Cultural Diversity
Native Americans and Alaska Natives
Heart disease Cirrhosis of the liver Diabetes mellitus Fetal alcohol syndrome
Cultural Blindness
Occurs when one ignores differences and proceeds as though they do not exist.
Cultural Imposition
The belief that everyone else should conform to your own belief system
Natural/Unnatural Illnesses
"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.
Cultural Factors that Affect Nursing Care: Asians
(Beliefs and practices vary, but most Asian cultures share some characteristics.) Welfare of the family is valued above the person. Extended families are common. A person's lineage (ancestors) is respected. Sharing among family members is expected. Folk and Traditional Health Care Theoretical basis is in Taoism, which seeks a balance in all things. Good health is achieved through the proper balance of yin (feminine, negative, dark, cold) and yang (masculine, positive, light, warm). An imbalance in energy is caused by an improper diet or strong emotions. Diseases and foods are classified as hot or cold, and a proper balance between them will promote wellness (e.g., treat a cold disease with hot foods). Many Asian health care systems use herbs, diet, and the application of hot or cold therapy. Also, many Asians believe that there are points on the body that are located on the meridians or energy pathways. If the energy flow is out of balance, treatment of the pathways may be necessary to restore the energy equilibrium. Acumassage—Technique of manipulating points along the energy pathways Acupressure—Technique for compressing the energy pathway points Acupuncture—Technique by which fine needles are inserted into the body at energy pathway points Strong sense of self-respect and self-control High respect for age Respect for authority Respect for hard work Praise of self or others is considered poor manners Strong emphasis on harmony and the avoidance of conflict Nursing Considerations Some members of Asian cultures may be upset by the drawing of blood for laboratory tests. They consider blood to be the body's life force, and some do not believe that it can be regenerated. Some members believe that it is best to die with the body intact, so they may refuse surgery except in dire circumstances. Members of many Asian cultures seldom complain about what is bothering them. Therefore, the nurse must carefully assess the patient for pain or discomfort by observing for nonverbal signs of discomfort, such as facial grimacing or wincing and holding of the painful area. Some Asians consider it polite to give a person the responses the person is expecting. Therefore, the client may transmit misinformation to the questioner in an effort to be respectful. Some members may change physicians in an attempt to be cured of an illness, but to avoid insulting or embarrassing a physician, they will not inform him or her that they are going to another practitioner. This can result in confusion, inaccuracies, and overmedication. Some Asians may refuse diagnostic studies because they believe that a skilled and competent physician can diagnose an illness solely through a physical examination. Some members may have a difficult time understanding the importance of a medication regimen because many folk treatments involve the ingestion of just one dose of herbal mixtures. Dietary counseling may be necessary if the patient is on a salt-restricted diet because many Asian foods have a high salt content related to the use of soy sauce.
Cultural Factors that Affect Nursing Care: Native Americans
(Each tribe's beliefs and practices vary to some degree.) Families are large and extended. Grandparents are official and symbolic leaders and decision makers. A child's namesake may become the equivalent to another parent to the child. Folk and Traditional Health Care Medicine men (shaman) are heavily used. Heavy use of herbs and psychological treatments, ceremonies, fasting, meditation, heat, and massages Present oriented. Taught to live in the present and not to be concerned about the future. This time consciousness emphasizes finishing current business before doing something else. High respect for age Great value is placed on working together and sharing resources. Failure to achieve a personal goal frequently is believed to be the result of competition. High respect is given to a person who gives to others. The accumulation of money and goods often is frowned on. Some Native Americans practice the Peyotist religion, in which the consumption of peyote, an intoxicating drug derived from mescal cacti, is part of the service. Peyote is legal if used for this purpose. It is classified as a hallucinogenic drug. Nursing Considerations: The family is expected to be part of the nursing care plan. Note taking often is taboo. It is considered an insult to the speaker because the listener is not paying full attention to the conversation. Good memory skills often are required by the nurse. Indirect eye contact is acceptable and sometimes preferred. It often is considered rude or impolite to indicate that you are not clearly hearing what they are saying. A low tone of voice often is considered respectful. A Native American patient may expect the caregiver to deduce the problem through instinct instead of asking many questions and history taking. If this is the case, it may help to use declarative sentences rather than direct questioning.
Culturally Competent Care
1.) 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 2.) Demonstrating knowledge and understanding of the client's culture, health-related needs, and culturally specific meanings of health and illness 3.) Accepting and respecting cultural differences in a manner that facilitates the client's and family's abilities to make decisions to meet their needs and beliefs 4.) Not assuming that the health care provider's beliefs and values are the same as the client's 5.) Resisting judgmental attitudes such as "different is not as good" 6.) Being open to and comfortable with cultural encounters 7.) Accepting responsibility for one's own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices
Assuring Cultural Competence in Health Care
1.) Ensure that all patients/consumers 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. 2.) Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. 3.) Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. 4.) 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. 5.) Ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. 6.) Maintain a current demographic, cultural, and epidemiological 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.
