Mental Health Chapter 5- Cultural and Spiritual Concepts Relevent to Psychiatric Mental Health Nursing

Hope

- has been defined as a special kind of positive expectation. With hope, individuals look at a situation, and no matter how negative, find something positive on which to focus. -functions as an energizing force -hope may promote healing, facilitate coping, and enhance quality of life -they could hope for additional time to live, to be with loved ones, for freedom from pain, or for a peaceful death with dignity -Hope and optimism produce positive physical changes in the body that can influence the immune system and the functioning of specific body organs.

Jewish Americans

-4 Religion Groups: Orthodox; Reform; Conservative; Reconstructionist -Orthodox Jews adhere to strict interpretation and application of Jewish laws and ethics. Torah (the five books of Moses) are divine, eternal, and unalterable. -Reform Judaism is the largest Jewish religious group in the United States. The Reform group believes in the autonomy of the individual in interpreting the Jewish code of law, and a more liberal interpretation is followed. -Conservative Jews also accept a less strict interpretation. They believe that the code of laws come from God, but they accept flexibility and adaptation of those laws to absorb aspects of the culture while remaining true to Judaism's values. -The Reconstructionists have modern views that generally override traditional Jewish laws. They do not believe that Jews are God's chosen people, and they reject the notion of divine intervention. Reconstructionists are generally accepting of interfaith marriage. -Spain, Portugal, Germany, and Eastern Europe -5 million in the US currently -English language; Hebrew is used for prayer. Early immigrants spokje Judeo-German dialect called Yiddah -Formal education -Formal education is highly respected -Time orientation: simultaneously past, present & future (never forget) raised with stories of the past (Holocaust) -Children highly valued—expected to be forever grateful to parents -Children are considered blessings and valued treasures, treated with respect, and deeply loved. They play an active role in most holiday celebrations and services. Respecting and honoring one's parents is one of the Ten Commandments. Children are expected to be forever grateful to their parents for giving them the gift of life. -The rite of passage into adulthood occurs during a religious ceremony called a bar or bat mitzvah (son or daughter of the commandment) and is usually commemorated by a family celebration. - practice preventive health care, with routine physical, dental, and vision screening. Circumcision for male infants is both a medical procedure and a religious rite and is performed on the eighth day of life. The procedure is usually performed at home and is considered a family festivity. -Tay-Sachs disease, Gaucher's disease, and familial dysautonomia -Health conscious, maintaining mental health as important as physical -Genetic diseases; higher rate side effects with clozapine (20%) can cause agranulocytosis - inflammatory bowel disease (ulcerative colitis and Crohn's disease), colorectal cancer, and breast and ovarian cancer. -Alcohol, especially wine, is an essential part of religious holidays and festive occasions. It is viewed as appropriate and acceptable as long as it is used in moderation. For Jewish people who follow the dietary laws, a tremendous amount of attention is given to the slaughter of livestock and the preparation and consumption of food. -Laws dictate food prep, serve, & consumption; ETOH in moderate (kosher) no pork or eating milk and meat together -urban, larger cities -opposes discrimination against people with physical, mental, and developmental conditions -Mental incapacity has always been recognized as grounds for exemption from all obligations under Jewish law -To be Jewish is to belong to a specific group of people and a specific religion. The term Jewish does not refer to a race.

