoms. It is discovered that the patient has gained about five pounds in the last three days despite not being able to eat very much food. As the doctor auscultates heart sounds, he notes that his patient’s heart rate is very rapid. After careful consideration the physician diagnoses the patient with heart failure. Now what? The nurse must anticipate the level of care her patient is going to require while considering the many effects the diagnosis of heart failure is going to have on the patient. We would like to take this opportunity to now explain exactly what heart failure is, the details of its diverse effects, and describe the care expected.

Heart failure is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle’s ability to fill and pump enough oxygenated blood to meet the metabolic demands of the body. Seventy five percent of heart failure cases are caused by systemic hypertension (Grandinetti, 1974/​2010). A third of patients experiencing a heart attack will also develop heart failure; another common cause is structural heart changes such as: valvular dysfunction especially pulmonic or aortic stenosis which leads to pressure or volume overload on the heart. (Grandinetti, 1974/​2010).

However, those are not the only risk factors. Other serious risk factors that nurses should be aware of are: coronary artery disease, irregular heartbeats, diabetes, medications used to treat diabetes such as Avandia or Actos, sleep apnea, congenital heart defects, viruses, alcohol, certain kidney conditions, and of course, genetics (Mayo Clinic, 2010).

As you can see, CHF is a very intricate disease process that involves more than just the heart muscle itself. Complications from chronic heart failure take a serious toll on a patient’s ability to perform ADLs without becoming short of breath or easily exhausted. The patient may have activity limitations demonstrated by the avoidance of walking long distances, walking up stairs, or exerting themselves because they become dyspenic very easily. The nurse must assess the patient’s ability to perform minor tasks such as putting on shoes. Since heart failure can lead to severe swelling especially in the feet and ankles, the patient may not be able to put his or her shoes on without assistance or in some cases a specially designed shoe may be necessary. It is also important that the nurse inquire the patient about the ability to perform simultaneous arm and leg work, such as carrying groceries. This type of activity may place an intolerable demand on the failing heart (Ignatavicius, 1991/​2010).

Congestive heart failure does not solely affect the patient’s ability to perform activities of daily living, yet it affects other portion of life such as their family, social, and spiritual lives. Patients with advanced CHF often require help with daily tasks (i.e. making food, getting dressed, running errands, housekeeping); and family members often help out by doing these tasks for their loved ones. If the patient lives with a family member, that person may also be responsible for further management of cares in the home. This requires the family to be willing to learn about the disease process, and when it is necessary to call the health care provider or bring the patient into the hospital. This can cause a great amount of stress on the family member due to the responsibility of managing care. The fact that the patient may not be able to perform tasks on their own may lead to frustration which can further lead to self isolation due to the fact that they don’t want to be bothersome nor embarrassed by their deficits. This is damaging to their social life and may cause depression.

While the patient may be struggling with managing their social lives and trying to remain as independent from family members as possible the patient may turn to their religion. They may turn to their faith and pray more in hopes that it will benefit them and make it easier for them to deal with losing their independence. Spiritual well-being is an important, modifiable coping resource for depression, but little is known about the role of spiritual well-being in patients with heart failure (Bakelman, 2010). However, hope is a major indicator of one’s wellbeing. This is especially true for patients with heart failure. Those who are hopeful tend to feel better and are more socially involved (Ignatavicius, 1991/​2010).

Another factor that plays a major role in how patients with heart failure manage their care is the cultural background which they are from. For instance, those in minority communities may require more direct contact and consistent encouragement to follow the recommendations for treating their disease. A 2006 study concluded that:

“Nurse management can improve functioning and modestly lower hospitalizations in ethnically diverse ambulatory care patients who have heart failure with systolic dysfunction. Sustaining improved functioning may require continuing nurse contact” (Sisk, 2006).

It is not well understood why this is, but it may be likely that those patients who reside in minority communities do not have access to the types of health promotion and prevention programs as those who reside in a more socioeconomically stable community.

Moving on now to the psychological effects that disease casts upon its victims; many patients with heart failure are at risk for anxiety and frustration. They may experience symptoms such as dyspnea, which further complicates their anxiety level. Those who are dealing with an advanced disease are certainly at high risk for depression. It is not certain whether the function impairment contributes to the depression or the depression affects functional ability. It is thought that those who are rehospitalized for an acute episode of heart failure are more likely to be depressed (Ignatavicius, 1991/​2010). Nurses may help these patients with alternative coping methods.

