CH 6 Culture and ethncity.docx

INTRODUCTION Clients vary by age, gender, race, health status, education, religion, occupation, and economic level. Culture, the focus of this chapter, is another characteristic that contributes to client diversity (differences among groups of people). Nurses have always cared for clients with diffe...

INTRODUCTION Clients vary by age, gender, race, health status, education, religion, occupation, and economic level. Culture, the focus of this chapter, is another characteristic that contributes to client diversity (differences among groups of people). Nurses have always cared for clients with differences of many sorts. Despite cultural differences, the traditional tendency has been to treat clients as though none exist. Although equal treatment is politically correct, ignoring differences can contradict the best interests of clients. Consequently, there is a movement toward eliminating acultural nursing care (care that avoids concern for cultural differences) and promoting culturally sensitive nursing care (care that respects and is compatible with each client’s culture). This chapter provides information about cultural concepts, cultural variations among different ethnic and racial groups, and intercultural communication. Although components of culture are specific to a particular group of people, individual clients within each cultural group may deviate from others of similar origins. Therefore, nurses are advised to always consider cultural needs from an individual’s perspective. Every human being is in some way “like all others, like some others, and like no other” (Andrews, 2014). CONCEPTS RELATED TO CULTURE Culture Culture (the values, beliefs, and practices of a particular group) (Giger, 2013) incorporates the attitudes and customs learned through socialization with others. It includes but is not limited to language, communication style, traditions, religion, art, music, dress, health beliefs, and health practices. p. 72 p. 73 TABLE 6-1 Culturally Diverse Groups within the United States CITY OR REGION PREDOMINANT CULTURAL GROUP New England Irish Detroit, Buffalo, Chicago Polish Upper Midwest (Minnesota, North Dakota) Scandinavians Ohio and Pennsylvania Amish Washington State and Oregon Southeast Asians (Laotian, Vietnamese) New York (Spanish Harlem) Puerto Rican Miami (Little Cuba) Cuban San Francisco (Chinatown) Chinese New York (Little Italy) Italian Louisiana Cajun (French/Indian) Southwest Latin American/Native American Hawaiian Islands Pacific Islanders/Japanese/Chinese Michigan (Dearborn) Shi’a Muslims A group’s culture is passed from one generation to the next. According to Hinkle and Cheever (2013), culture is learned from birth; shared by members of a group; influenced by environment, technology, and the availability of resources; and dynamic and ever-changing. Although the United States has been described as a “melting pot” in which culturally diverse groups have become assimilated, that is not always the case. People from various cultural groups have settled, lived, and worked in the United States while continuing to maintain unique identities (Table 6-1). Race Cultural groups tend to share biologic and physiologic similarities. Race (biologic variations) is a term used to categorize people with genetically shared physical characteristics. Some examples include skin color, eye shape, and hair texture. Despite wide ranges in physical variations, skin color has traditionally been the chief, albeit imprecise, method for categorizing races. However, skin color is just one of a variety of inherited traits. More importantly, nurses should not equate race with any particular cultural group. To do so leads to two erroneous assumptions: (1) all people with common physical features share the same culture and (2) all people with physical similarities have cultural values, beliefs, and practices that differ from those of Anglo-Americans (white people in the United States who trace their ancestry to the United Kingdom and Western Europe). Minority The term minority is used when referring to collective people who differ from the dominant group in terms of cultural characteristics such as language, physical characteristics such as skin color, or both. Minority does not necessarily imply that there are fewer group members in comparison with others in the society. Rather, it refers to the group’s status with regard to power and control. For example, men of European ancestry are the current majority in the United States. Slightly more women than men make up the population of the United States, but women are considered the minority group. According to the U.S. Census Bureau (2012), the population of those who identified themselves as white will slowly decrease by the year 2060. By 2060, the number of Latinos and Asian Americans living in the United States is expected to more than double, and the number of African Americans will rise slightly to 14.7% of the U.S. population. American Indians and Alaska Natives will increase by more than half to 1.5% of