Subcultures
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.
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 Example: "That client needs to learn that pain is best managed with traditional medications like morphine"
Whites
Breast cancer Heart disease Hypertension Diabetes mellitus Obesity
Cultural Factors That Affect Nursing Care: African Americans
Close and supportive extended-family relationships Strong kinship ties with nonblood relatives from church or organizational and social groups Family unity, loyalty, and cooperation are important. Usually matriarchal Varies extensively and may include spiritualists, herb doctors, root doctors, conjurers, skilled elder family members, voodoo, faith healing Present oriented Members of the African American clergy are highly respected Frequently highly religious Nursing Considerations: Many African American families may still use various folk healing practices and home remedies for treating particular illnesses. Special care may be necessary for the hair and skin. Special consideration should be given to the sometimes extensive and frequently informal support networks of patients (e.g., religious and community group members who offer assistance in a time of need).
Respecting 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 fact 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.
Characteristics of Culture
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 individuals, there are differences both within cultures and among cultures.
Traditional Therapies
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.
Hispanics
Diabetes mellitus Lactose intolerance
Promptness and Punctuality
In some South Asian cultures, being late is considered a sign of respect. 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 Factors That Affect Nursing Care: Hispanics
Familial role is important. Compadrazgo: special bond between a child's parents and the child's grandparents Family is the primary unit of society. Curanderas(os): folk healers who base treatments on humoral pathology—basic functions of the body are controlled by four body fluids or "humors": Blood—hot and wet Yellow bile—hot and dry Black bile—cold and dry Phlegm—cold and wet The secret of good health is to balance hot and cold within the body; therefore, most foods, beverages, herbs, and medications are classified as hot ( caliente) or cold ( fresco, frio) For example, a cold disease will be cured with a hot treatment). Respect is given according to age (older) and sex (male). Roman Catholic Church may be very influential. God gives health and allows illness for a reason; therefore, many perceive illness as a punishment from God that can be cured through atonement and forgiveness. Nursing Considerations: It may be difficult to convince an asymptomatic patient that he or she is ill. Special diet considerations are necessary if the patient believes in the hot/cold theory of treating illnesses. Diet counseling may be necessary at times, because the usual diet of many members is high in starch.
Cultural Factors that Affect Nursing Care: Hawiian
Familial role is important. Ohana, or extended families, are jointly involved in childrearing. Hierarchy of family structure—each gender and age have specific duties. Closely knit families in small, isolated communities Kahuna La'au Lapa'au is the ancient Hawaiian medical practitioner. View patient's illness as part of the whole. Relationships among the physical, psychological, and spiritual Emphasis on preventive medicine Treatment uses more than 300 medicinal plants and minerals Aloha: a deep love, respect, and affection between people and the land Christian God replaced the myriad of Hawaiian gods. Lifestyle more revered than compliance with health care issues Present oriented, less initiative and drive rather than direction and achievement Death seen as part of life and not feared Nursing Considerations: Many Hawaiians may still use folk healing practices and home remedies. Special consideration given to the extensive family network during hospitalization Acceptance from health care practitioners of current health practices and lifestyle
Treatment of Disease
Herbs are a common method of treatment in many cultures. 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.
Mental Health
Hispanic people deal with problems within the family and consider it inappropriate to tell problems to a stranger. Traditional Chinese people often 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 asataques. This behavior is a culturally accepted reaction. Be aware of these variations and accept them as culturally appropriate.
Asians
Hypertension Cancer of the liver Lactose intolerance Thalassemia
African Americans
Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids
Family
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.
Gender Roles
In many 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. In many African American and White families, the woman is often 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 individual may need help in verbalizing needs, particularly if the needs differ from those the dominant member perceives as being important.
Folk/Traditional Healers
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.
Accommodating Cultural Practices into 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.
Cultural Factors Factors that Affect Nursing Care: Appalachian
Intense interpersonal relations Family is cohesive, and several generations often live close to each other. Elderly are respected as providers. Tend to live in rural, isolated areas Folk and Traditional Health Care "Granny" woman, or folk healer, provides care and may be consulted even if receiving traditional care. Various herbs, such as foxglove and yellow root, are used for common illnesses such as malaise, chest discomfort, heart problems, and upper respiratory infections. Elderly may have had only limited contact with health care providers and may be skeptical of modern health care. Independence and self-determination Isolation is accepted as a way of life. Person oriented May be fatalistic about losses and death Belief in a divine existence rather than attending a particular church Nursing Considerations: Treat each person with regard for personal dignity. Allow family members to remain with patient as support system. Accept the person's current health practices and lifestyle. Allow patients to make decisions about care.
