How Can Wound Care Nurses Provide Culturally Sensitive Care? Protection Status
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by Lindsay D. Andronaco RN, BSN, CWCN, WOC, DAPWCA, FAACWS

Cultural sensitivity and awareness is something that as healthcare providers, we say we practice – but do we always practice what we preach?

A Case Study in Providing Cultural Care

I will give you a case that I had about 6 months ago. She was a female in her 70s who had suffered a stroke. She was down for an unknown amount of time after her stroke until the family found her. She developed a large deep tissue injury (DTI) on the sacral area. Testing concluded that she had no brain function on admission, and with each day it worsened.

All clinical studies showed that this patient would be a good candidate for organ donation, however the family did not agree. They believed, in their culture, that she would walk out of the hospital. They even brought her a "going home" outfit and hung it in the room. They believed in miracles as their culture did not allow them to "give up" on the body.

Now I am not one for taking away hope or to say that miracles cannot happen.

If the family desired that we do "everything," including keep her a full code after being in this worsening state over 4 months, then I would continue to provide the best care possible.

We had multiple family meetings, which consisted of in-person family and those from across the country, on a conference call with an interpreter. We discussed her wound and the aggressiveness to which they wanted us to treat it. Surgery said she would need full debridement with a diverting colostomy, but no one wanted to perform the surgery because of her risk-to-benefit ratio. The family continued to have faith she would heal.

Ethical Responsibilities and Challenges in Wound Care

The DTI unroofed to a stage IV pressure ulcer. The bone was exposed, but there was no raging infection. The family felt we had tried all the remedies that Western medicine could provide, and now they wanted to try their own. They described that mixing aloe, olive oil, honey and crushing a "healing herbal compound" into an applesauce like consistency and packing it into the wound would make her heal. The healing properties of this mixture "has helped people in [their] culture for centuries."

Who knows if that will cause an infection? Would they sue? Who is liable? What is the difference and where is the line between being sensitive to different cultures/providing care the patient wants – and saying we cannot ethically perform such treatment?

What would you do? Would you feel you were harming the patient?

I will tell you, some staff, nurses and providers had a very hard time with this – it became a question for their morals and ethics and what they would do. If you don't provide the care the family and patient requests, are you being "culturally insensitive?" Sometimes the self-reflection is the most interesting part.

For more information on culturally sensitive care, check out the College of Nurses of Ontario's guide here [PDF].

About the Author
Lindsay (Prussman) Andronaco is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. Her clinical focus is working with Diabetic Limb Salvage/Surgical/Plastic Reconstruction patients, though her interests and experience are varied and include surgical, urological and burn care, biotherapeutics and Kennedy Terminal Ulcer research. Lindsay is the 2011 recipient of the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse' and has been recognized in Case In Point Magazine as being one of the "Top People in Healthcare" for her "passionate leadership and an overall holistic approach to medicine."

Lindsay is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. In 2011, Lindsay was honored with the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse.'

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


This is a good example of a cultural dilemma, although I am not clear on how the patient could have, "no brain function on admission, and with each day it worsened." I assume she was on a ventilator, which would preclude dismissing her home to the care of her family.

This situation is actually made less complex by the fact that the patient's poor condition precluded conventional surgical wound management options. As care providers, we must avoid becoming territorial and recognize that holistic care includes the family. Dr. Charalambos Agathangelou of Cyprus involves families in the care of similarly debilitated patients with PUs, using PolyMem to atraumatically clean the wounds and facilitate surprisingly brisk wound closure (an internet search for his name and PolyMem will lead to his peer-reviewed poster PDFs).

If PolyMem were unacceptable to the family, their own remedy, while far less efficient, should promote autolytic debridement and moist wound healing. Why not ask the family to sign a waiver and allow them to try their remedy? My area of research interest is sustainable wound management in rural areas of tropical developing countries. Based upon my research, I would advise that the nurses provide the family with barrier cream for the periwound, a thin film covering to keep their concoction moist, and absorbent pads to contain the large amounts of exudate that are expected when autolytic debridement occurs. I would allow the family to perform the dressing changes themselves, with a nurse documenting what they do.

In Japan socialized medicine only covers PU treatment in the elderly for 6 months, leading to the discovery that covering PUs with ordinary food wrap is as effective as some "modern" dressings at promoting wound closure (see studies by Bito and Takahashi). Because many EU countries are now facing similar regulations due to economic difficulties, this sort of improvisation may become widespread.

In summary, there are at least three evidence-based non-surgical choices for this patient.
1) show the family the posters from Cyprus and suggest using PolyMem dressings, which would allow them to participate in the care of their loved one while providing a proven wound healing solution
2) ask the family to sign a waiver and let them use their homemade remedy, providing as much protection for the patient as is feasible (barrier cream, etc.)
3) inform the family that food wrap alone may close the wound without the need for surgery

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