Cultural Diversity

KEY CONCEPTS +Society in the United States is increasingly made up of people from many diverse backgrounds. Cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. The knowledge and skills for understanding cultural diversity and providing culturally respectful care have become essential components of nursing practice. +Culture may be defined as a shared system of beliefs, values, and behavioral expectations that provides social structure for daily living. Culture influences roles and interactions with others as well as within families and communities and is apparent in the attitudes and institutions unique to particular groups. +Ethnicity is a sense of identification with a collective cultural group, largely based on the group's common heritage. One belongs to a specific ethnic group or groups either through birth or through adoption of characteristics of that group. +Racial categories are typically based on specific physical characteristics such as skin pigmentation, body stature, facial features, and hair texture. Because of the significant blending of physical characteristics through the centuries, however, race is becoming harder to define.

+Cultural influences on health care are many and varied: physiologic variations, reactions to pain, mental health, biological sex roles, language and communication, orientation to space and time, food and nutrition, family support, and socioeconomic factors. +People's values and beliefs about health, illness, and care for an illness develop as a direct result of cultural and ethnic influences. People from different cultures may also have different beliefs about the best way to treat an illness or disease. +Providing culturally competent, or in newer terms, culturally respectful nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse populations within society.

+Becoming culturally competent is a lifelong challenge. Nurses should strive to be culturally humble—recognizing what we don't yet know about those entrusted to our care and being willing to learn what we need to know. +Nurses who value cultural competence strive to enhance their understanding of the following: -Beliefs, values, traditions and practices of a culture -Culturally defined, health-related needs of individuals, families and communities -Culturally based belief systems of the etiology of illness and disease and those related to health and healing -Culturally based attitudes toward seeking help from health care providers

+Nursing care can become complicated when the patient and the nurse have distinctly different cultural norms. Cultural imposition in health care is the tendency for health personnel to impose their beliefs, practices, and values on people of other cultures. Closely related to cultural imposition is ethnocentrism, the belief that one's own culture's ideas, beliefs, and practices are the best, superior, or most preferred to those of another culture. +Cultural competence takes time. It involves developing awareness, acquiring knowledge, and practicing skills.

ASKED mnemonic: to examine your cultural competence Awareness Skill Knowledge Encounters Desire

-Ask yourself how aware you are of your own biases and prejudices toward people different from you. -Ask yourself if you can complete a cultural assessment being sensitive to cultural differences and sensitivities. -Ask yourself how much you know about different cultures and ethnic groups, about their beliefs, customs, and biologic variations. -Ask yourself what level of interest you have in interacting with people from different cultures or ethnicities. -Finally, ask yourself if you really have interest in becoming culturally competent

Cultural beliefs and values to assess include: -Value orientation (principles of what values and behaviors are considered right or wrong by a group or an individual) -Beliefs about human nature -Beliefs about relationship with nature -Beliefs about purpose of life -Beliefs about health, illness, and healing

-Beliefs about what causes disease -Beliefs about health -Beliefs about who serves in the role of healer or what practices bring about healing -Beliefs about the meaning of suffering and pain

Tips for Communicating Effectively About Medication With Culturally Diverse Patients -Encourage cultural sensitivity in health care workers in your particular setting. Acquire basic information about health beliefs and practices of various cultural groups in your health care setting. This provides a basis for assessing patient's beliefs and practices. Recognize, however, that within all cultures and ethnic groups, there are members who do not hold all the values of the group. -Consider biological variations (e.g., color, body structure, pharmacogenetics) when performing a baseline assessment and administering medications. -Be alert to atypical drug responses or unexpected adverse effects that may occur in certain ethnic groups. This knowledge helps you direct assessment questions as appropriate. -Ask specifically about the use of folk or home remedies prescribed by a nontraditional healer. -Ask specific questions about possible adverse effects, rather than asking general questions or waiting for the patient to voice concerns. For example, do not ask, "Are you having any problems with your medicine?" Instead, ask, "Have you noticed any unusual, involuntary movements?" -Consider individual cultural health practices, values, and definitions of health and illness when teaching patients and families. Ask, "What do you think caused your health problem?" and "What treatment do you think will help?" -Include culturally sensitive information in all basic health teaching. For example, consider the patient's perception of time and space when teaching.

-Consider the impact of their social organization and roles when presenting information. Involve the family and other members of the community as appropriate. -Determine the patient's language preferences for spoken and written communication. Use trained medical interpreters as needed. -Use printed or audiovisual information that is in the language spoken by your patients. Recognize that diversity exists within cultural groups. For example, the Hispanic population includes Mexicans, Cubans, Puerto Ricans, and other Latino groups. -Help culturally diverse patients to value and understand the importance of communicating concerns and asking questions about prescribed medications. --- -Patients and families need to know how to identify major adverse effects of the medications they are taking and the appropriate person(s) to contact if these effects are noted.

When caring for a patient from a cultural or ethnic group different from your own, it is important to perform a transcultural assessment of communication : -What language does the patient speak during usual activities of daily living? -How well does the patient speak and write in English? -Does the patient need an interpreter? Are family members or friends available? Are there people the patient would not want to serve as an interpreter?

-How does the patient prefer to be addressed? -What cultural values and beliefs of the patient (such as eye contact, personal space, or social taboos) may change your techniques of communication and care? -How does the patient's nonverbal behavior affect the responses of members of the health care team? -What are the cultural characteristics of the patient's communications with others?

Assuring Cultural Competence in Health Care -Ensure that all patients/families receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. -Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. -Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

-Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/family with limited English proficiency at all points of contact, in a timely manner during all hours of operation. -Make available easily understood patient-related materials and post signs in the language of the commonly encountered groups and/or groups represented in the service area. -Ensure that data on the individual patient's/family's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. -Maintain a current demographic, cultural, and epidemiologic profile of the community, as well as a needs assessment, to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

The characteristics of culture include the following: -Culture helps shape what is acceptable behavior for people in a specific group. It is shared by, and provides an identity for, members of the same cultural group. -Culture is learned by each new generation through both formal and informal life experiences. Language is the primary means of transmitting culture.

-The practices of a particular culture often arise because of the group's social and physical environment. -Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. -Culture influences the way people of a group view themselves, have expectations, and behave in response to certain situations. Because a culture is made up of people, there are differences both within cultures and among cultures.

CULTURAL ASSESSMENT Purposes and Scope of Assessment The main purposes of assessing culture in a health care setting are: -To learn about the client's beliefs and usual behaviors associated with health and illness, including beliefs about disease causes, caregiving, expected treatments (both Western medicine and folk practices), daily hygiene, food preferences and rituals, religious beliefs relative to health care

-To compare and contrast the client's beliefs and practices to standard Western health care -To compare the client's beliefs and practices with those of other persons from a similar cultural background (to avoid stereotyping) -To assess the client's health relative to diseases prevalent in the specific cultural group

Transcultural Assessment: Health-Related Beliefs and Practices -To what cause(s) does the patient attribute illness and disease (e.g., divine wrath, imbalance in hot/cold or yin/yang, punishment for moral transgressions, hex, soul loss, pathogenic organism)? -What are the patient's cultural beliefs about the ideal body size and shape? What is the patient's self-image compared to the ideal? -What name does the patient give to his or her health-related condition? -What does the patient believe promotes health (e.g., eating certain foods; wearing amulets to bring good luck; sleep; rest; good nutrition; reducing stress; exercise; prayer; rituals to ancestors, saints, or intermediate deities)?

-What is the patient's religious affiliation (e.g., Judaism, Islam, Pentecostalism, West African voodooism, Seventh-Day Adventism, Catholicism, Mormonism)? -How actively involved in the practice of this religion is the patient? -Does the patient rely on cultural healers (e.g., curandero, shaman, spiritualist, priest, minister, monk)? -Who determines when the patient is sick and when the patient is healthy? Who influences the choice/type of healer and treatment that should be sought? -In what types of cultural healing practices does the patient engage (e.g., use of herbal remedies, potions, massage; wearing of talismans, copper bracelets, or charms to discourage evil spirits; healing rituals, incantations, prayers)? -How are biomedical/scientific health care providers perceived? How do the patient and the patient's family perceive nurses? What are the expectations of nurses and nursing care? -What comprises appropriate "sick role" behavior? Who determines what symptoms constitute disease/illness? --Who decides when the patient is no longer sick? Who cares for the patient at home? -How does the patient's cultural group view mental disorders? Are there differences in acceptable behaviors for physical versus psychological illnesses?