those living in the United States. The population of Native Hawaiian and other Pacific Islanders is expected to nearly double (U.S. Census Bureau, 2012). Minorities as a whole will comprise 57% of the population by 2060. However, until these groups acquire more political and economic power in society, they will continue to be classified as minorities (Fig. 6-1). Gerontologic Considerations Between 2010 and 2050, 60% of the projected growth in the population of older adults in the United States will be among older minorities (Haber, 2013). Ethnicity Ethnicity (a bond or kinship a person feels with his or her country of birth or place of ancestral origin) may exist regardless of whether a person has ever lived outside of the United States. Pride in one’s ethnicity is demonstrated by valuing certain physical characteristics, giving children names that reflect their heritage, wearing unique items of clothing, appreciating folk music and dance, and eating native dishes. Because cultural characteristics and ethnic pride represent what may be considered the majority in a homogeneous group, they tend to go unnoticed. When two or more cultural groups mix, however, as often happens at the borders of various countries or through the process of immigration, unique differences become more obvious. One or both groups may experience cultural shock (bewilderment over behavior that is culturally unfamiliar). Consequently, many ethnic groups have been victimized as a result of bigotry based on stereotypical assumptions and ethnocentrism. FACTORS THAT AFFECT PERCEPTION OF INDIVIDUALS Stereotyping Stereotypes (fixed attitudes about all people who share a common characteristic) develop with regard to age, gender, race, sexual preference, and/or ethnicity. Because stereotypes are preconceived ideas usually unsupported by facts, they tend to be neither real nor accurate. In fact, they can be dangerous because they interfere with accepting others as unique individuals. FIGURE 6-1 Percent of total population by race and Hispanic origin: 2012 and 2060. AIAN, American Indian and Alaska Native; NHPI, Native Hawaiian and Other Pacific Islander. Gerontologic Considerations Ageism, a form of negative stereotypical thinking about older adults, promotes false beliefs about older adults being physically and cognitively impaired, lacking interest in sex, and being burdensome to families and society. Generalization Generalization (supposition that a person shares cultural characteristics with others of a similar background) is different from stereotyping. Stereotyping prevents seeing and treating another person as unique, while generalizing suggests possible commonalities that may or may not be individually valid. Assuming that all people who affiliate themselves with a particular group behave alike or hold the same beliefs is always incorrect. Despite what may appear to be a homogenous group, diversity always exists among individuals in any group. A generalization provides a springboard from which to explore a person’s individuality. For example, when a nurse is assigned to care for a terminally ill client whose last name is Vasquez, the nurse may assume that the client is Roman Catholic because Catholicism is a religion common among many Latinos. However, before contacting a priest to assist with the client’s spiritual needs, the culturally sensitive nurse understands that this generalization concerning religion may not be accurate. The nurse must strive to obtain information that confirms or contradicts the original generalization. Ethnocentrism Ethnocentrism (belief that one’s own ethnicity is superior to all others) has no place in intercultural relationships. Ethnocentrism is manifested by treating anyone different as deviant and undesirable. This form of cultural intolerance was the basis for the Holocaust during which the Nazis committed genocide, attempting to murder an entire ethnic group (in this case, European Jews), killing 6 million Jews. Ethnocentrism continues to play a role in the ethnic conflicts around the world, including between pro-Russian separatists in Ukraine; between Arabs and Israelis in the Middle East; Boko Haram in Nigeria; the Islamic State of Iraq and Syria (ISIS) militants in the Middle East; and other regions where culturally diverse groups live in close proximity. Similar conflicts also occur among varying ethnic groups in the United States. CULTURES IN THE UNITED STATES Culture in the United States can be described as anglicized, or English-based, because it evolved primarily from its early English settlers. Box 6-1 provides an overview of some common characteristics of U.S. culture. To suggest that everyone who lives in the United States embraces the totality of its culture, however, would be erroneous and foolhardy. Although it is a gross oversimplification, four major minority groups exist in the United States. In addition to Anglo-Americans, there are also African Americans, Latinos, Asian Americans, and Native Americans like the Lakota Sioux (Table 6-2). The 2010 Census allowed