Asian/Pacific Islander Americans

-4.9% -third-and even fourth-generation Americans -Includes peoples (and their descendants) from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands. -Traditionalist versus Enculturated -Soft spoken, to raise the voice indicates loss of control -Eye contact avoided (it connotes rudeness and lack of respect); touching is not considered appropriate by some Asian Americans; personal and social spaces are larger -Loyalty to family emphasized, education highly valued -Elderly are highly valued because of their wisdom -Religion diverse: Taoism, Confucianism, Hindu, Buddhist, Islam, and Christianity -Time orientation both past & present: honor their elders that came before them -Yin and Yang fundamental concept relevant to health: imbalance is when illness occurs (light-dark, hot-cold, soft-hard) -Lactose intolerant so milk seldom consumed Rice, vegetables, & fish primarily consumed -Do not have a problem with obesity, but do have a problem with insulin resistance, so diabetes is common -Psychiatric illness is viewed as behavior that is out of control and brings great shame to the family; try to take care of the pt first within the family and then seek help when it becomes to hard to handle -Incidence of ETOH dependence is low: why? isoenzyme vairent that quickly converts alcohol to acetaldehyde and the absence of an isoenzyme that is needed to oxidase acetaldehyde. The result is a rapid accumulation of acealdehyde that produces unpleasant symptoms: flushing headaches, and palpitations. Alcohol dependence is low-generic intolerance -may encounter communication problems because of the differences in meaning assigned to nonverbal cues, such as facial gestures, verbal intonation and speed, and body movements -touching during communication has historically been considered unacceptable -difficulty expressing emotions -may be perceived as shy, cold, or uninterested -loyalty to family is emphasized above all else -Children are expected to obey and honor their parents. Misbehavior is perceived as bringing dishonor to the entire family. Filial piety (one's social obligation or duty to one's parents) is held in high regard. Failure to fulfill these obligations can create a great deal of guilt and shame in an individual. A chronological hierarchy exists with the elderly maintaining positions of authority. -education is highly valued among Asian Americans, many remain undereducated -Religious beliefs and practices are diverse and exhibit influences of Taoism, Buddhism, Confucianism, Islam, Hinduism, and Christianity. -Emphasis is placed on the wishes of one's ancestors, while adjusting to demands of the present. Little value is given to prompt adherence to schedules or rigid standards of activities.

Religion

-A set of beliefs, values, rites, and rituals adopted by a group of people. The practices are usually grounded in the teachings of a spiritual leader. -is one way in which an individual's spirituality may be expressed. There are more than 6500 religions in the world -to find answers to fundamental questions that they have about life and indeed about their very existence -Others, although they may regard themselves as spiritual, choose not to affiliate with an organized religious group. -Brodd (2009) suggested that all religious traditions manifest seven dimensions: experiential, mythic, doctrinal, ethical, ritual, social, and material. -Affiliation with a religious group has been shown to be a health-enhancing endeavor -Maryland psychologist John Gartner (1998) found that individuals with a religious commitment had lower suicide rates, lower drug use and abuse, less juvenile delinquency, lower divorce rates, and improved mental illness outcomes. -churches actively promote healthy lifestyles and discourage behavior that would be harmful to health or interfere with treatment of disease -opportunities for social interaction -steady decline in American society -Approximately 25 percent of people with schizophrenia and 15 to 22 percent of people with bipolar disorder have religious delusions

Table 5-2 Examples of Cultural Syndromes

-Amok -Ataques de nervios -Brain fag -Ghost sickness -Hwa-byung -Koro -Pibloktoq -Shenjing Shuairuo (neirasthenia) -Shen-kuei or shenkui -Susto -Taijin kyofusho

How Cultures Differ? (Ginger 2013 describes six cultural phenomena that vary with application and use yet are evidenced among all cultural groups)

-Communication -Space -Social organization -Time -Environmental Control -Biological Variations

Ghost sickness

-Culture: American Indian tribes -Symptoms: Preoccupation with death and the deceased; symptoms include anxiety, confusion, weakness, feelings of danger, anorexia and bad dreams; sometimes associated with witchcraft

Shenjing Shuairuo (neirasthenia)

-Culture: China -Symptoms: Weakness, emotional excitement, nervous symptoms, and sleep disturbances; condition is featured in the Chinese Classification of Mental Disorders under a section called "Other Neuroses"

Pibloktoq

-Culture: Eskimo cultures -Symptoms: Sometimes called arctic hysteria, an abrupt episode of extreme excitement preceded by withdrawal or mild irritability and followed b seizure activity and coma; during the attack the individual engages in aberrant and bizarre verbal and motor behavior; afterward, person usually reports complete amnesia for the attack.

Taijin kyofusho

-Culture: Japan -Symptoms: Intense anxiety and fear about possibly offending others, particulary with their body functions, appearance, or odor

Hwa-byung

-Culture: Korea (ofte attributed to suppression of anger) -Symptoms: Symptoms closely related to those of depression, including insomnia, fatigue, indigestion, dysphoria, anorexia, body aches, and loss of interest.

Susto

-Culture: Latin America -Symptoms: Symptoms include appetite and sleep disturbances, sadness, pains, headache, stomachache, and diarrhea; the soul is thought to leave the body (during dreams or following a traumatic event), resulting in unhappiness and illness

Ataques de nervios

-Culture: Latin America, Latin Caribbean, and Mediterranean (often occurs in response to a stressful family event such as death or divorce) -Symptoms: Uncontrollable shouting, crying, trembling, verbal or physical aggression, sometimes accompanied by dissociative experiences, seizure-like or fainting episodes, and suicidal gestures.