CULTURAL IMPACT ON ASSESSMENT OF LEARNING NEEDS In addition to determining the language spoken in the home and use of eye and physical contact, investigate the following during the assessment:

-Who is the person caring for the child at home? -Who is the authority figure in the family? -What is the social support structure? -Are there any special dietary needs and concerns? -Are any traditional health practices used (e.g., healers, shamans, talismans, folk remedies, and herbs)? -Are any special clothes or other items used to help maintain health? -What religious beliefs, ceremonies, and spiritual practices are important?

Nursing Guidelines to Conduct a Culturally Sensitive Pain Assessment 1. Explain to the client why a pain assessment is completed and how it will be used. 2. Explore what pain means to the client. Listen carefully. 3. Discuss possible religious and spiritual beliefs the client has about pain. If they are different from your beliefs, listen and accept the client's beliefs as valid for the client.

4. Determine the client's level of acculturation to his or her culture of origin or to the local dominant culture in which the client now lives. 5. Explore the client's prior experiences with pain, the level of pain expected, and pain treatments and outcomes received in the past. 6. Ask the client to describe his or her pain treatment expectations. 7. Explore prior use of folk medicine or complementary/alternative therapies for treating pain (such as herbs, teas, rubs, acupuncture, and others). Explain the need to evaluate previous treatments used for possible interactions with newly prescribed treatments. 8. Explain the effects of pain on the body and why it is important to attempt to reduce pain. (For example, pain control can increase mobility, which helps prevent complications such as pneumonia.) 9. Do not impose values and beliefs on the client; respect variations in beliefs, expectations of pain and pain treatment, and acceptance or rejection of prescribed pain treatment.

CULTURAL COMPETENCE To provide high-quality health care, nurses must know how to assess what is normal or abnormal for all persons who seek care. This necessitates cultural competence. Cultural competence has a number of components and allows a nurse to integrate a cultural assessment into the health assessment of each client.

According to Campinha-Bacote (2015), there are five constructs in the cultural competence process: -cultural awareness -cultural skill -cultural knowledge -cultural encounters -cultural desire.

Guidelines for Nursing Care Transcultural nursing, now both a specialty and a formal area of practice providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society

A nurse who is culturally respectful has the knowledge and skills to adapt nursing care to cultural similarities and differences. Cultural competence takes time. It involves developing awareness, acquiring knowledge, and practicing skills. Each patient must be considered a unique person. What is true of one person may not be true of another, even if they are from the same cultural background.

Mutual cultural assimilation also occurs, with both groups taking on some characteristics of the other. For example, many Hispanic immigrants to the United States learn to speak English, and many Americans learn to cook and enjoy traditional Hispanic foods. We all gain from the many cultures with which we live. Although we seldom think about it, the clothes we wear, the foods we eat, the music we enjoy, many of the words we use, and the leisure activities we practice are all influenced by acculturation.

A person may experience culture shock when placed in a different culture he or she perceives as strange. Culture shock may result in psychological discomfort or disturbances, because the patterns of behavior a person found acceptable and effective in his or her own culture may not be adequate or even acceptable in the new culture. The person may then feel foolish, fearful, incompetent, inadequate, or humiliated. These feelings can eventually lead to frustration, anxiety, and loss of self-esteem.

Steps of Client and Family Education The steps of client and family education are similar to the steps of the nursing process. The nurse must assess the client, develop a plan, implement services needed, perform follow-up evaluation, and finally document education. Once the nurse achieves a level of comfort and experience with each of these steps, they all blend together into one harmonious whole that becomes an everyday part of nursing practice. Client education begins with the first client encounter and proceeds through discharge and beyond. Reassessment after each step or change in the process is critical to ensuring success.

ASSESSING TEACHING AND LEARNING NEEDS Excellent nursing care begins with a thorough assessment of the client. In the same way, client and family education begins with a learning needs assessment that includes the client's and family's learning needs, learning styles and preferences, and potential barriers to learning. Based on the results of the assessment, an individualized plan can be developed to reduce the time and effort required for teaching while maximizing learning for the client and family. Although actual nursing care in pediatrics is given to the child, the educational process is targeted at both the child, when developmentally appropriate, and the adult members of the family. Therefore, it is advisable to conduct a learning needs assessment on both the adult caregivers and the child, when appropriate. This is also a good time to establish rapport with the family, demonstrating your interest in them and your confidence in their ability to learn. Share the assessment with all members of the interdisciplinary team so that the entire team can support the client's and family's learning. Although assessment generally takes place during the first or second meeting with the client and family, it should also occur with each encounter to check for any changes that may occur.

Research has demonstrated that crowded living conditions foster depersonalization, correlate with higher crime rates, and lead to psychological problems such as schizophrenia, alienation, and feelings of worthlessness. Such conditions also contribute to an increased incidence and severity of disease and illness because of the closer proximity of people, the sharing of utensils and belongings, poor sanitation, and poor health habits.

Accessing health care facilities frequently requires transportation, which often is neither affordable nor available to poor people. Their access to health insurance also is frequently limited, and they often must choose between purchasing food and obtaining health care. Those in upper-income groups tend to live longer and to experience less disability than those in lower-income groups. Other barriers to health care include isolation, language or communication difficulties, seasonal occupations, migration patterns, depersonalization, and institutional prejudice.

Communicate in a nonthreatening manner. -Conduct the interview in an unhurried manner. -Follow acceptable social and cultural amenities. -Ask general questions during the information-gathering stage. -Be patient with a respondent who gives information that may seem unrelated to the patient's health problem. -Develop a trusting relationship by listening carefully, allowing time, and giving the patient your full attention. Use validating techniques in communication. -Be alert for feedback that the patient does not understand. -Do not assume meaning is interpreted without distortion. Be considerate of reluctance to talk when the subject involves sexual matters. -Be aware that in some cultures, sexual matters are not discussed freely with members of the opposite sex.

Adopt special approaches when the patient speaks a different language. -Use a caring tone of voice and facial expression to help alleviate the patient's fears. -Speak slowly and distinctly, but not loudly. -Use gestures, pictures, and play acting to help the patient understand. -Repeat the message in different ways if necessary. -Be alert to words the patient seems to understand and use them frequently. -Keep messages simple and repeat them frequently. -Avoid using medical terms and abbreviations that the patient may not understand. -Use an appropriate language dictionary. Use interpreters to improve communication. -Ask the interpreter to translate the message, not just the individual words. -Obtain feedback to confirm understanding. -Use an interpreter who is culturally sensitive.

SPECIFIC LEARNING PRINCIPLES RELATED TO PARENTS Adults are self-directed. Adults value independence and want to learn on their own terms. Teaching strategies that include such concepts as role playing, demonstration, and self-evaluation are most helpful. Using this model, nurses can partner with families to ensure that education is interactive and adopt the role of facilitator rather than lecturer. Adults are problem-focused and task-oriented. Adults learn best when they perceive there is a gap in their knowledge base and want information and skills to fill the gap. Providing a reason to learn can often motivate families that appear slow to comply with their child's care and education.

Adults are goal oriented. Adults learn best at a time when learning meets an immediate need. Presenting information in an organized, sequential, and timely fashion can often help families understand the importance of learning a particular piece of information or task. Adults value past experiences and beliefs. Adults bring an accumulated wealth of experiences to each health care encounter; this provides a rich base for new learning. Education should take into account a wide range of backgrounds. Appreciating and using individual differences during teaching encounters can help improve compliance and reduce resistance to educational goals.

CULTURALLY RESPECTFUL NURSING CARE Providing culturally respectful nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse populations within society.