individuals to self-select from seven race and ethnicity categories (Table 6-3). The term African Americans is used to identify those whose ancestral origin is Africa. It is sometimes used interchangeably, though not always accurately, with black Americans. Latinos, a shortened term for Latino Americano, refers to those who trace their ethnic origins to Mexico, Puerto Rico, Cuba, Central and South America, or other Spanish-speaking countries, such as the Dominican Republic. Latinos are sometimes referred to as Hispanics, a term coined by the U.S. Census Bureau when referring to those residing in the eastern portion of the United States such as Florida and Texas. The term Mexican American is the preferred term used when referring to people from Mexico who were born in the United States. Chicano is a term used by some Americans of Mexican descent, though some have used it derogatorily in the past. Asian Americans (those who come from countries in Asia like China, Japan, Korea, the Philippines, Thailand, Laos, Vietnam, India, Pakistan, and Afghanistan, to name a few) make up the third group. Native Americans include descendants of indigenous peoples of the United States (except Hawaii and the U.S. territories); they belong to 566 federally recognized tribes in the United States (Department of Interior, Bureau of Indian Affairs, 2015). BOX 6-1 Examples of Common Cultural Characteristics in the United States • English is the language of communication. • The pronunciation or meaning of some words varies according to regions within the United States. • The customary greeting is a handshake. • A distance of 4 to 12 ft is customary when interacting with strangers or doing business (Giger, 2013). • In casual situations, it is acceptable for women as well as men to wear pants; blue jeans are common apparel. • The majority of Americans are Christians. • Sunday is recognized as the Sabbath for Christians. • Government is expected to remain separate from religion. • Guilt or innocence for alleged crimes is decided by a jury of one’s peers. • Selection of a marriage partner is an individual’s choice. • Legally, men and women are equals. • Marriage is monogamous (only one spouse); fidelity is expected. • Divorce and subsequent remarriages are common. • Parents are responsible for their minor children. • Aging adults live separately from their children. • Status is related to occupation, wealth, and education. • Common beliefs are that everyone has the potential for success and that hard work leads to prosperity. • Daily bathing and use of a deodorant are standard hygiene practices. • Many Anglo-American women shave the hair from their legs and underarms; men without beards shave their faces daily. • Licensed practitioners provide health care. • Drugs and surgery are the traditional forms of Western medical treatment. • Americans tend to value technology and equate it with quality. • Generally, Americans are time-oriented and therefore rigidly schedule their activities according to clock hours. • Forks, knives, and spoons are used, except when eating “fast foods,” for which the fingers are appropriate. TABLE 6-2 Minority Demographic Groups in the United States as Projected in 2015 As reported by the U.S. Census Bureau (2015). TABLE 6-3 Categories of Race and Ethnicity for Federal Statistics CATEGORY DESCRIPTION White Origins in Europe, the Middle East, or North Africa Hispanic, Latino, or Spanish Origins in Cuba, Mexico, Puerto Rico, South or Central America, or other Spanish culture, regardless of race Asian Origins in East Asia, Southeast Asia, or the Indian subcontinent, such as Cambodia, China, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and Vietnam Black or African American Origins in any racial groups of Africa including Haiti American Indian or Alaska Native Origins in any of the peoples of North and South America who maintain tribal affiliation or community attachment Native Hawaiian or Other Pacific Islander Origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands Other races Persons who identify with more than one race U.S. Census Bureau. (2011). 2010 Census redistricting data (Public Law 94-171) summary file. Although Anglo-American culture predominates in the United States, those of African, Asian, Latino/Hispanic, Native American, and Hawaiian/Pacific Islander descent will soon outnumber those who trace their ancestry to the United Kingdom and Western Europe. As the population of non–Anglo-Americans rises and becomes more diverse, cultural competence in nursing is increasingly important. p. 75 p. 76 TRANSCULTURAL NURSING Madeleine Leininger (1925 to 2012) coined the term transcultural nursing (providing nursing care within the context of another’s culture) in the 1970s. Aspects of transcultural nursing include: Assessments of a cultural nature Acceptance of each client as an individual Knowledge of health problems that affect particular cultural groups Planning of care within the client’s health belief system to achieve the best health outcomes To provide culturally