Amok

-Culture: Malaysia Laos, Philippines, Polynesia, Papua New Guinea, Puerto Rico, and among the Navajo (may be precipitated by the perception that they have been insulted in some way) -Symptoms: A state of depression followed by violent or homocidal behavior and ending with a period of exhaustion, somnolence, and amnesia. Persecutory ideas are also common.

Koro

-Culture: Southern and Eastern Asia -Symptoms: Intense anxiety associated with the fear that the penis (in males) or the vulva and nipples (in females) will retract into the body and cause the person to die

Shen-kuei or shenkui

-Culture: Taiwan, China -Symptoms: Panic anxiety and somatic symptoms; sexual dysfunctions are common but without indentified physical cause, attributed to fear of excessive semen loss related to frequent sexual activity; semen is considered part of one's vital essence

Brain fag

-Culture: West Africa (usually occuring in high school or university students during periods of academic stress) -Symptoms: Difficulty concentrating, poor memory retention, pain and pressure around head and neck, blurred vision; students often complain of "brain fatigue"

Northern European Americans

-Dominant culture in US today -Value territory; personal space about 1.5 (18 inches) to 3 feet. -Less value on marriage & religion than prev. generations: half of first marriages end in divorce -Punctuality & efficiency highly valued: promotes work ethic -Future oriented -Value healthy lifestyle but enjoy fast food- high in fats and cholestrol and low in fiber -include people with origins in England, Ireland, Iceland, Wales, Finland, Sweden, Norway, Denmark, and the Baltic states of Estonia, Latvia, and Lithuania -English language -Individualistic cultures stress independence, self-reliance, and freedom. -Traditional European American culture in the United States is a highly individualistic culture -Northern European Americans, particularly those who achieve middle-class socioeconomic status, value preventive medicine and primary health care. This value follows along with the socioeconomic group's educational level, successful achievement, and financial capability to maintain a healthy lifestyle. Most recognize the importance of regular physical exercise.

Latino Americans

-Fastest growing culture in the US- 16.9%; largest ethnic minority group -trace their ancestry to countries such as Mexico, Spain, Puerto Rico, Cuba, and other countries of Central and South America. -Touch is common form of communication (but tend to be modest)-likely to withdraw from any infringement on their modesty -Group oriented, primary social organization large extended family -Present oriented: The concept of being punctual and giving attention to activities that concern the future are perceived as less important than activities in the present time. -male dominated -> increased incidence of intimate partner violence -Women are responsible for educating the children, but they are not allowed to make familial decisions -Catholicism is predominate religion—folk medicine Curandero (male) Curandera (female) folk healer -"hot" and "cold" theory of disease -Especially in times of crisis, such as in cases of illness and hospitalization, Latino Americans rely on priests and the family to carry out important religious rituals, such as promise making, offering candles, visiting shrines, and offering prayers -is believed to have a gift from God for healing the sick and is often the first contact made when illness is encountered. = -Prevalence for psychiatric illness is higher among US born Latinos than it is for immigrants from the same cultural group. - -High incidence of PTSD -Massage, diet, rest, suggestions, practical advice, indigenous herbs, prayers, magic, and supernatural rituals are common medical treatments - Latino Americans are those who come from Latin American countries but currently reside in the United States. The term is often shortened to Latino, but individual preferences about this term vary. The term Hispanic is used to refer to people who share the common language of Spanish. Brazilian=Portuguese -Asking clients how they would describe their cultural identity is in the interest of averting an unintentional insult and demonstrates cultural sensitivity -Touching and embracing are common modes of communication. - lifetime prevalence for selected psychiatric disorders is 36.8 percent for U.S.-born Latinos, which is higher than the prevalence for immigrants from the same cultural group

Forgiveness

-Feelings of bitterness and resentment take a physical toll on an individual by generating stress hormones, which maintained for long periods can have a detrimental effect on a person's health. Forgiveness enables a person to cast off resentment and begin the pathway to healing. -To forgive is not necessarily to condone or excuse one's own or someone else's inappropriate behavior. -Holding on to grievances causes pain, suffering, and conflict. -offers freedom and peace of mind

Promoting Spiritual Growth

-Find your souls desire -Heal your heart and learn to love -Live ethically: feeling good by doing good -Calm your mind -See clearly & recognize the sacred in all things -Develop wisdom -Embrace generosity & the joy of service

Spiritual Needs- Meaning and Purpose

-Humans by nature appreciate order and structure in their lives. Having a purpose in life gives one a sense of control and the feeling that life is worth living.