Among the elements of cultural competence are the following: -Developing an awareness of one's own existence, sensations, thoughts, and environment to prevent them from having an undue influence on those from other backgrounds -Demonstrating knowledge and understanding of the patient's culture, health-related needs, and culturally specific meanings of health and illness -Accepting and respecting cultural differences in a manner that facilitates the patient's and family's abilities to make decisions to meet their needs and beliefs -Not assuming that the health care provider's beliefs and values are the same as the patient's -Resisting judgmental attitudes such as "different is not as good" -Being open to and comfortable with cultural encounters -Accepting responsibility for one's own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices

Factors Affecting Approach to Providers The following may affect interactions between clients and their health care providers: -Ethnicity (of both client and health care provider) -Generational status (of both client and health care provider) -Educational level -Religion -Previous health care experiences -Occupation and income level -Beliefs about time and space -Communication needs/preferences

Autonomy is assumed to be a right of all health care consumers in the United States, meaning that individuals have the right to know about diagnosis and treatment plans and to make decisions for themselves. Studies show that Asians and Americans tend to keep more space between them and others when speaking. Latins, both Mediterranean and Latin American, stay closer to each other; and Middle Easterners move in the closest.

The increase in the number of single-parent female families (also known as the feminization of poverty), has had the greatest potential for increasing the number of people living in poverty.

Health Disparities The term health disparities refers to health differences between groups of people; they can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death. Many different populations are affected by disparities, including racial and ethnic minorities; residents of rural areas; women, children, and the older adult; and persons with disabilities.

Biological Sex Roles In some cultures, the man is the dominant figure and generally makes decisions for all family members. For example, if approval for medical care is needed, the man may give it regardless of which family member is involved. In male-dominant cultures, women are often passive. On the other hand, there are cultures in which women are dominant.

Knowing who is dominant in the family is important when planning nursing care. For example, if the dominant member is ill and can no longer make decisions, the whole family may be anxious and confused. If a nondominant family member is ill, the person may need help in verbalizing needs, particularly if the needs differ from those the dominant member perceives as being important.

BARRIERS TO PAIN ASSESSMENT Barriers to correct pain assessment may be present and must be assessed as well. Cultural and physiologic differences account for most of these. ---- Consider cultural variation to exist in all patient populations and not just among persons from other countries. Also, gender differences are expressed differently in different cultures. Nurses' and other health care providers' beliefs about pain can also affect the assessment.

BARRIERS BASED ON BELIEFS -Acknowledging pain is not manly; it is a sign of weakness. -Pain is a punishment (often thought to be from God) for past mistakes, sins, or behaviors, and must be tolerated. -Pain indicates that my condition/disease is getting worse, and that I am going to die soon. If I don't acknowledge it, it won't be so bad. -Pain medications are addictive; cause awful side effects; and make me "dopey," confused, and sleepy or unconscious. -All people have pain, especially as they age. This is just normal pain and I should not say anything about it.

BARRIERS BASED ON PHYSICAL CONDITIONS -The disease/illness/injury for which the patient is being treated is not the source of the pain. -Both the current disease and another disease are causing pain. -The patient expresses few, if any, pain-related behaviors once accommodated to prolonged chronic pain conditions.

BARRIERS BASED ON HEALTH CARE PROVIDERS' BELIEFS -Patients who complain of pain frequently are just trying to get more pain medicine or are addicts wanting more narcotics. -Patients who complain of pain but do not show physical and behavioral signs of pain do not need more pain medication, whether they are chronic pain patients or acute pain patients. -Old people simply have more pain. -Confused or demented patients, or very young patients, neonates, and fetuses do not feel pain. -Patients who are sleeping do not have pain. -Pain medication causes addiction/respiratory depression/too many side effects. -Giving as much pain medication as possible at night will make the patients sleep and not disturb the nurses.

Blood Products, Transfusions, and Organ Donations Use of blood products and blood transfusions is accepted by most religions except for Jehovah's Witnesses. Organ donation and autopsy are not accepted by certain cultural groups, including Christian Scientists, Orthodox Jews, Greeks, and some Spanish-speaking groups (because of the belief that the person will suffer in the afterlife if organs are removed or autopsy is done). African Americans (12.6% of the population) donate at a low level but make up a substantial portion of the need for donated organs have listed barriers to minority donation from both deceased and living donors.

Barriers from deceased donors: -Lack of awareness of transplantation -Religious or cultural distrust of the medical community -Fear of medical abandonment (if donating) -Fear of racism Barriers from living donors: -Unwillingness to donate -Medical comorbid conditions -Distrust or fear of medical community -Loss to follow-up (not returning for follow-up appointments) -Poor coping mechanisms -Financial concerns -Reluctance to ask family members and friends -Fear of surgery -Lack of awareness about living donor kidney transplantation

The ESFT model: is a cross-cultural communication tool that helps health care professionals strengthen communication and identify potential threats to treatment adherence. Explanatory model of health and illness Social and environmental factors Fears and concerns Therapeutic contracting

Nurses can use this model to improve health care outcomes and address health disparities.

Language and Communication Assimilation is likewise slower for people who stay at home, especially if they live in communities of their ethnic and cultural background. Children usually assimilate more rapidly and learn the language of the dominant culture quickly if they leave home each day to go to school and make new friends in the dominant culture. Wage earners also tend to learn a new language more quickly through the work setting. Language acquisition is thus tied to necessity and assimilation rather than to degree of difficulty. Because the United States has such a diverse population, with many languages spoken, communication problems can arise during health care activities. This problem is not unique to non-English-speaking patients; even in different regions of the country, certain dialects or word meanings can cause differences in understanding.

Consider how difficult it must be to describe symptoms or give a personal health history when you do not understand the questions being asked. In addition, patients may forget English words or revert to their more familiar language when experiencing the stress of an injury, illness, or pain. Imagine for a moment finding yourself in an emergency room with crushing chest pain in a foreign country where no one speaks your language.

Also affecting cultural sensitivity are cultural imposition, which is the belief that everyone else should conform to your own belief system, and cultural blindness, which occurs when one ignores differences and proceeds as though they do not exist.

Cultural imposition and cultural blindness can be observed within the health care system, especially in regard to nontraditional methods of care. Culture conflict occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values

TERMS AND DEFINITIONS RELATED TO CULTURE Acculturation—The circumstance when a person gives up the traits of his or her culture of origin as a result of context with another culture, to variable degrees. Assimilation—The gradual adoption and incorporation of characteristics of the prevailing culture. Cultural diversity—The co-existence of a difference in behavior, traditions, and customs—in short, a diversity of cultures, often resulting from cross-border population flows; perhaps better referred to as "cultural pluralism". Cultural imposition—The intrusive application of the majority group's cultural view upon individuals and families (citing the United Nations, 1948, Universal Declaration of Human Rights).

Cultural relativism—The belief that the behaviors and practices of people should be judged only from the context of their cultural system. Culture—The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making Enculturation—A natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one's culture through socialization. Ethnicity—A socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come into contact.

Cultural Variations of Traditional Healers and Practices Culture Asian traditions Traditional Healers -Chinese medical practitioners -herbalists Preventive and Healing Practices -Prevent or rebalance yin/yang -hot/cold foods and conditions -wear amulets, acupuncture, cupping, moxibustion

Culture African traditions Traditional Healers -Magico herbalist, Hoodoo (also known as conjurers), or other traditional healers known as "Old Lady," "granny," or lay midwife Preventive and Healing Practices -Magical and herbal mix of herbs, roots, and rituals, talismans or amulets Culture Native American/Alaska Native traditions Traditional Healers -Medicine men or shamans Preventive and Healing Practices -Respect for nature and avoid evil spirits, use masks, herbs, sand paintings, amulets

Culture Hispanic (Mexican, Central and South America, Spain/Portugal) traditions Traditional Healers Folk healers (curandero/a, bruja/o [witch], yerbero/a, partera [midwife]) Preventive and Healing Practices -Hot/cold balance for diet, herbs, amulets, prayers to God and saints and spiritual reparations for sins, avoiding "evil eye" caused by jealousy and envy

Culture Western European traditions Traditional Healers Homeopathic physicians, physicians, and other health professionals Preventive and Healing Practices -Maintain physical and emotional well-being with proper science-based modern nutrition, exercise, cleanliness, belief in and faith in God

Why do nurses need to understand culture? Nurses interact with clients every day. A client who looks like you and comes from your community may actually hold very different beliefs about illness and health, about when and from whom to seek care, about who makes the decision about health-related issues for the family. If someone who seems so similar to you could be so different, imagine the possible differences you may encounter when you care for clients from obviously different cultural backgrounds or for immigrants to your country. In addition there has been a long history of disparity in the level of health care received by persons from certain racial groups or minorities, and the problems of ethnocentrism and stereotyping mentioned earlier. In addition, there are regulatory reasons for understanding and applying cultural knowledge, among them the National Standards for Care.