It is important to keep in mind that nurses have a great amount of responsibility when it comes to prevention and treatment for those suffering from heart failure. Preventative measures that can be taught and reinforced to clients are: to quit smoking, control certain conditions such as hypertension, stay physically active, eat healthy foods, maintain a healthy weight, and tips for reducing and managing stress (Mayo Clinic, 2010). Treatment for these clients is generally directed by the physician, but the nurse reinforces the treatment plan and continues to guide the care throughout its course.

Treatment often starts with conservative measurements such as treating the underlying cause, for example, a rapid heart rate or repairing a heart valve (not as conservative). But for most people, treatment involves a balance between the right medications and in some cases devices that help the heart beat and contract properly. Medications often used are: ACE inhibitors, ARBs, Digoxin, beta blockers, diuretics, and aldosterone antagonists. If medications alone are unable to treat the disease, other forms of treatment such as coronary bypass surgery or heart pumps may be used (Mayo Clinic, 2010).

Furthermore, nurses must continue to intervene and assess the patient’s response to prescribed treatments. As mentioned before, nurses can educate their clients on the measures taken to prevent heart failure. Even more so, if the patient already has heart failure, the nurse shall administer medications as prescribed, place the patient on physical and emotional rest, while continuing to monitor for their therapeutic response to the medication and reducing the workload of the heart to increase its reserve. The nurse shall also monitor for complications such as excessive fluid volume, by weighing the patient daily and carefully assessing for lung sounds that would indicate fluid buildup (i.e. crackles in the lung fields) (Grandinetti, 1974/​2010).

Another nursing intervention that may be useful in helping the patient to manage their care at home is to teach them about MAWDS, an acronym that stands for Medications, Activity, Weight, Diet, and Symptoms. This module is an easy way to teach patients about medication usage, recommended activity level, maintaining weight and the boundaries for weight loss and weight gain, a heart healthy diet, which includes low sodium (2-3gms) and fluid restrictions, as well as symptoms that should be noted and reported to the physician immediately (Ignatavicius, 1991/​2010). This is a very concise and understandable tool that is beneficial to both the nurse providing the education and the patient required to remember and comply with the self-management techniques.

It is critical for nurses to understand the care needed to manage the patient with heart failure. They must be able to comprehend all aspects of its affect upon the patient in order to know how to direct them toward the right health choices and to know when to intervene to prevent complications. As we have discussed heart failure affects more than just the patient’s cardiovascular system, and there are many other factors that are involved in the disease process as well. Lifestyle changes must be made and maintained, those in minority communities may need more frequent contact to manage their care, and the health care provider must also remain aware of the psychosocial effects such as depression. Once these factors are understood to the best of their knowledge then improvement and management of this dynamic disease can be attained. Even if this means aggressive treatment because the conservative course did not serve its purpose as expected. Sometime drastic measures must be done. Either way nurses shall continue to provide teachings and management strategies to improve the outcome of their patients care. References

References

Bakelman, D. B. (2010). Spiritual Well-Being and Depression in Patients with Heart Failure. Journal of General Internal Medicine, 22(4), 470-477.

Grandinetti, D. (Ed.). (2010). Lippincott Manual of Nursing Practice (9th ed.). Ambler, PA: Wolters Klewer Health, Lippincott Company. (Original work published 1974)

Ignatavicius, D. (2010). Medical Surgical Nursing: Patient-Centered Collaborative Care (6th ed.) (L. Henderson, Ed.). St. Louis, MO: Saunders Elsevier. (Original work published 1991)

Mayo Clinic. (2009, December 23). In Mayo Foundations for Medical Education & Research (Eds.), Heart Failure. Retrieved February 19, 2011, from Mayo Clinic: http://www.mayoclinic.com/health/heart-failure/DS00061

Sisk, J. E. (2006). Effects on Nurse Management on the Quality of Heart Failure Care in Minority Communities. Annals of Internal Medicine, 145(4), 273-283.

• 
  Amber Hussain
  

Abstract

:

The aim of this study is to identify the influence of culture in nursing curriculum. 30 nursing instructors participated in the study. A questionnaire was distributed, which included five thematic categories. Findings revealed that teachers view definition of culture differently and they are aware of its importance in nursing in order to provide cultural sensitive patient care, but they view student diversity as challenging in classroom setting.

