by ARISTOTLE V. IBASCO, RN

Patient safety and satisfaction have always been a priority in nursing, but they can be compromised by nursing priority and time constraint. With higher patient to nurse ratios, increase patient acuity, managed health care system, and higher demands for quality patient care, nurses today are working harder. Who has the time to deal with psycho-social-cultural issues of each patient in the hospital? Nurses tend to use social workers, case managers, religious services, interpreters, patient relations departments, charge nurses, and supervisors to deal with any personal issues or complaints from the patient. As a charge nurse, I had the opportunity to witness a cross-cultural conflict between Mr. Pasamonte's bathroom habit and the staff on the floor. This paper provides an understanding that sensitivity to socio-cultural issues and personal biases in nursing care can makes a more holistic approach and can be as important as medical care.

Mr. Pasamonte was admitted for hypotension, dizziness, and a mass on his rectal prostate area. He was awake, alert and oriented, able to get up and do daily activities without assistance. He has no previous medical history and denied any hospitalization. He is a fifty eight year old Filipino who was recently emigrated to the States five months ago. He came from a rural farming barrio with limited electricity. A radio was the only form of mass communication. He speaks Tagalog and Ilocano dialect; he understands limited English and an interpreter is necessary if a family member is not at the bedside.

The nursing staff, housekeepers, and two patients who were previously roommate of Mr. Pasamonte had been complaining that the toilet lid was always dirty, that there were shoe marks, and water all over the toilet seat. One incident report was filed that Mr. Pasamonte rang the emergency call light in the bathroom and was found squatting on the toilet seat. He was pale, sweaty and dizzy. He was assisted back to bed and able to recover. The staff interventions were to keep Mr. Pasamonte on bed rest related to his dizziness, place him in fall precautions, and let him use the bedpan or bedside commode for safety reasons. Mr. Pasamonte was unable to use the bedpan or bedside commode. He refused to use the bedpan or bedside commode and continuously got up without assistance to use the bathroom. The nursing staff labeled him as a non-compliant patient. The staff made fun of his squatting habit in using the toilet. Furthermore, the housekeepers and staff were irritated by the dirty bathroom and water spills on the toilet seat.

I was the charge nurse on the floor at that time and I assisted the cardiologist with interpretation and examination of Mr. Pasamonte. The cardiologist informed the patient that the pressure of the large mass in the rectal prostate region and bearing down while having a bowel movement causes a vaso-vagal nerve reflex that causes the blood pressure to drop and makes him dizzy. The doctor ordered stool softener, a high fiber diet, and bathroom privileges without bearing down during defecation. I noticed that Mr. Pasamonte had limited direct eye contact with doctors and non-Filipino nurses. He addressed each one of the staff as ma'amor sirand never called them by their first name. According to Orque (1983), Filipino patients relate to authority figures with formality and modesty. Furthermore, little direct eye contact with authority figures (nurses and doctors) is one form of nonverbal communication among Filipinos (Cantos & Rivera, 1996).

What was the reason for Mr. Pasamonte's bathroom habit of squatting and spilling water all over the toilet seat? Mr. Pasamonte assumed that it was proper to squat on a toilet. He was raised and accustomed to squatting while using the toilet since childhood in his farming village. He explains that a kasilyas or a dig-in-a-pit type of bathroom was the common type of restroom in his village. The bathroom is commonly located in the backyard; it is separated and far from the house as it is considered dirty in the first place. There is no water faucet in the bathroom. It is commonly understood that when a man is walking in the backyard carrying a tabo or a liter of water it signifies a bathroom breaks. Mr. Pasamonte mentioned that once he completed his toileting, cleaning the bathroom was unnecessary because the water spills would dry on its own. Here in the States, he added that no one commented on his squatting practice even at the Filipino home where he is presently staying. Furthermore, in his farming village, the common practice of wiping and cleaning the rectal area after bowel movement was to rinse it with water; therefore, water spills in bathroom were common in his village. He added that they never use toilet paper. He was aware of toilet paper but he felt that toilet paper does not clean his rectal area well and causes irritation and mild bleeding to the rectum.

Americans have a reputation for being preoccupied with cleanliness. Filipinos value a clean house; although, many time this is not extended to the bathroom. The floor of the living room must be spotless, as an example, but Filipinos seem to think of the bathroom as an innately dirty place, and no one worries if its floor is wet or messy. For Americans, however, a dirty bathroom reflects badly on the family even more than other rooms, so they strive to keep it clean (Goulet & Morales-Goulet, 1974). For toileting practices, Filipino patients are very modest. They will insist on using the bathroom for privacy and to do a thorough perirectal wash using soap and water. In addition, some Filipino patients prefer soap and water wash after bowel movements or urination (Cantos et al., 1996).

A nursing intervention that is culturally relevant and sensitive to the needs of Mr. Pasamonte is very important. The first nursing intervention that applies to this incident is to monitor his safety and to prevent any injury related to dizziness. I explained to Mr. Pasamonte that assistance in going to the bathroom is always available. I continued to remind him to avoid bearing down during defecation and to report to the nurse any symptoms of dizziness to the nurse. Secondly, it is imperative to allow the patient to verbalize his bathroom habits and to resume his normal bathroom privileges. The patient will achieve independence and retain his modesty by being allowed to use the bathroom in private. Next, it is also important to educate the nursing staff and housekeepers about different cultural practices in using the bathroom. Lastly, it is important to educate the patient to keep the toilet seat clean at all times and to contain water spills both on the toilet seat and floor for safety reasons. This can be accomplished by providing the patient with cleaning towels, a trash bin and the disinfectant spray readily available in the bathroom.

Mr. Pasamonte was sensitive to the concept of hiya or bringing of shame to oneself (Burgonio-Watson, 1977; Cantos et al., 1996; Orque, 1983). This was evidenced by being apologetic and sorry for the inconvenience of his bathroom habits. He promised to be a good patient and verbalized his understanding related to the nursing intervention in regards to his toilet practice. Mr. Pasamonte maintains pakikisama system or smooth personal relationship among staff. Filipinos are very friendly and always show a spirit of camaraderie (Bonpua, 1979). In addition, Filipinos bury conflict if possible, avoid direct confrontation, and will go to great lengths to preserve smooth personal relationships (Goulet et al., 1974; Munoz 1971).This beliefs led him being very compliant with the nursing care plan once his concerns were addressed. Mr. Pasamonte's remaining stay in the hospital was quiet and no incident of injury was reported.

In summary, this incident provided me with an opportunity to evaluate my own cultural biases and behavior in relation to my patient's cultural background, health practices, and health habits. This knowledge will prevent sociocultural misunderstanding, will provide appropriate nursing interventions, and will maintain greater awareness of my patient's psycho-social and medical care needs.

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