Culture may be defined as a shared system of values, beliefs, and learned patterns of behavior.

Culture-Bound Syndromes Middle East Zar Experience of spirit possession. Laughing, shouting, weeping, singing, hitting head against wall. May be apathetic, withdrawn, refuse food, unable to carry out daily tasks. May develop long-term relationship with possessing spirit (not considered pathologic in the culture).

Culture-Bound Syndromes North America, Western Europe Anorexia nervosa Associated with intense fear of obesity. Severely restricted food and calorie intake. Bulimia nervosa Associated with intense fear of obesity. Binge eating and self-induced vomiting, laxative, or diuretic use.

Develop Cultural Self-Awareness Before you can provide culturally competent care to patients from diverse backgrounds, you'll need to become aware of the role of cultural influences in your own life. Objectively examine your own beliefs, values, practices, and family experiences. As you become more sensitive to the importance of these factors, you'll also become more sensitive to cultural influences in others' lives. Identify your biases. How do they affect your feelings about others? How could they affect your nursing care of others?

Develop Cultural Knowledge Learn as much as possible about the belief system and practices of people in your community and of patients in the area in which you work. Practice techniques of observation and listening to acquire knowledge of the beliefs and values of patients for whom you provide care. Some people, especially those of minority cultures, may have been belittled or ridiculed and may be hesitant to discuss their beliefs and practices. Approach this topic with patients carefully. If you are motivated by sincerity, respect, and concern, your attitude will convey this, and most patients will respond positively. On the other hand, if you are motivated merely by curiosity and have a condescending attitude, most patients will respond negatively.

Culture may be defined as a shared system of beliefs, values, and behavioral expectations that provides social structure for daily living. The NIH defines culture as the combination of a body of knowledge, a body of belief, and a body of behavior.

Elements include personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are specific to ethnic, racial, religious, geographic, or social groups.

The ESFT Model The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches.

E—Explanatory Model of Health and Illness -What do you think caused your problem? -Why do you think it started when it did? -How does it affect you? -What worries you most? -What kind of treatment do you think you should receive? S—Social and Environmental Factors -How do you get your medications? -Are they difficult to afford? -Do you have time to pick them up? -How quickly do you get them? -Do you have help getting them if you need it? F—Fears and Concerns -Does the medication sound okay to you? -Are you concerned about the dosage? -Have you heard anything about this medication? -Are you worried about the adverse effects? T—Therapeutic Contracting -Do you understand how to take the medication? -Can you tell me how you will take it?

Orientation to Space and Time Personal space is the area around a person regarded as part of the person. This area, individualized to each person and to different cultures and ethnic groups, is the area into which others should not intrude during personal interactions. If others do not consider a person's personal space, that person may become uncomfortable or even angry. When providing nursing care that involves physical contact, you should know the patient's cultural personal space preferences.

For example, people of Arabic and African origin commonly sit and stand close to one another when talking, whereas people of Asian and European descent are more comfortable with more distance between themselves and others. Many people and almost all institutions in the United States value promptness and punctuality. When arriving for an appointment, doing a job, or carrying out an activity, being on time and getting the job done promptly are viewed as important. This is not true in some other cultures. For example, in some South Asian cultures, being late is considered a sign of respect. In addition, while some cultures are future oriented (including activities that promote future good health), other cultures are more concerned with the present or the past. Understanding the patient's orientation to time is important as you communicate, for example, the need to be on time for appointments for health care procedures and when taking medications.

Cultural Norms of the Health Care System -Beliefs -Standardized definitions of health and illness -Omnipotence of technology -Critical importance of safety and quality measures -Practices -Maintenance of health and prevention of illness -Annual physical examinations and diagnostic procedures

Habits Documentation Frequent use of jargon Use of a systematic approach and problem-solving methodology Likes Promptness Neatness and organization Compliance Dislikes Tardiness Disorderliness and disorganization Customs Professional deference and adherence to the pecking order found in autocratic and bureaucratic systems Use of certain procedures attending birth and death

Multicultural Web Resources Diseases and Conditions, Centers for Disease Control and Prevention -Provides information on all diseases but concentrates on infectious disease topics. Available in English and Spanish. Culture Clues -Tip sheets designed to increase awareness of the customs and preferences of patients and their families from diverse cultures. EthnoMed -Provides information on cultural beliefs, medical issues, and related topics pertinent to the health care of immigrants in Seattle and throughout the United States. It focuses on Cambodian, Ethiopian, Hispanic, Oromo, Somali, Tigrean, and Vietnamese cultures.

Health Information Translations -Health education resources in multiple languages for diverse populations. Searchable by keyword, topic, and language. Healthy Roads Media -A source of health information on over 100 topics and patient education materials in many formats. Search by topic or language. MedlinePlus -Allows users to browse for authoritative health information in over 50 languages. The Refugee Health Information Network -Contains patient health materials in many languages and formats as well as provider tools with information on refugee cultures. U.S. Committee for Refugees and Immigrants -Culturally appropriate material for consumers and health care professionals. Search by topic or language.

Culture-Bound Syndromes Africa and African Origin in Americas Falling out or blacking out Sudden collapse preceded by dizziness, spinning sensation. Eyes may remain open but unable to see. May hear and understand what is happening around them but unable to interact. Rootwork Belief that illnesses are supernatural in origin (witchcraft, voodoo, evil spirits, or evil person). Anxiety, gastrointestinal complaints, fear of being poisoned or killed. Spell Communicates with dead relatives or spirits, often with distinct personality changes (not considered pathologic in culture of origin).

High blood Slang term for high blood pressure, but also for thick or excessive blood that rises in the body. Often believed to be caused by overly rich foods. Low blood Not enough or weak blood caused by diet. Bad blood Blood contaminated, often refers to sexually transmitted infections. Boufeedeliriante (Haiti) Zar (Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern countries) A panic disorder with sudden agitated outbursts, aggressive behavior, confusion, excitement. May have hallucinations or paranoia. Spirit possession with symptoms such as dissociative episodes with laughing, shouting, hitting the head against a wall, singing, or weeping; may show apathy or withdrawal; may refuse to eat or participate in activities of daily living; may develop long-term relationship with possessing spirit. Not necessarily considered pathologic in the culture.

CULTURAL INFLUENCES ON HEALTH AND ILLNESS People's values and beliefs about health, illness, and health care are influenced by cultural and ethnic groups. For example, in some groups, illnesses are classified as either natural or unnatural. "Natural illnesses" are caused by dangerous agents, such as cold air or impurities in the air, water, or food. "Unnatural illnesses" are punishments for failing to follow God's rules, resulting in evil forces or witchcraft causing physical or mental health problems.

In some cultures, the power to heal is thought to be a gift from God bestowed on certain people. People in these cultures believe that these folk or traditional healers know what is wrong with them through divine intervention and experience. A patient accustomed to traditional healers may think that health care providers are incompetent because they have to ask many questions before they can treat an illness. Traditional healers speak the patient's language, often are more accessible, and are usually more understanding of the patient's cultural and personal needs.

Socioeconomic Factors Low income is a major problem in the United States and is often described as having created a culture of poverty. Of that population, the lowest income was found in African Americans, Native Americans, and Alaska Natives.

In terms of economics, a person or family whose income falls below an established poverty line is considered poor. The U.S. Census Bureau defines poverty according to money or income guidelines that vary by family size and composition. If the family's total income is less than a set threshold, all members of the family are considered poor. Others have stated that poverty is a relative term that reflects a judgment based on community standards. Such standards vary at different times and in different places; what is judged to be poverty in one community might be regarded as wealth in another. At highest risk are children, older people, families headed by single mothers, and the future generations of those now living in poverty. Access to financial resources affects how individuals and families meet their basic needs and maintain their health. Poverty often leads to problems such as lack of health insurance, inadequate care of infants and children, lack of access to basic health care services, and homelessness. All these are of concern to nursing.