Nursing Dianoses

-Impaired verbal communication -Anxiety (moderate to severe) -Imbalanced nutrition -Spiritual distress

Culture concepts:

-Influence on human behavior, the interpretation of human behavior, and the response to human behavior. -Caution: not all individuals Who share a culture or ethnic group are the same. (Do not stereotype)

African American

-Language dialect has history of various African languages & other culture groups present at time of settlement. -Some completely assimilated into the dominant culture - find it difficult to assimilate into the mainstream culture and choose to remain within their own social organization. -40.4% headed by women -have a strong religious orientation, and the vast majority practice some form of Protestantism -have assimilated into the dominant culture are likely to be well educated, professional, and future oriented. Some who have not become assimilated may believe that planning for the future is hopeless, a belief based on their previous experiences and encounters with racism and discrimination -unemployed or have low-paying jobs and little expectation for improvement. They are unlikely to value time or punctuality to the same degree as the dominant cultural group, which may result in their being labeled as irresponsible by those with different values about time. -Large support groups of family and friends -May use folk medicine, receive care from a "granny", "old lady", or "spiritualist." -Genetic tendencies (HTN, sickle cell anemia) -Diet differs little from mainstream, but "soul' food popular, especially in the South: poke salad, collard greens, beans, corn, fried chicken, black-eyed peas, grits, okra, and cornbread

Box 5-4 Spiritual Assessment Tool

-Meaning and Purpose -Inner Strengths -Interconnections -Relationships -Behavior and Activities -Environment

Arab Americans

-Most religion of Islam: favor professional occupations -trace their ancestry and traditions to the nomadic desert tribes of the Arabian Peninsula -Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. -First-wave immigrants, primarily Christians, came to the United States between 1887 and 1913 seeking economic opportunity. -Second-wave immigrants entered the United States after World War II. Most are refugees from nations beset by war and political instability. -includes a large number of professionals and individuals seeking educational degrees who have subsequently remained in the United States. Most are Muslims and favor professional occupations. -Arabic is the official language of the Arab world. -Conversations: stand close; steady eye contact & touch the other's hand or shoulder (same gender) -Speech loud & expressive, lots of gesturing -Present oriented (time); punctuality not taken seriously except: -Man is head of the household and women are subordinate to men; women are considered objects -Genders do not mix! -Women value modesty & many observe custom of hijab when in places where men may be (hijab, covering the body except for one's face and hands, as offering them protection in situations in which the genders mix) -Family is primary social organization; children loved & indulged -Communication is highly contextual, where unspoken expectations are more important than the actual spoken words. While conversing, individuals stand close together, maintain steady eye contact, and touch (only between members of the same gender) the other's hand or shoulder. -Speech may be loud and expressive and characterized by repetition and gesturing, particularly when involved in serious discussions. -Privacy is valued -Among friends and relatives, Arabs express feelings freely. Devout Muslim men may not shake hands with women. When an Arab man is introduced to an Arab woman, the man waits for the woman to extend her hand. -The man is the head of the household, and women are subordinate to men. -The father is the disciplinarian and the mother is an ally and mediator. Loyalty to one's family takes precedence over personal needs. Sons are responsible for supporting elderly parents. -Food eaten with right hand; many spices; bread every meal; bread is considered a gift from God -Obligatory Islam; Rituals; Mental Illness "bad nerves" or evil spirits -Mental illness a major social stigma—symptoms present as physical: abdominal pain, lassitude, anorexia, and shortness of breath. When mental illness is accepted as a diagnosis, treatment with medications, rather than counseling, is preferred. -bread is serves with every meal (gift from God), no pork, chicken and lamb most common -Spices and herbs include cinnamon, allspice, cloves, ginger, cumin, mint, parsley, bay leaves, garlic, and onions. -Food is eaten with the right hand because it is regarded as clean. -Eating and drinking at the same time is viewed as unhealthy. Eating properly, consuming nutritious foods, and fasting are believed to cure disease. Gastrointestinal complaints are the most frequent reason for seeking health care. Lactose intolerance is common. -The devout client may request that his or her chair or bed be turned to face Mecca and that a basin of water be provided for ritual washing or ablution before praying. Sometimes illness is considered punishment for one's sins. -cardiovascular, sickle cell anemia are more prominent issues, thalassemias -Sedentary life style and high fat intake -The rates of cholesterol testing, colorectal cancer screening, and uterine cancer screening are low; however, in recent years, the rate of mammography screening has increased.