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.
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
Dominant and Minority culture groups
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.
Cultural Factors That Affect Nursing Care: Whites
Nuclear family is highly valued. Elderly family members may live in a long-term care facility when they can no longer care for themselves. Self-diagnosis of illnesses Use of over-the-counter drugs (especially vitamins and analgesics) Dieting (especially fad diets) Extensive use of exercise and exercise facilities Youth is valued over age Cleanliness Orderliness Attractiveness Individualism Achievement Punctuality Nursing Considerations: Careful assessment of client's use of over-the-counter medications (observe for signs and symptoms of toxic medication levels, especially fat-soluble vitamins) Nutritional assessments of dietary habits
Language and Communication
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. 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 often discourage using family members or friends as translators. People sometimes talk more loudly to someone who does not understand what they are saying, but remember that this is a communication problem, not a hearing problem.
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
Food and Nutrition
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.
Race
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 using simple classifications, and physical characteristics are not considered a reliable way to determine an individual's race.
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.
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. Be sensitive to other 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. Pain is what the patient says it is, and every complaint of pain should be assessed carefully. 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 patients' right to respond to pain in their own manner. Never stereotype a patient's perceptions of or responses to pain based on the person's culture.
Eye Contact
The American dominant culture emphasizes eye contact while speaking, but many other cultures regard this behavior in different ways. 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, gender, 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
Socioeconomic Factors
The amount of money a person or family has affects how they meet their basic needs and maintain their health. Poverty often leads to other problems such as lack of health insurance, inadequate care of infants and children, and homelessness. All these are of concern to nursing. 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 an individual has no Social Security or Medicare benefits. 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. 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
Cultural Factors that Affect Nursing Care: Muslims
The family forms the basic building block of Muslim society. The man is considered the head of the family. Marriage forms the sole basis for sexual relations and parenthood. Islamic law generally discourages the use of contraception, extolling the virtues of large families, but there seems to be a trend toward smaller families. Preventive health care strategies in Muslim experience include personal hygiene, dietary measures such as the restriction in eating specific ingredients (such as pork and its byproducts, and drinking alcohol), and the avoidance of addictive habits such as smoking tobacco or overconsumption of food. Some Muslims may perceive a sudden death or illness as a sign of punishment or a test from God. Belief that there is no God but Allah and that Muhammad is his messenger. Belief that God created humans and gave them their bodies as gifts to be cared for through general hygiene, diet, and exercise. Belief that Allah will determine when they die; Death is an important part of the traditional Islamic life cycle. By tradition, family members wash the body of the deceased and bury it as soon as possible. Cremation is not allowed under Islamic law, and embalming should be avoided unless it is required by civil law. Nursing Considerations: Respect the modesty needs of both men and women: special clothing or draping may be necessary, assign health care providers of the same sex, avoid touching patients of the opposite sex, and limit eye contact. Make accommodations for prayer needs. Maintain bodily purity by observing their cleansing and ablution rituals. Offer a halal diet free of alcohol and pork or pork products; make sure medications are alcohol- and pork-free. During Ramadan, Muslims must fast from sunrise to sunset. Fasting includes abstaining from all substances, including pharmaceuticals and IV drips. However, illness is an exception.
Culture Shock
The feelings a person may experience when placed in a different culture perceived as strange. May result in psychological discomfort or disturbances, as the patterns of behavior a person found acceptable and effective in one's own culture may not be adequate or even acceptable in the new one. The person may then feel foolish, fearful, incompetent, inadequate, or humiliated. These feelings eventually can lead to frustration, anxiety, and loss of self-esteem.
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 may change your techniques of communication and care (such as eye contact, personal space, or social taboos)? 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?
Cultural Assimilation
When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different, and they make take on the values of the dominant culture. This process is called cultural assimilation or acculturation. Mutual cultural assimilation also occurs, with both groups taking on some characteristics of the other.
Cultural Assessment
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. A useful tool for this is the Andrews and Boyle Transcultural Nursing Assessment Guide See also the Purnell model for cultural competence. Similarly, the Giger and Davidhizar model takes into account six cultural phenomena: communication, space, social organization, time, environmental control, and biological variations. The Campinha-Bacote Model of Cultural Competence 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.
Stereotyping
When one assumes that all members of a culture, ethnic group, or race act alike. May be positive or negative. Negative stereotyping includes racism, ageism, and sexism. These are mistaken beliefs that certain races, an age group, or one gender is inherently superior to others, leading to discrimination against those considered inferior
Personal Space
You should know the patient's cultural personal space preferences. People of Arabic and African origin commonly sit and stand close to one another when talking People of Asian and European descent are more comfortable with some distance between themselves and others.