Mental Health Most mental health norms originate in research and observations made of White, middle-class people. -many ethnic groups have their own norms and acceptable patterns of behavior for psychological well-being, as well as different normal psychological reactions to certain situations. -For example, many Hispanic people deal with problems within the family and consider it inappropriate to tell problems to a stranger. Some traditional Chinese people consider mental illness a stigma and seeking psychiatric help a disgrace to the family.

In times of high stress or anxiety, some Puerto Ricans may demonstrate a hyperkinetic seizure-like activity known as ataques; this behavior is a culturally accepted reaction. Be aware of these variations and accept them as culturally appropriate.

CULTURAL IMPACT ON ASSESSMENT OF LEARNING NEEDS In addition to determining the language spoken in the home and use of eye and physical contact, investigate the following during the assessment: -Who is the person caring for the child at home? -Who is the authority figure in the family? -What is the social support structure? -Are there any special dietary needs and concerns? -Are any traditional health practices used (e.g., healers, shamans, talismans, folk remedies, and herbs)? -Are any special clothes or other items used to help maintain health? -What religious beliefs, ceremonies, and spiritual practices are important?

Learning needs can then be negotiated with the family and met based on the assessment. Issues encountered when teaching immigrant or refugee families might include confusion regarding the use of the English versus the metric scale; preparing formulas and medicines using a "handful" or "pinch" of ingredients rather than specific measurements such as a measuring cup or syringe; access to refrigeration for liquid antibiotics; and breast-feeding practices.

COMPONENTS OF LEARNING NEEDS ASSESSMENT Assess Learner characteristics: Find out more about the child and family's life and how the child's illness has affected it. Learn more about the child and family's social, cultural, and spiritual values. Learner needs and readiness: Including what they want and need to know and what they know already; readiness and willingness to learn; motivation to learn and emotional concerns; capacity to learn such as physical or cognitive abilities including ability to read and developmental level.

Learning style: How does the child and family learn best; preferred learning methods. Learning barriers: Cultural or language barriers; cognitive or physical disabilities; presence of pain; lack of support network.

Culture-Bound Syndromes Latin (American or Mediterranean) Ataque de nervios Results from stressful event and build up of anger over time. Shouting, crying, trembling, verbal or physical aggression, sense of heat in chest rising to head. Empacho Especially in young children, soft foods believed to adhere to stomach wall. Abdominal fullness, stomach ache, diarrhea with pain, vomiting. Confirmed by rolling egg over stomach and egg appears to stick to an area. Mal de ojo (evil eye) Children, infants at greatest risk; women more at risk than men. Cause often thought to be stranger's touch or attention. Sudden onset of fitful sleep, crying without apparent cause, diarrhea, vomiting, and fever.

Mal puesto or brujeria See rootwork entry under Africa and African Origin in Americas in this table. Susto Spanish word for "fright," caused by natural means (cultural stressors) or supernatural means (sorcery or witnessing supernatural phenomenon). Nervousness, anorexia, insomnia, listlessness, fatigue, muscle tics, diarrhea. Caida de la mollera Mexican term for fallen fontanel. Thought to be caused by midwife failing to press on the palate after delivery; falling on the head; removing the nipple from the baby's mouth inappropriately; failing to put a cap on the newborn's head. Crying, fever, vomiting, diarrhea are thought to be indications of this condition (note the similarity to dehydration).

Linguistic competence refers to the ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter. Nurses who work in a geographic area with a high population of residents who speak a language other than English should learn pertinent words and phrases in that language.

Many facilities also have a qualified interpreter, or one can be found in the community. To avoid misinterpretation of questions and answers, it is important to use an interpreter who understands the health care system. Sometimes a family member or friend can translate for the nurse, but such a person may be protective and not the most reliable means of transferring information; thus, guidelines discourage using family members or friends as translators.

Relating to Patients From Different Cultures Assess your personal beliefs surrounding people from different cultures. -Review your personal beliefs and past experiences. -Set aside any values, biases, ideas, and attitudes that are judgmental and may negatively affect care. Assess communication variables from a cultural perspective. -Determine the ethnic identity of the patient, including generation in the United States. -Use the patient as a source of information when possible. -Assess cultural factors that may affect your relationship with the patient and respond appropriately. Plan care based on the communicated needs and cultural background. -Learn as much as possible about the patient's cultural customs and beliefs. -Encourage the patient to reveal cultural interpretation of health, illness, and health care. -Be sensitive to the uniqueness of the patient. -Identify sources of discrepancy between the patient's and your own concepts of health and illness. -Communicate at the patient's personal level of functioning. -Evaluate effectiveness of nursing actions and modify nursing care plan when necessary.

Modify communication approaches to meet cultural needs. -Be attentive to signs of fear, anxiety, and confusion in the patient. -Respond in a reassuring manner in keeping with the patient's cultural orientation. -Be aware that in some cultural groups, discussion concerning the patient with others may be offensive and may impede the nursing process. Understand that respect for the patient and communicated needs is central to the therapeutic relationship. -Communicate respect by using a kind and attentive approach. -Learn how listening is communicated in the patient's culture. -Use appropriate active listening techniques. -Adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by culture.

Culture-Based Treatments Culture-based treatments are often misinterpreted in Western health care settings, as they frequently produce marks on the skin that are interpreted as evidence of abuse. Assuming abuse can create a very bad nurse-client interaction and can cause the culturally different client to reject Western-style health care in the future. Some of the more common Asian treatments are cupping, coining, and moxibustion. Cupping, often used to treat back pain, involves placing heated glass jars on the skin. Cooling causes suction that leaves redness and bruising. Coining involves rubbing ointment into the skin with a spoon or coin. It leaves bruises or red marks, but does not cause pain. It is used for "wind illness" (a fear of being cold or of wind, which causes loss of yang), fever, and stress-related illnesses such as headache.

Moxibustion is the attachment of smoldering herbs to the end of acupuncture needles or the placement of the herbs on the skin; this causes scars that look like cigarette burns. It is used to strengthen one's blood and the flow of energy, and generally to maintain good health. Native American culture, medicine is more about healing the person than curing a disease. There is a spiritual element at the base of their healing practices. One of the most common forms of Native American healing practices involves the use of herbal remedies. These herbal remedies include teas, tinctures, and salves. A common Native American remedy for pain uses bark from a willow tree, which contains acetylsalicylic acid, also known as aspirin. Other treatments are related to different beliefs about what causes disease. In many cultures an imbalance in hot/cold is believed to cause disease, so treatment would be to take foods, drinks, or medication of the opposite type (hot for a cold condition and cold for a hot condition). What is thought to be hot or cold has no relation to temperature. Cancer, headache, and pneumonia are described as cold, whereas diabetes mellitus, hypertension, and sore throat or infection are hot. One example of a Western versus Latino treatment belief difference is pregnancy. Pregnancy is a hot condition; iron-containing foods are also hot, thus a pregnant female should not eat iron-containing foods. In Asian societies, hot/cold is also associated with the body's energy of yin/yang, which must remain in balance for health. The yin/yang balance is maintained through diet, lifestyle, acupuncture, and herbs. Some standard Western treatments are unacceptable in other cultures. Counseling or psychiatric treatments are resisted by some Asians and many other cultures because psychological or psychiatric illness is considered shameful.

Myths and Realities About Older Adults Old age begins at 65 years of age. -Defining 65 years of age as old age happened arbitrarily when 65 years of age was set for Social Security payments in the 1930s, based on the labor market and the economy of that time. Most older adults live in long-term care facilities. -Although the largest percentage of residents in long-term care facilities are older adults, many of whom have disabilities, only about 3% of older adults live in long-term care facilities. Most older adults are sick. As of 2015, 80% of older adults aged 65-74 and 68% of older adults over age 85 rate their health good, very good, or excellent. Old age means mental deterioration. Although response time may be prolonged due to a longer processing time, neither intelligence nor personality normally decrease because of aging.

Older adults are not interested in sex. Although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults don't care how they look. Older adults want to be attractive to others. Most older adults are isolated and lonely. Loneliness results from death of loved ones or other losses, just as it does for people of all ages. Many older adults participate in social and community activities. Bladder problems are a problem of aging. Incontinence is not a part of aging; it generally has a root cause and requires medical attention. Older adults do not deserve aggressive treatment for serious illnesses. Older adults deserve aggressive treatment if they want it. Older adults cannot learn new things. Many older adults today are more educated than previous generations, and have had to adapt to technologic advances; they continue to use technology into old age.