Introduction:

Development of curriculum plays a vital role in creating educational change. In order to improve classroom practices and students learning, large-scale curriculum reforms are instigated but these often fall short. There can be variety of reasons for these shortfalls, among which cultural influence is one. To develop and implement a high quality curriculum, a culture-sensitive approach to curriculum development is necessary (Nijhuis, Pieters &Voogt, 2013). This approach have equal or even more importance in the field of nursing, as nurses are the one who are confronted with patients who belong to different cultural backgrounds. According to Spritzer et al. (1996), in order to improve nurse’s cross-cultural awareness, major efforts have been made to develop culturally sensitive theoretical knowledge. To develop this awareness, teacher has to play a major role as; teachers’ multicultural competency is becoming an increasingly vital element in educational curriculum (Malta, 2012). Therefore, a teacher’s role is to be aware of their own culture, student’s culture and make students sensitive to cultural diverse patient care, which can be implemented by using varied teaching strategies in classroom setting. According to Maltby (2008), there are a variety of teaching techniques that can be used to engage students in the process of becoming culturally competent such as role plays, using exemplars and web-based interactions.

Methodology

Using convenience sampling, 30 nursing instructors of more than 1 year experience, participated in study. The participants teach at different teaching institutions of nursing i.e. Ziauddin college of Nursing, Baqai College of Nursing and Aga Khan University School of Nursing. A survey questionnaire was given to rate responses according to five broad aspects: definition of culture, cultural content, students’ diversity, teachers own cultural values and classroom pedagogies on 3 point likert scale (refer Appendix A).

Results

The study found that the definition of culture is perceived differently by different teachers. 83% view it as lifestyle of people, 33% believe that it is transformed from one generation to another and 37% perceive it as identity of people. 77% teachers disagree that cultural diverse patient care is incorporated in nursing curriculum taught in Pakistan and almost the same percentile (80%) of teachers agreed with the consensus that the curriculum is adapting from west and it diverts students from own culture. 73% stated that diversity among students creates conflict and it arise difficulty in students learning.100% teachers perceive that they are aware of their own culture, 93% knew that it is their responsibility to know about student’s culture and therefore 83% believe that it is important to train teachers regarding cultural diversity. 80% believe that they also face challenge to teach multicultural class. Majority of teachers use different teaching pedagogies like ice breaker (90%), case studies (77%), internet/videos (70%), reflections (67%) and group work (86%), still there are few who are not using these pedagogies.

Discussion

To investigate what teachers think about the role of culture in teaching and learning in nursing curriculum, questions were asked from them. Results are presented in appendix B and C. The results suggest that teachers in nursing schools perceive the understanding of culture differently. Majority view it as life style of people and few perceive it as identity of people and few believe that it is transformed from one generation to another .There are various understandings regarding culture. According to Stephens (2007, as cited in Nijhuisetal., 2013), culture gives meaning to beliefs and actions of individual and societies. It is an ideational tool which can be used to describe and evaluate that action. Nijhuis, Pieters and Pieters (2013) view culture as static or fixed phenomena.

For nursing content part, results show that 77% of the teachers disagree with the opinion that the curriculum present in local context provides enough cultural information. These finding indicated that the kind of information available on the textbooks is not sufficient to teach the culture, which indentifies a gap in the curriculum content that expose students to foreign culture. Maltby (2008) also questioned the depth of cultural content taught in nursing curriculum. Moreover 80% agree that, nursing curriculum is adapted from western culture and it diverts students from their local culture. The idea emphases that, as most of the textbooks of nursing are adapted from foreign culture, they may cause learners to lose their own cultural identity. According to Thomas (1997) Poor contextual curriculum leads to cultural mismatches on the level of local context.

In relation to the cultural diversity in students, majority of instructors reported that their classroom students are culturally diverse, and they believe that this creates challenge for both students and teachers, for example for teachers it would be difficult to respect and inculcate each individual student’s cultural needs and use teaching strategies accordingly, whereas, for students, diversity creates difficulty in reaching to a consensus. According to Phuntsog (2001) diversity in student directs teachers to provide equal opportunities to all students irrespective of their culture, caste and learning style. On the other hand, according to Marshall (1995) many institutions value cultural diversity but find it as challenging in a group work because there is a probability of developing a false consensus, as one think differently than other.