sensitive care, nurses must become skilled at managing language differences, understanding biologic and physiologic variations, promoting health education that will reduce prevalent diseases, and respecting alternative health beliefs or practices. Cultural Assessment To provide culturally sensitive care, the nurse strives to gather data about the unique characteristics of clients. Pertinent data include: Language and communication style Hygiene practices, including feelings about modesty and accepting help from others Special clothing or ornamentation Religion and religious practices Rituals surrounding birth, passage from adolescence to adulthood, illness, and death Family and gender roles, including child-rearing practices and kinship with older adults Proper forms of greeting and showing respect Food habits and dietary restrictions Methods for making decisions Health beliefs and medical practices Assessment of these areas is likely to reveal many differences. Examples of variations include language and communication, eye contact, space and distance, touch, emotional expressions, dietary customs and restrictions, time, and beliefs about the cause of illness. Language and Communication Because language is the primary way to share and gather information, the inability to communicate is one of the biggest deterrents to providing culturally sensitive care. Foreign travelers and many residents in the United States do not speak English, or they have learned it as their second language and do not speak it well. Estimates are that 60.5 million of those who live in the United States speak a language other than English at home; Spanish is the most often spoken language other than English in the United States (Fig. 6-2) (U.S. Census Bureau, 2013). Those who can communicate in English may still prefer to use their primary languages, especially under stress. FIGURE 6-2 Top 10 languages other than English spoken at home in the United States. LEP, limited English proficiency. (U.S. Bureau of the Census. [n.d.]. Language use in the United States, 2011. Washington, DC. Retrieved from https://www.census.gov/library/publications/2013/acs/acs-22.html) p. 76 p. 77 Equal Access Federal law, specifically Title IV of the Civil Rights Act of 1994, states that people with limited English proficiency (LEP)—an inability to speak, read, write, or understand English at a level that permits interacting effectively—are entitled to the same health care and social services as those who speak English fluently. In other words, all clients have the right to unencumbered communication with a health provider. Using children as interpreters or requiring clients to provide their own interpreters is a civil rights violation. The Joint Commission (TJC) requires that hospitals provide effective communication for each client. The use of untrained interpreters, volunteers, or family is considered inappropriate because it undermines confidentiality and privacy. It also violates family roles and boundaries. It increases the potential for modifying, condensing, omitting, adding information, or projecting the interpreter’s own values during communication between the client and the health care provider. The best form of communication with a client who has LEP is with a certified interpreter. A certified interpreter is a translator who is certified by a professional organization through rigorous testing based on appropriate and consistent criteria. Unfortunately, individuals who meet these qualifications are few and far between. To comply with the laws and accreditation requirements, health care agencies are strongly encouraged to train professional interpreters. A competently trained interpreter demonstrates the skills listed in Box 6-2. When a trained or certified interpreter is not available in person or by video, there are a variety of other options. In descending order of preference, the following may be used: agency-employed interpreters, bilingual staff, volunteers, and least desirable, family or friends. TJC requires the use of qualified, professional interpreters to achieve compliance (Newnum, 2019). Qualifications and competencies can be met in various ways. Of utmost importance is that the interpreter is language-proficient, trained in the practice of interpreting, and qualified to translate health care information (Wilson-Stronks, 2014). For example, when an on-site interpreter is not available, use of a video or telephonic interpreting (over-the-phone translation) can be used as an alternative. AT&T On Demand Interpreter Service provides translators in 170 languages whenever and wherever it is needed. Voice-to-text apps also exist, whereby one person speaks into his or her mobile device in one language and the other person does the same in his or her preferred language. Each language is translated into the other’s language in real time. In addition, though it does not meet all the needs of an LEP client, a picture or dual-language communication board may be useful for immediate bedside interactions between the client and