Ageism and Common Stereotypes Ageism is a form of prejudice, like racism, in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different and will remain different; therefore, they do not experience the same desires, needs, and concerns as other adults. Our industrial technologic world places a high priority on productivity, and some may think that older employees or retired people have outlived their usefulness.

Older people may be incorrectly viewed as being rigid or narrow-minded, unable to learn, unreliable because of memory loss, too old to enjoy sexual pleasure, or childlike and dependent. Many people fear advancing age because of pervasive views that older people are poor, lonely, in frail health, and headed for institutionalization in a long-term care facility. These descriptors are not true for most older adults. Most older adults are satisfied with their lives, finding retirement and old age more enjoyable than they had anticipated. Most older adults live in homes or apartments (96%), with the likelihood of living in a long-term care facility increasing as the person ages. Older women are less likely to be married and more likely to live alone. In fact, 27% of women aged 65 to 74, 42% of women aged 75 to 84, and 56% of women aged 85 and older live alone. Most older adults maintain close ties with their families, and 90% of older adults have incomes above the poverty level

Keep in mind that talking more loudly to someone who does not understand what you are saying is not helpful. Remember that language difference is a communication problem, not a hearing problem. Make sure you are familiar with the linguistic resources available in your practice settings and pertinent policies. The U.S. Department of Health and Human Services Office of Minority Health created a health care language services implementation guide to help health care organizations implement effective language access services to meet the needs of their patients with limited English proficiency, thereby increasing their access to health care.

One of the most culturally variable forms of nonverbal communication is eye contact. The American-dominant culture emphasizes eye contact while speaking, but many other cultures regard this behavior in different ways. For example, direct eye contact may be considered impolite or aggressive by many Asians, Native Americans, Indochinese, Arabs, and Appalachians; these groups of people tend to avert their eyes while speaking. Hispanics may look downward in deference to age, biological sex, social position, economic status, or authority. Muslim-Arab women often indicate modesty by avoiding eye contact with men, and Hasidic Jewish men may avoid direct eye contact with women.

Family Support In many cultural and ethnic groups, people have large, extended families and consider the needs of any family member to be equal to or greater than their own. They may be unwilling to share private information about family members with those outside the family (including health care providers).

Other cultural groups have great respect for the elders in the family and would never consider institutional care for them. Including the family in planning care for any patient is a major component in nursing care to meet individualized needs, especially if those needs can be met only through consideration of all members of the family.

People from different cultures may also have different beliefs about the best way to treat an illness or disease. For example, herbs are a common method of treatment in many cultures. In fact, many medications used today have a basis in herbs or other plant sources that have been used for centuries to cure illnesses. If a patient traditionally drinks an herbal tea to alleviate symptoms of an illness, there is no reason that both the herbal tea and prescribed medications cannot be used, as long as the tea is safe to drink and the ingredients do not interfere with or exaggerate the action of the medication.

Other traditional therapies include the use of cutaneous stimulation, therapeutic touch, acupuncture, and acupressure, Cutaneous stimulation by massage, vibration, heat, cold, or nerve stimulation reduces the intensity of the sensation of pain. Therapeutic touch is an intentional act that involves an energy transfer from the healer to the patient to stimulate the patient's own healing potential. Acupuncture, long used in China, is a method of preventing, diagnosing, and treating pain and disease by inserting special needles into the body at specified locations. Acupressure involves a deep-pressure massage of appropriate points of the body.

Examples of Common Health Problems in Specific Populations

POPULATION African Americans COMMON HEALTH PROBLEMS Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids POPULATION Hispanics COMMON HEALTH PROBLEMS -Diabetes mellitus -Lactose intolerance

Examples of Common Health Problems in Specific Populations

POPULATION Native Americans and Alaska Natives COMMON HEALTH PROBLEMS -Heart disease -Cirrhosis of the liver -Diabetes mellitus -Fetal alcohol syndrome POPULATION Asians COMMON HEALTH PROBLEMS -Hypertension -Cancer of the liver -Lactose intolerance -Thalassemia

Examples of Common Health Problems in Specific Populations

POPULATION Whites COMMON HEALTH PROBLEMS -Breast cancer -Heart disease -Hypertension -Diabetes mellitus -Obesity POPULATION Eastern European Jews COMMON HEALTH PROBLEMS -Cystic fibrosis -Gaucher's disease -Spinal muscular atrophy -Tay-Sachs' disease

Reactions to Pain Some cultures allow or even encourage the open expression of emotions related to pain, whereas other cultures encourage suppression of such emotions. NEVER assume that a patient who does not complain of pain is not having pain. If you make this assumption, you may overlook the pain-reduction needs of a patient who deals with pain quietly and stoically. To avoid this error, be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area, avoiding activities that intensify the pain, and uncontrollable, spontaneous expressions of discomfort, such as facial grimacing and moaning. You also should not consider patients who freely express their discomfort as constant complainers with excessive requests for pain relief.

Pain is a warning from the body that something is wrong. Pain is what the patient says it is, and every complaint of pain should be assessed carefully. Nursing care for a patient in pain is always individualized, but important culture-sensitive considerations include the following: -Recognize that culture is an important component of individuality, and that each person holds (and has the right to hold) various beliefs about pain. -Respect the patient's right to respond to pain in his or her own manner. -Never stereotype a patient's perceptions of or responses to pain based on the person's culture.

Culture-Bound Syndromes Native American Ghost sickness (Navajo) Feelings of danger, confusion, futility, suffocation, bad dreams, fainting, dizziness, hallucinations, loss of consciousness. Possible preoccupation with death or someone who died. Hi-Waitck (Mohave) Unwanted separation from a loved one. Insomnia, depression, loss of appetite, and sometimes suicide.

Pibloktoq or Arctic hysteria (Greenland Eskimos) An abrupt onset, extreme excitement of up to 30 minutes often followed by convulsive seizures and coma lasting up to 12 hours, with amnesia of the event. Withdrawn or mildly irritable for hours or days before attack. During the attack, may tear off clothing, break furniture, shout obscenities, eat feces, run out into snow, do other irrational or dangerous acts. Wacinko (Oglala Sioux) Often reaction to disappointment or interpersonal problems. Anger, withdrawal, mutism, immobility, often leads to attempted suicide.

In some cases, the culture of poverty is passed from generation to generation. This appears to be especially true in such groups as migrant farm workers, families living on public assistance, and people who live in isolated areas such as Appalachia. Poverty cultures often have the following characteristics: -Feelings of despair, resignation, and fatalism -"Day-to-day" attitude toward life, with no hope for the future -Unemployment and need for financial or government aid -Unstable family structure, possibly characterized by abusiveness and abandonment -Decline in self-respect and retreat from community involvement

Poverty has long been a barrier to adequate health care. It prevents many people from consistently meeting their basic human needs. The lack of affordable or adequate housing is a problem experienced frequently by poor people. When low-income housing is available, it sometimes lacks such necessities as running water, heat, and electricity. To stretch their available money and to pool resources, many poor people live in crowded conditions, with several families living together in one household.

Death Rituals death rituals include views on death and euthanasia along with rituals for dying, burial, and bereavement, and are unlikely to vary from the practices of the client's original ethnic group. Practices that affect health care include such customs as ritual washing of the body, the number of family members present at the death of a family member, religious practices required during or after dying, acceptance of life-or death prolonging treatments, beliefs about withdrawing life support, and beliefs about autopsy. Responses to death and grief can vary from loud wailing to solemn, quiet grief. In addition, the expected duration of grief varies with culture.

Pregnancy and Childbearing Cultural variation concerning pregnancy and childbearing practices includes "sanctioned and unsanctioned fertility practices; views toward pregnancy; and prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and the postpartum period". It may be surprising to some nurses that accepted practices for getting pregnant, delivery, and childcare vary across cultures. Beliefs about conception, pregnancy, and childbearing are passed from generation to generation (an example of the transmission of culture).