Moreover, Majority of teachers have reported that they are familiar with their own cultural values and responsible towards knowing student cultural values. This brings forward the idea of culturally responsive teachers who takes the cultural identities of the students in the classroom into account. This would help teachers to teach in a way that recognizes that each learner is an individual, with a particular cultural inheritance, who may rely on a different ways of knowing. According to Malta (2012) by recognizing student diversity it would be possible for teachers to become aware of cultural barriers and learn to teach from a culturally sensitive perspective. Apart from this, majority of teachers had consensus on importance of receiving cultural training, since course trainings would help them to handle cultural themes and topics in more ease due to gaining proficiency in the subject area.

Lastly, the study shed light on what kind of activities teachers practice in their Classrooms. Majority of teachers agree that they use different teaching methodologies i.e. icebreakers, case studies, videos, internets, reflection writing and group work, in order make students understand their own culture, be socially comfortable and understand aspects of foreign culture. These findings are parallel to that of Gonen and Saglam (2012) whereby teachers use different channels of information which expose students to foreign culture. Therefore, teachers develop a critical view towards foreign culture and these various sources of information a use to foster understanding of diverse culture.

Conclusion

In conclusion, culture has an influence in nursing curriculum in the area of content, teaching and learning. In the field of nursing, there is a lack of in depth content regarding culturally diverse patient care and that limited knowledge is mainly adapted from foreign culture due to which we tend to neglect the aspect of native culture. Moreover, students and teachers’ diverse cultural background and values are also affecting the learning outcome in classroom setting. Therefore, it is important for teachers to incorporate those teaching pedagogies which foster the concept of cultural sensitive patient care and respect among each other.

References

Davidhizar, R., & Giger, J.N. (2002). Teaching culture within nursing curriculum using the

GigerDavidhizar model of transcultural nursing assessment.

Journal of Nursing Education, 40

(6), 282-284.

Flintoff, V.J., & Rivers, S. (2012). A reshaping of counseling curriculum: responding to the

changingcultural context.

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, 235-246.

Malta, B.V. (2012). Am I culturally competent? A study on multicultural teaching competencies

among school teachers in Malta.

The Journal of Multiculturalism in Education, 8

(1), 1-43.

Maltby, H.J. (2008). A reflection on culture over time by baccularte nursing students.

Contemporary Nurse, 28

(1), 111-118.

Marshall, S.P. (2006).Cultural competence in nursing curricula: How are we doing 20years later?

Guest Editorial, 45

(7), 243-244.

Nijhuis, C.G., Pieters, J.M., & Voogt, J.M. (2013). Influence of culture on curriculum

development in Ghana: an undervalued factor?

Curriculum Studies, 45

(2), 225-250.

Phuntsog, N. (2001). Culturally responsive teaching: what do selected United States elementary

School teachers think?

Intercultural Education, 12,

51-64.

Ruth, L.A. (2003). A critical way of knowing in a multi cultural nursing curriculum.

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(3), 129-134.

Sairanen, R., Richardson, E., Kelly, L., Bergknut, E., Koskinen, L., Lundberg, P., Muir, N., Olt,

H., & Vlieger, L. (2013). Putting culture in the curriculum: A European project.

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118-124.

Simunovi, V.J., Hren, D., Ivanis, A., Dorup, J., Krivokuca, Z., Ristic, S., verhaaren, H., Sonntag,

H., Ribaric, S., Tomic, S., Vojnikovic, B., Selescovic, H., Dahl, M., Marusic, A., & Marisic, M. (2007). Survey of attitudes towards curriculum reforms among medical teachers in different socio-economic and cultural environments.

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, 833-835.

Spitzer, A., Kesselring, A., Ravid, C., Tamir, B., Granot, M., & Noam, R. (1996). Learning

about another culture: project and curricular reflections.

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Thomas, E. (1997). Developing a culture-sensitive pedagogy: tackling a problem of melding

‘global culture’ within existing cultural contexts.

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Appendix A: Questionnaire used for data collection along with consent form:

Purpose:

The purpose of this project study is to identify the influence of culture on nursing curriculum. In this study, culture refers to values, beliefs, language and customs of a particular people that impact the area of nursing education and practice. The project basically analyze the presence of cultural content in nursing curriculum and its significance, effects of students diverse cultural characteristic in classroom learning and teachers competency in relation to culture.

Consent:

This is a project being conducted by Amber Hussain MSCN student in a course of Curriculum, Teaching and Learning at IED (institute of Educational Development). You are invited to participate in this project because you are associated with teaching in nursing profession.