Spiritual Care

-Nurses' are required to provide this based on the nursing code of ethics -Spirituality Defined: The human quality that gives meaning and sense of purpose to an individual's existence -Exists within each individual & force of interconnectedness between self & others, the environment, & a higher power -Meaning and Purpose in Life: gives one a sense of control & the feeling that life is worth living.

Western European Americans

-Physically expressive; warm & affectionate -Very family oriented -Father head of household; women mother & homemaker; children prized; elderly respected for age & wisdom -Predominate religion: French & Italian: Greek: -Present oriented; what happens in future is God's Will -Wine beverage of choice, but alcoholism rate is low -Superstitions: i.e. Italian: hang things up over head-baby cord problems, avoiding craivings causes problems with baby

Nursing Diagnoses R/T Spiritual Needs

-Risk for Spiritual distress -Spiritual distress -Readiness for enhanced spiritual well-being -Risk for impaired religiosity -Impaired religiosity -Readiness for enhanced religiosity -Focus: helping the client achieve meaning and purpose in life that reinforce hope, peace, contentment, and self-satisfaction

Space

-Spatial determinants relate to the place where the communication occurs and encompass the concepts of territoriality, density, and distance.

Culture-Bound Syndromes

-Symptoms associated with specific cultures that may be expressed differently from the American culture -Most are considered to be "illnesses" and most have local names. -Clients whose beliefs are culturally influenced is aimed at ensuring that those beliefs are not misunderstood & that nursing care includes elements that are important to the individual -Emphasis is also placed on developing a trusting relationship with the client and family, and eliminating barriers to communication.

Native Americans

-Touch is not highly regarded by Native Americans -Sometimes appear silent and reserved & Can be uncomfortable expressing emotions- keep private thought to oneself -Eye contact is avoided & considered rude. -distance 2-6 feet -Family & Tribe primary social organizations (respect tradition) -Present time oriented, casual (may be late or not show up at all) not ruled by clocks; some do not own clocks -Shaman uses variety of practice methods/may work with conventional medicine to heal the sick; often used before physician help -Increased Incidence of: alcohol and substance abuse, intimate partner violence (39% of women), child abuse, homicide, suicide (1.7 times higher than any other race), diabetes, and heart diseases -Less than half of native americans live on reservations -They will not touch dead bodies -Sticking your hand out for a hand shake is considered aggressive -The federal government currently recognizes 566 American Indian tribes and Alaska Native groups. Approximately 200 tribal languages are still spoken -The AI/AN group is described as a collectivist culture, which stresses their close dependence on and interconnectedness with family and tribe. -Some AI/AN view the traditional handshake as somewhat aggressive. Instead, if a hand is offered to another, it may be accepted with a light touch or just a passing of hands. -The risks of illness and premature death from alcoholism, diabetes, tuberculosis, heart disease, accidents, homicide, suicide, pneumonia, and influenza -Fruits and green vegetables are often scarce in many of the federally defined Indian geographical regions. Meat and corn products are identified as preferred foods. Fiber intake is relatively low, while fat intake is often of the saturated variety. Approximately 276 of the tribes recognized by the federal or state government receive commodity foods supplied by the U.S. Department of Agriculture's food distribution program

folk medicine

-a system of health care within various cultures that is provided by a local pracitioner who is not professionally trained but who uses techniques specific to that culture in the art of healing -the belief that health is a gift from God, whereas illness is a punishment from God or a retribution for sin and evil (African Americans) -African Americans turned to this because they could not afford the cost of mainstream medical treatment or because of the insensitive treatment by caregivers in the health-care delivery system

Communication

-all verbal and nonverbal behavior in connection with another individual is communication -expressed through language (the spoken and written word), paralanguage (the voice quality intonation, rhythm, and speed of the spoken word), and gestures (touch, facial expression, eye movements, body posture, and physical appearance).