Diet and Nutrition Dietary considerations in cultural assessment include the meaning of food to the individual, common foods eaten and rituals surrounding the eating, the distribution of food throughout a 24-hour day, religious beliefs about foods, beliefs about food and health promotion, and nutritional deficiencies associated with the ethnic group. If possible, compare the nutrients of foods not usual in the United States with nutrition charts to understand how healthy a diet is, especially with regard to diseases such as diabetes mellitus. It is very difficult to get a client to change habitual dietary habits drastically, even with knowledge of the interaction of diet and disease. What food means to the individual can also be very important. It may serve as a comfort, as a means to stay close to ethnic roots or family.

Providing food may be considered to reflect caring and love, while withdrawing food may be considered akin to torture. When meals are served can seriously affect appetite. For those who usually eat a midday meal at 2:00 or 3:00 PM, it is unappetizing to see lunch served at 11:00 AM or 12 noon, and a 5:00 or 6:00 PM dinner is considered a late lunch rather than an evening meal. Religious beliefs affect what can and cannot be eaten, such as the prohibition of pork or pork products for Jews and Muslims and religious practices of fasting. Asking about specific diet requirements or preferences is part of cultural assessment.

cultural imposition: tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group

cultural respect: enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients; critical to reducing health disparities and improving access to high-quality health care

Ethnicity is a sense of identification with a collective cultural group, largely based on the group members' common heritage. One belongs to a specific ethnic group or groups either through birth or through adoption of characteristics of that group. People within an ethnic group generally share unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns. Ethnicity largely develops through day-to-day life with family and friends within the community.

Race Although the term ethnicity is often used interchangeably with race, these terms are not the same. Racial categories are typically based on specific physical characteristics -skin pigmentation -body stature -facial features -hair texture Because of the significant blending of physical characteristics through the centuries, however, race is becoming harder to define using simple classifications, and physical characteristics are not considered a reliable way to determine a person's race.

Accommodate Cultural Practices in Health Care Incorporate factors from the patient's cultural background into health care whenever possible if the practices would not be harmful to the patient's health. To ignore or contradict the patient's background may result in the patient refusing care or failing to follow prescribed therapy. Modify care to include traditional practices and practitioners as much as possible, and be an advocate for patients from diverse cultural groups. Accommodate the cultural dietary practices of patients as much as possible. Dietary departments in many hospitals and long-term care facilities can provide meals that are consistent with special dietary practices. Families may be encouraged to bring food from home for patients with particular preferences when this practice does not violate policy. Teaching patients and families about therapeutic diets may also be appropriate within the framework of particular cultural practices.

Respect Culturally Based Family Roles Consider the cultural role of the family member who makes most of the important decisions. In some cultures, it is the husband or father, whereas in others it may be a grandmother or another respected elder. To disregard this person's role or to proceed with nursing care that is not approved by this person can result in conflict or in disregard for the patient's and family's values. Be careful to involve this person in the nursing care planning.

Avoid Mandating Change Keep in mind that health practices are part of the overall culture and that changing them may have widespread implications for the person. Provide support and reinforcement for the patient if it is necessary to change a health practice with a cultural basis. Do not force patients to participate in care that conflicts with their values. If a patient is forced to accept such care, resulting feelings of guilt and alienation from a religious or cultural group are likely to threaten that patient's well-being.

Seek Cultural Assistance Seek assistance from a respected family member, member of the clergy, or traditional healer, as appropriate, so that the patient is more likely to accept health care services. Acknowledging the role of the person's traditional healer can be an important way of building trust. Folk medicine practitioners can work closely with professional health practitioners in the interest of the patient and family. Such efforts promote mutual understanding, respect, and cooperation.

Culture-Bound Syndromes Asian (South or East) Amok (Malaysia) Occurs among males (20-45 years old) after perceived slight or insult. Aggressive outbursts, violent or homicidal, aimed at people or objects, often with ideas of persecution. Amnesia, exhaustion, finally, return to previous state. Koro (Malaysia, Southeast Asia) Similar to conditions in China, Thailand, and other areas. Fear that genitalia will retract into the body, possibly leading to death. Causes vary, including inappropriate sex, mass cases from belief that eating swine flu-vaccinated pork is a cause. Latah (Malaysia) Occurs after traumatic episode or surprise. Exaggerated startle response (usually in women). Screaming, cursing, dancing, hysterical laughter, may imitate people, hyper suggestibility.

Shen kui (China) Dhat (India) Similar conditions that result from the belief that semen (or "vital essence") is being lost. Anxiety, panic, sexual complaints, fatigue, weakness, loss of appetite, guilt, sexual dysfunction with no physical findings. Taijinkyofusho (Japan) Dread of offending or hurting others by behavior or physical condition such as body odor. Social phobia. Illness (Asia) Fear of wind, cold exposure causing loss of yang energy.

Ethnocentrism—The universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways. Stereotyping—An oversimplified conception, opinion, or belief about some aspect of an individual or group.

Subculture—A group of people with a culture that differentiates them from the larger culture of which they are a part. Worldview—The way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them; includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magicoreligious beliefs, and aesthetics.

transcultural nursing: providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society

culture: the knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by humans as members of society

The number of female-headed households is increasing as a result of divorce, abandonment, unmarried motherhood, and changes in abortion laws. Because it is now common that two incomes are required in a household for economic survival, a single woman supporting a household is at a financial disadvantage. The number of single-parent families headed by women is associated closely with the increasing number of children living in poverty and the number of homeless families with children.

The increasing population of older people has also raised problems associated with poverty. Many older people live on fixed incomes that often do not keep up with inflation, and many (particularly widows) are on the borderline of poverty or have already slipped below the poverty level. Socioeconomic status often differs by the cultural group of the older adult. For example, Pacific/Asian, African-American, Native American, and Hispanic elders generally have lower incomes than elders in the majority population. The work history of the cultural group, especially those who have labored all their lives as agricultural workers, often means that a person has no Social Security or Medicare benefits.

Culture Pain is a universal human experience, but how people respond to it varies with the meaning placed on pain and the response to pain that is expected in the culture in which the person is raised. There are certain patterns of pain expression that vary across cultures. Pain can have several meanings among different cultures that lead to these difference response patterns. If a cultural group accepts pain as a normal part of life, persons of that culture may not see pain as a clinical problem with a clinical solution.

The most important factor is this: DO NOT STEREOTYPE! "the relationship between pain and ethnicity is shaped by experience, learning and culture". This means that even though there are tendencies for people from a particular cultural background to exhibit certain characteristics, many people of that culture will not. The nurse must assess what the person says about pain and how the person perceives pain. In other words, treat each client as a unique individual, assess each client, respect each client's responses to pain, and treat each client with dignity and consideration.

culture defines values (learned beliefs about what is held to be good or bad) and norms (learned behaviors that are perceived to be appropriate or inappropriate). Culture is learned, shared, associated with adaptation to the environment, and is universal. All people have a socially transmitted culture. Our own culture forms our worldview based on the values, beliefs, and behaviors sanctioned by it. That worldview becomes, for us, reality.

The perception that one's worldview is the only acceptable truth, and that one's beliefs, values, and sanctioned behaviors are superior to all others, is called ethnocentrism.

Cultural diversity can be defined as the coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit. Culture is an integral component of both health and illness because of the cultural values and beliefs that we learn in our families and communities. Nurses and other health care providers must be familiar with the concepts of cultural diversity in order to understand characteristics common to certain populations.

These groups include, but are not limited to, people of varying: -religion -language -physical size -sexual orientation -age -disability -occupational status -geographic location.

Contexts for Assessment Culture includes contexts beyond the basic beliefs and behaviors that vary. Culture also includes family structure and function, spirituality and religion, and community, which serve as context for growth and development, health and illness, and health care delivery.

Together these form the major contexts for seeing a client as an individual or from a specific group. Each individual or group is inseparable from the background contexts. The nurse must perceive the client within these contexts and be able to assess aspects of these contexts when performing a health assessment.

Fertility control varies by culture and religion. Use of sterilization is accepted by some, rejected by others, and forcibly used in other cultures. Rituals to restrict sexuality are used in some cultures, including female circumcision (removal of the clitoris or the vulva, sewing together of the surrounding skin, leaving only a small hole for urination and menstruation). Stoning or other forms of killing women who become pregnant out of wedlock is common in some Islamic cultures.