Your participation in this study is voluntary. The procedure involves filling a questionnaire. Your responses will be kept confidential and the results of this study will be used for research purpose.

Participant Signature: ______________________

C ulture	Agree	Neutral	Disagree
	Culture is a lifestyle of people
	Culture of people is permanent because it is transmitted from one generation to another
	Culture is the totality of people’s identity
Nursing Content
	The nursing curriculum taught in Pakistan provides continuous opportunities that enable students in providing culturally diverse patient care
	Nursing curriculum taught in Pakistan , tend to adopt the dominant (western) culture
	Nursing content alienate students from their traditional culture
	When nursing is practiced, it reflects patients values and beliefs
Diversity in students
	The student body in nursing classroom is culturally diverse
	Language barriers among students in a particular class arise difficulty in learning
	Cultural diversity among students frequently creates conflict in the classroom.
Teachers Values
	I am aware of my own cultural values and beliefs
	My own values and believes sometimes interfere with the content I teach
	Teachers have the responsibility to be aware of their students’ cultural backgrounds
	Nursing teachers’ attempts to socialize or enculturate students into a community of nursing.
	As classrooms become more culturally diverse, the teacher’s job becomes more challenging
	It is important for all nursing teachers to receive ongoing cultural diversity training
Teaching Methodologies
	Icebreakers are used to introduce students to each other before they are socially comfortable.
	Case studies are provided to students to solve problems by applying knowledge to new situations
	Videos and internet are used to illustrate an aspect of foreign culture
	Students are asked to write reflections on their cultural values and beliefs
	Students are given group work which gives them time to reflect on issues that arise in the discussion

Appendix B: Compilation of the responses received by respondents on a


3 point likert scale:

Categories	Questions	Agree	Neutral	Disagree		Agree	Neutral	Disagree
DEFINITION OF CULTURE	Lifestyle of People	25	4	1		83%	13%	3%
Transmitted from one generation to another	10	8	12		33%	27%	40%
People Identity	11	15	4		37%	50%	13%
CULTURAL CONTENT IN NURSING CURRICULUM	Content pro vides opportunities for culturally diverse patient care	6	1	23		20%	3%	77%
Adopt western culture	24	1	5		80%	3%	17%
Diverts student from native culture	25	0	5		83%	0%	17%
Reflects patients values and beliefs	23	6	1		77%	20%	3%
DIVERSITY IN STUDENTS	Student body is culturally diverse	23	6	1		77%	20%	3%
Language barriers arise difficulty in learning	22	6	2		73%	20%	7%
Creates conflicts in classroom	21	2	7		70%	7%	23%
TEACHERS VALUES	Aware of my culture	30	0	0		100%	0%	0%
Own values interfere with content I teach	11	7	12		37%	23%	40%
Aware of their students’ cultural backgrounds	28	2	0		93%	7%	0%
Socialize students into a community of nursing	23	7	0		77%	23%	0%
Culturally diverse classroom is a challenge	24	5	1		80%	17%	3%
Culture diverse training is important	25	5	0		83%	17%	0%
TEACHING METHODOLOGIES	Ice Breaking	27	3	0		90%	10%	0%
Case studies	23	7	0		77%	23%	0%
Videos and Internet	21	8	1		70%	27%	3%
Reflection Writing	20	3	7		67%	10%	23%
Group Work	26	4	0		87%	13%	0%

Appendix C: Graphical representation of the responses based on 5 broad categories:

Graph 1: The above graph depicts that 83% of the teacher’s view culture as a lifestyle of people and about one third of the respondents view it as people identity and a permanent phenomena which is transformed from one generation to another.

Graph 2: The above graph shows that 77% of the teachers believe that nursing curriculum taught in Pakistan does not provide opportunities for culturally diverse patient care but 77% of the respondents agreed that the nursing curriculum reflect patient’s values and beliefs. Around 80% of the respondent’s view that nursing curriculum is adopted from western culture and it alienates students from native culture.

Graph 3: The above graph depicts that more than 77% of the teacher’s agreed that the student body in classroom is culturally diverse. Around 70% of the respondents also agreed that the language barriers create difficulty in learning and diversity creates conflicts in classroom.

Graph 3:

Graph 5: The above graph depicts that more than 70% of the teacher’s use the above teaching methodologies frequently in order to achieve different learning objectives.