Assimilate

-by incorporating practices and values of the dominant culture

Culture

-describes a particular society's entire way of living, encompassing shared patterns of beliefs, feelings, and knowledge that guide people's conduct and are passed from generation to generation. -a particular society's entire way of living, encompassing shared patterns of beliefs, feelings, and knowledge that guide people's conduct and are passed down from generation to generation

Spiritual Concepts:

-including spiritual treatment, because insanity was considered a disruption of mind and spirit -believed that religion had a negative effect on mental health and that it was linked to a host of psychiatric symptoms -Faith: faith , combined with conventional treatment and an optimistic attitude, can be a very powerful element in the healing process; believing in something you can't see -Hope: promote healing, facilitate coping, and enhance quality of life -Love: life's most powerful force and most required need; greatly affects the immune system -Forgiveness: ability to release guilt toward self or anger toward another; not forgiving others can be bad for your health -Religion (just one way to express spirituality)

Faith

-is often thought of as the acceptance of a belief in the absence of physical or empirical evidence -rise above that which they can only experience through the five senses - combined with conventional treatment and an optimistic attitude, can be a very powerful element in the healing process.

Distance

-is the means by which cultures use space to communicate

Love

-may be identified as a projection of one's own good feelings onto others -To love others, one must first experience love of self and then be able and willing to project that warmth and affectionate concern for others -may be a very important key in the healing process -love has a positive effect on the immune system -higher levels of endorphins, thereby contributing to a sense of euphoria and helping to reduce pain -the earlier people have the benefit of a strong, loving relationship, the better they seem able to resist the effects of a deleterious lifestyle

Territorially

-refers to the innate tendency to owen space. The need for territoriality is met only if the individual has control of a space, can establish rules for that space, and is able to defend the space against invasion or misuse by others.

Density

-refers to the number of people within a given environmental space, can influence interpersonal interaction

Ethnicity

-relates to people who identify with each other because of a shared heritage -a somewhat narrower term and relates to people who identify with each other because of a shared heritage

Sterotyping

-the process of classifying all individuals from the same culture or ethnic group as identical -not to assume that all individuals who share a culture or ethnic group are identical or exhibit behaviors perceived as characteristic of the group

Acculturate

-to dominant cultural practices (give up cultural practices or values as a result of contact with another group)

Walsh (1999) describes "seven perennial practices" that he believes promote enlightenment, aid in transformation, and encourage spiritual growth:

1) Transform your motivation: Reduce craving and find your soul's desire. 2) Cultivate emotional wisdom: Heal your heart and learn to love. 3) Live ethically: Feel good by doing good. 4) Concentrate and calm your mind: Accept the challenge of mastering attention and mindfulness. 5) Awaken your spiritual vision: See clearly and recognize the sacred in all things. 6) Cultivate spiritual intelligence: Develop wisdom and understand life. 7) Express spirit in action: Embrace generosity and the joy of service.

Curandera

A female folk healer in the Latino culture.

Curandero

A male folk healer in the Latino culture.

Time

An awareness of the concept of time is a gradual learning process. Some cultures place great importance on values that are measured by clock time. Punctuality and efficiency are highly valued in the United States, whereas some cultures are actually scornful of clock time. For example, some rural people in Algeria label the clock as the "devil's mill" and therefore have no notion of scheduled appointment times or meal times (Giger, 2013). They are totally indifferent to the passage of clock time, and they despise haste in all human endeavors. Other cultural implications regarding time have to do with perception of time orientation. Whether individuals are present oriented or future oriented in their perception of time influences many aspects of their lives.

Intervention 1: Use an interpreter if nexessary to ensure that there are no barriers to communication.

Be careful with nonverbal communication because it may be interpreted differently by different cultures (Asains and Native Americans may be uncomfortable with touch and direct eye contact, whereas Latios and Western Europeans perceive touch as a sign of caring).

Biological Variations

Biological differences exist among people in various racial groups. These differences include body structure (both size and shape), skin color, physiological responses to medication, electrocardiographic patterns, susceptibility to disease, and nutritional preferences and deficiencies. Giger (2013) suggests that nurses who possess factual knowledge about biological variations among diverse groups are better able to provide culturally appropriate health care.

Social Organization

Cultural behavior is socially acquired through a process called enculturation, which involves acquiring knowledge and internalizing values (Giger, 2013). Children are enculturated by observing adults within their social organizations. Social organizations include families, religious groups, and ethnic groups.