U.S. culture has pregnancy taboos just as others do. Pregnant women are expected to avoid environments with very loud noises, avoid smoking and alcohol, avoid high caffeine and drug intake, and be cautious about taking prescription and over-the-counter medications. Other cultures have pregnancy taboos such as having the mother avoid reaching over her head to prevent the umbilical cord from going around the baby's neck, not buying baby clothes before birth (Navajo), and not permitting the father to see the mother or baby until the baby is cleaned.

Nursing care can become complicated when the patient and the nurse have distinctly different cultural norms. Cultural imposition in health care is the tendency for health personnel to impose their beliefs, practices, and values on people of other cultures. Closely related to cultural imposition is ethnocentrism, the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture. When health professionals assume that they have the right to make choices and decisions for patients of another culture, patients may respond in the same way that minority cultures often respond to such an attitude by the dominant culture: by becoming passive, resistive, angry, or resistant to treatment.

Unless nurses are willing to examine carefully and clarify their own attitudes and values and to be sensitive to others who are "different," their use of cultural concepts when providing care will be unsuccessful. The nurse's role is to understand the patient's needs and to adapt care to respectfully meet those needs. A careful merging of modern and traditional cultural beliefs is a necessary prerequisite for safe, considerate, and successful nursing care of all patients. National standards issued by the Office of Minority Health (2001) were developed to ensure that all people entering the health care system be provided equitable and effective treatment in a culturally and linguistically appropriate manner.

culture: sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group

culture conflict: situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values

subculture is a large group of people who are members of the larger cultural group but who have certain ethnic, occupational, or physical characteristics that are not common to the larger culture. For example, nursing is a subculture of the larger health care system culture, and teenagers and older adults are often regarded as subcultures of the general population in the United States. Most societies include both dominant culture groups and minority culture groups. The dominant group has the most ability to control the values and sanctions of the society. It usually is (but does not have to be) the largest group in the society. Minority groups usually have some physical or cultural characteristic (such as race, religious beliefs, or occupation) different from those of the dominant group.

When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different, and they may take on the values of the dominant culture. This process is called cultural assimilation or acculturation. For example, when people immigrate and encounter a new dominant culture as they work, go to school, and learn the dominant language, they often move closer to the dominant culture. The process and the rate of assimilation are individualized.

The Office of Minority Health of the U.S. Department of Human Services created "Think Cultural Health" , an online service whose goal is to advance health equity at every point of contact through the development and promotion of culturally and linguistically appropriate services. Nurses who recognize and respect cultural diversity are better equipped to exhibit cultural sensitivity and provide nursing care that accepts the significance of cultural factors in health and illness. The health care system is itself a culture with customs, rules, values, and a language of its own, with nursing as its largest subculture. Although nursing as a whole is actively recruiting more diverse members, many nurses are members of, and have the same value systems as, the dominant U.S. middle-class culture.

When a nurse with a particular set of cultural values about health interacts with a patient with a different set of cultural values about health, the following factors affect this interaction: -The cultural background of each participant -The expectations and beliefs of each about health care -The cultural context of the encounter (e.g., hospital, clinic, home) -The extent of agreement between the two persons' sets of beliefs and values

Food and Nutrition Food preferences and preparation methods often are culturally influenced. Certain food groups serve as staples of the diet based on culture and remain so even when members of that culture are living in a different country. Patients in a hospital or long-term care setting often do not have much choice of foods. This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition.

When assessing the possible causes of a patient's decreased appetite, try to determine whether the problem may be related to culture. It may be possible for family or friends to bring in foods that satisfy the patient's nutritional needs while still meeting dietary restrictions. Dietary teaching must be individualized according to cultural values about the social significance and sharing of food.

Cultural Assessment The National Center for Cultural Competence urges health care professionals who value cultural competence to enhance their understanding of the following: -Beliefs, values, traditions, and practices of a culture -Culturally defined, health-related needs of individuals, families, and communities -Culturally based belief systems of the etiology of illness and disease and those related to health and healing -Attitudes toward seeking help from health care providers

When caring for patients from a different culture, it is important to first ask how they want to be treated based on their values and beliefs. An effective way to identify specific factors that influence a patient's behavior is to perform a cultural assessment. The primary informant should be the patient, if possible. If the patient is not able to respond to the questions, a family member or a friend can be consulted. The Giger and Davidhizar model takes into account six cultural phenomena: communication, space, social orientation, time, environmental control, and biologic variations. The Campinha-Bacote Model of Cultural Competence (2011) emphasizes becoming culturally competent and integrating cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. You can also anticipate a patient's cultural needs by obtaining this information through research before initiating contact with the patient. Remember, however, that information about any culture is general, and that it must be individualized for the specific patient once the actual interaction begins.

Federal standards for race classification provide five categories: ---American Indian or Alaska Native -Asian -Black -African American -Native Hawaiian or Other Pacific Islander -White provide the opportunity for people to identify themselves in multiple categories.

When one assumes that all members of a culture, ethnic group, or race act alike, stereotyping is at work. Stereotyping may be positive or negative. Negative stereotyping includes racism, ageism, and sexism. These are mistaken beliefs that certain races, an age group, or one biological sex is inherently superior to others, leading to discrimination against those considered inferior.

Regardless of the culture background of the patient, nurses need to assess each patient individually to provide culturally respectful care. Asking open-ended questions provides an opportunity to obtain specific information from the patient about his or her beliefs related to health care.

When providing care to a person from a culture that is different from your own or the dominant culture, you may use past experiences with members of that culture as a guide but never as the answer to all cultural issues. Learn from your mistakes and do not repeat them. All nurses make mistakes at some time when caring for patients from different cultures. Inadvertent mistakes are just that, but repeated mistakes are careless and disrespectful; they will adversely affect your interaction with patients and coworkers.

Pain Pain is now the fifth vital sign in U.S. health care. Assessing pain is necessary for each client. However, the experience of pain may vary by cultural conditioning. Some believe that pain is punishment for wrongdoing; others believe it is atonement for wrongdoing. The response to pain is based on cultural values.

When the caregiver and the client come from different cultures, interpreting the actual level of pain being felt is difficult. It is necessary to explain the therapeutic reasons for treating pain so that a person from a stoic culture may become less reluctant to express or describe pain.

cultural assimilation: process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different

cultural blindness: the process of ignoring differences in people and proceeding as though the differences do not exist

cultural competence: care delivered with an awareness of the aspects of the patient's culture

cultural diversity: (1) coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit; (2) diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location

cultural awareness or sensitivity: being alert to and having knowledge of cultural preferences, aspects, or perspectives that may impact the health care experience, including communication, personal choices, or other elements cultural humility: acknowledging one's cultural knowledge deficits using self-reflection, continuous self-evaluation, and consultation with others (including patients) to detect barriers to culturally competent care and address bias, or lack of knowledge or skills related to a culture other than one's own, to provide culturally appropriate care

cultural nursing assessment: a systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices culturally competent nursing care: effective, individualized care that demonstrates respect for the dignity, personal rights, preferences, beliefs, and practices of the person receiving care while acknowledging the biases of the caregiver and preventing these biases from interfering with the care provided culturally congruent nursing care: nursing care that is customized to fit each person's cultural values, beliefs, traditions, practices, and lifestyle

culture shock: those feelings, usually negative, a person experiences when placed in a different culture

ethnicity: sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns

ethnocentrism: belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs

linguistic competence: ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter

personal space: external environment surrounding a person that is regarded as being part of that person

race: division of human beings based on distinct physical characteristics

stereotyping: assigning characteristics to a group of people without considering specific individuality

subculture: group of people with different interests or goals than the primary culture

ethnocentrism: making a value judgment on another culture from the vantage point of one's own culture minority: a group of people whose physical or cultural characteristics differ from the dominant culture or majority of people in a society

subculture: relatively large groups of people who share characteristics that identify them as a distinct entity transcultural nursing: providing nursing care to patients and families across cultural variations

cultural respect enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. Moreover, cultural respect is critical to reducing health disparities and improving access to high-quality health care

vital to remember that each person may be a member of multiple cultural, ethnic, and racial groups at one time.