Exemplar of cultural safety in the ED
When reflecting on our emergency department responds to the needs of a client's cultural safety I consider that we perform this function in many ways on a daily basis. As the nurse educator for the emergency department I am in a position to observe nurses working with individuals and their families and recall a particular case which to me provides an example where nurses adapted their practice to accommodate a particular clients cultural needs without compromising the emergency management of his presenting complaint.
On this particular afternoon shift we had received word from the paramedics that there had been a scuffle at a local swimming pool between rival gang members. The paramedics had been called and were unable to assess the individual because of his reluctance to be assessed and the combative nature of fellow gang members. We were told he was being brought by car to the hospital.
On arrival in the ED he was wheeled into the department on a wheelchair slumped forward with blood all over his face and back and was only responding to voices. We quickly realised that he that he was haemodynamically compromised and needed urgent intervention. We managed to get him from the wheelchair on to a bed and quickly begin oxygen. At this stage he was combative and his friends were very sketchy on what had happened. Blood was coming through the many layers of clothing on his back and it was clear to me that we needed to get his clothing off to assess where the blood was coming from. This proved difficult because his friends were insistent that we didn't remove his clothing.
Realising the significance of the vest and patch that indicated his gang affiliation I quietly talked with him and his friends about why we needed to remove the jacket and other t shirts at the same time acknowledging how important the jacket was to him and that we would be able to leave it lying underneath him when we took it off. His girlfriend and friend were very combative and appeared to be guarding his honour in this situation and were not going to allow us to remove his clothing. Whilst this was happening nurses were quietly attaching monitoring equipment and carrying out the primary survey as well as they could. It wasn't until the arrival of another member of the gang who obviously had the respect of the girlfriend and friend that we were started to get anywhere.
With this mans help we were all able to help take off the jacket (something in any other circumstance that would have been cut off almost immediately on arrival) without damaging it. We acknowledged the help that he gave us and from then we utilised this man to convey information to the many other gang members who had assembled at the hospital. Without asking he appeared to initiate a roster of 'dogs' gang brothers to be at this mans bedside which met there need to be with him and also helped us by calming him down.
Following removal of the clothing we found 3 stab wounds to his back, on assessment of his breathing we became aware of the potential for him to have a pnuemothorax on the right side. The doctor was called to formerly assess the patient (up until now then they had made an initial eyeball assessment and indicated what they wanted done from a medical perspective). During this time we as nurses had switched off to the conversational language of the members present and were not offended by it so when the doctor came to assess the young man and told him to settle down and not speak to the nurses like that we felt the tension in the room increase. We all just continued the way we were and said quietly to the doctor that we were ok and were not having any difficulty managing the young man and his friends.
We continued to take responsibility for the care of this young man utilising the older gang member who appeared to be in charge when going for CT and X-ray and also when the chest drain was inserted. We keep them informed at all times and described procedures and examinations to allay there concerns. Prior to admitting him to the ward we spoke with both after hours and the ward about this patient and how we had managed to care for him in ED and what we had identified as potential consideration for them on the ward. This allowed them time to arrange for a single room and a bed for a support person before we escorted him up to the ward.
I think this case shows how we as ED nurses adapt our practice to both manage an emergency condition at the same time as respecting the individual cultural needs of the patient.