Direct communication

Display of emotions acceptable within limits; constructive criticism considered helpful for others; vast public use of social media provides instant connections that can strengthen or hinder relationships

Informality and friendliness

First name commonly used when addressing others; many friendly expressions such as "let's get together soon" and "drop by anytime" are sincere at the time, but because of busy lifestyles are not meant literally

Intervention 6: Follow the health-care practices that the client views as essential, provided they do no harm or do not interfere with the healing process of the client.

For example, the concepts of yin and yang and the hot and cold theory of disease are very important to the well-being of some Asians and Latinos, respectively. Try to ensure that a balance of these foods are included in the diet as an important erinforcement for traditional medical care.

Intervention 5: Be aware of different beliefs about health care among the various cultures, and recognize the importance of these beliefs to the healing process.

If an individual from another culture has been receiving health care from a spiritualist, granny, curandero, or other nontraditional healer, it is important for the nurse to listen to what has been done in the past and even to consult with these cultural healers about the care being given to the client.

Individuality

Independence; ambition; self-reliance; control over one's life; desire for individual choices results in long-term debates concerning government control of health care, school choice, possession of personal firearms, and so on

Intervention 8: The nurse working in psychiatry must realize that psychiatric illness is stigmatized in some cultures.

Individuals who believe that expressing emotions is unacceptable (Asian Americans and Native Americans) will present unique problems when they are clients in psychiatric setting. Nurses must have patience and work slowly to establish trust in order to provide these individuals with the assistance they require.

Intervention 2: Make allowances for individuals from other cultures to have family members around them and even to have family members participate in their care.

Large numbers of extended family members are very important to African Americans, Native Americans, Asian Americans, Latino Americans, and Western European Americans. To deny access to these family support systems could interfere with the healing process.

Consumerism

Mass luxuries and growth of comfort pleasures; need for material goods; "high-end" designer products—homes, clothing, automobiles—desired in all income levels; long-distance travel vacations; vast accumulation of goods leading to economic stress and excessive debt; overconsumption in food practices resulting in increased obesity and decreased overall health

Intervention 4: Be aware of the differences in concept of time amoung the various cultures.

Most members of the dominant American culture are future oriented and place in a high value on punctuality and efficiency. Other cultures, such as African Americans, Native Americans, Asian Americans, Latino Americans, Arab Americans, and Western European Americans, are more present-time oriented. Nurses must be aware that such individuals may not share the value of punctuality. They may be late to appointments and appear to be indifferent to some aspects of their therapy. Nurses must be accepting of these differences and refrain from allowing existing attitudes to interfere with delivery of care.

Time adherence

Punctuality considered important; activities organized around specific schedules; hurried, active lifestyles causing difficulty with relaxation, stress tolerance, and physical fitness

Intervention 3: Ensure that the individual's spiritual needs are being met.

Religion is an important source of support for many individuals, and the nurse must be tolerant of various rituals that may be connected with different cultural beliefs about health and illness.

Perfectionism

Strong emphasis placed on achievement in school, jobs, sports, and physical beauty

Social challenges

Suburban tract housing; widespread consumption of fast food; frequent relocations; solo car travel; decreased family and community connections; mall shopping preferred to local shopping; increase in bullying behaviors in school and workplace; proliferation of violence and traumatic events within the family and community

yin and yang

The fundamental concept of Asain health practices. Yin and yang are opposite forces of energy, such as negative/positive, dark/light, cold/hot, hard/soft, and feminine/masculine. Food, medicines, and herbs are classified according to their yin and yang properties and are used to restore a balance, thereby restoring health.

Intervention 7: Be aware of favorite foods of individuals from different cultures.

The health-care setting may seem strange and somewhat isolated, and for some individuals it feels good to have anything around them that is familiar. They may even refuse to eat foods that are unfamilar to them. If it does not interfere with his or her care, allow family members to provide favorite foods for the client.

Enculturation

The process of learning the norms within a culture

Environmental Control

The variable of environmental control has to do with the degree to which individuals perceive that they have control over their environment. Cultural beliefs and practices influence how an individual responds to his or her environment during periods of wellness and illness. To provide culturally appropriate care, the nurse not only should respect the individual's unique beliefs but also should have an understanding of how these beliefs can be used to promote optimal health in the client's environment.

Asian Americans

These individuals incorporate traditional values and beliefs with Western values and beliefs. They become integrated into the American culture, while maintaining a connection with their ancestral culture.

The marginal people

These individuals reject the traditional values and totally embrace Western culture. Often they are members of the younger generations.

The traditionalists

These individuals tend to be the older generation Asians who hold on to the traditional values and practices of their native culture. They have strong, internalized Asian values. Primary allegiance is to the biological family.

Relationships

These questions assess a person's ability to connect in life-giving ways with familym friends, and social groups to engage in the forgiveness of others. -Who are the significant people in your life? -Who are your readily available, nearby support people? -Who are the people to whom you are closest? -Describe any groups in which you are an active participant. -How comfortable are you with asking people for help when you need it? -How comfortable are you with sharing your feelings with others? -What are some of the most loving things that others have done for you? -What are the loving things that you do for other people? -What are your thoughts about forgiving others?

Environment

These questions assess a person's ability to experience a sense of connection with life and nature, an awareness of the effects of the environment on life and well-being and a capacity or concern for the health of the environment. -How does your environment have an impact on your state of well-being? -What are your environmental stressors at work and at home? -What strategies reduce your environmental stressors? -Do you have any concerns for the state of your immediate environment? -Are you involved with environment issues such as recycling environmental resources at home, work, or in your community? -Are you concerned about the survival of the planet?

Inner Strengths

These questions assess a person's ability to manifest joy and recognize strengths, choices, goals, and faith. -What brings you joy and peace in your life? -What can you do to feel alive and full of spirit? -What traits do you like about yourself? -What are your personal strengths? -What choices are available to you to enhance your healing? -What life goals have you set for yourself? -What do you think is the role of stress, if any, in your illness? -How aware were you of your body before you became sick? -What do you believe in? -How has your illness influenced your faith? -How important is faith in your overall health and sense of well-being?

Meaning and Purpose

These questions assess a person's ability to seek meaning and fullfillment in life, manifest hope, and accept ambiguity and uncertainty. -What gives your life meaning? -Describe your sense of purpose in life. -How does your illness affect your life goals? -How hopeful are you about obtaining a better degree of health? -How would you describe your role in maintaining your heath? -What kind of changes will you be able to make in your life to maintain your health? -Describe your level of motivation to get well. -What is the most important or powerful thing your life?

Behavior and Activites

These questions assess a person's capacity for finding meaning in worship or religious activities, and a connectedness with a divinity. -How important is worship to you? -What do you consider the most significant act of worship in your life? -Describe any religious activities in which you are an active participant. -Describe any spiritual activities, if any, that you find meaningful. -Do you find prayer meaningful? -To whom do you turn for support? -Describe any activities in which you engage for coping and support. -Describe any activities in which you have previously engaged and have not found helpful.

Interconnections

These questions assess a person's positive self-concept, self-esteem, and sense of self; sense of belonging in the world with others; capacity to pursue personal interests; and ability to demonstrate love of self and self-forgiveness. -How do you feel about yourself right now? -How do you feel when you have a true sense of yourself? -Describe any activities of personal interest that you pursue. -What do you do to show love for yourself? -Can you forgive yourself? -What do you do to heal your spirit?

Race

a more biological term, describing a group of people who share similar inherited characteristics such as skin color, facial features, and blood groups

Cultural syndromes

are syndromes that are specific to a culutral group and do not share an exact correlation to any Diagnostic and Statistical Manual of Mental Disorders, diagnostic category.

Spiritual distress

elated to inability to participate in usual religious practices because of hospitalization, evidenced by alterations in mood (e.g., anger, crying, withdrawal, preoccupation, anxiety, hostility, apathy)

Imbalanced nutrition

less than body requirements, related to refusal to eat unfamiliar foods provided in the health-care setting, evidenced by loss of weight

Shaman

medicine man (or woman) -may use a variety of methods in his or her practice. -Some use crystals to diagnose illness, some sing and perform healing ceremonies, and some use herbs and other plants or roots to create remedies with healing properties. -AI/AN healer may confer with a physician regarding the care of a client in the hospital

Impaired verbal communication

related to cultural differences evidenced by inability to speak the dominant language

Anxiety (moderate to severe)

related to entry into an unfamiliar health-care system and separation from support systems evidenced by apprehension and suspicion, restlessness, and trembling

Spirituality

the human quality that gives meaning and sense of purpose to an individual's existence. Spirituality exists within each individual regardless of belief system and serves as a force for interconnectedness between the self and others, the environment, and a higher power.

Hall (1966) identified three primary dimensions of spave in interpersonal interactions in the Western culture:

the intimate zone (0 to 18 inches) the personal zone (18 inches to 3 feet), and the social zone (3 to 6 feet)