the nursing staff (Fig. 6-3). BOX 6-2 Characteristics of a Skilled Interpreter • Learns the goals of the interaction • Demonstrates courtesy and respect for the client • Explains his or her role to the client • Positions him or herself to avoid disrupting direct communication between the health care worker and the client • Has a good memory for what is said • Converts the information in one language accurately into the other without commenting on the content • Possesses knowledge of medical terminology and vocabulary • Attempts to preserve both the emphasis and emotions that people express • Asks for clarification if verbalizations from either party are unclear • Indicates instances in which a cultural difference has the potential to impair communication • Maintains confidentiality Culturally Sensitive Nurse–Client Communication If the nurse is not bilingual (able to speak a second language fluently) and a trained interpreter is not available, he or she must use an alternative method for communicating (see Nursing Guidelines 6-1 for more information). Understanding some unique cultural characteristics involving aspects of communication may ease the transition toward culturally sensitive care. It is helpful to be aware of general communication patterns among the major cultural groups in the United States. Native Americans Native Americans have traditionally been fearful of the health care establishment (Satter et al., 2014). Consequently they tend to be private and may hesitate to share personal information with health care providers they do not know. They may interpret questioning as prying or meddling. The nurse should be patient when awaiting an answer and listen carefully, because impatience may be considered disrespectful (Lipson & Dibble, 2012). Navajos, currently the largest tribe of Native Americans, believe that no person has the right to speak for another and may refuse to comment on a family member’s health. Because Native Americans traditionally preserved heritage through oral rather than written history, they may be suspicious of nurses who write down what they say. If possible, the nurse should write notes after, rather than during, the interview. African Americans African Americans may be mistrustful of the medical establishment, in part because of unethical practices employed in past research projects such as the U.S. Public Health Service Tuskegee Study of Untreated Syphilis (Centers for Disease Control and Prevention, 2013), during which African American men were told they were receiving free health care, but for 40 years, diagnosis and available treatment were withheld from nearly 40 men with syphilis. African Americans have also often been treated as second-class citizens when seeking health care. The nurse must demonstrate professionalism by addressing clients by their titles and last names and introducing him or herself. The nurse should follow up thoroughly with requests, respect the client’s privacy, and ask open-ended rather than direct questions until trust has been established. Because of generations of discrimination, African Americans may hesitate to give any more information beyond what is asked. Communicating with Non–English-Speaking Clients Greet or say words and phrases in the client’s language, even if carrying on a conversation is impossible. Using familiar words indicates a desire to communicate with the client even if the nurse lacks the expertise to do so extensively. Use websites with the client that translate English to several foreign languages and vice versa. Examples include Google and www.babelfish.com. A computer with internet access provides sites with easy-to-use, rapid, free translations of up to 150 words at a time. Refer to an English/foreign language dictionary or use appendices in references such as Taber’s Cyclopedic Medical Dictionary. Some dictionaries provide medical words and phrases that may provide pertinent information. Compile a loose-leaf folder or file cards of medical words in one or more languages spoken by clients in the community. Place it with other reference books on the nursing unit. A homemade reference provides a readily available language resource for communicating with others in the local area. Request a trained interpreter. If that option is impossible, call ethnic organizations or church pastors to obtain a list of people who speak the client’s language and may be willing to act as emergency translators. Someone proficient at speaking the language is more effective at obtaining necessary information and explaining proposed treatments than is someone relying on a rough translation. Contact an international telephone operator in a crisis if there is no other option for communicating with a client. International telephone operators are generally available 24 hours a day; however, their main responsibility is the job for which they were hired. When several interpreters are available, select one who is of the same gender and approximately the same age as the client. Some clients are embarrassed relating personal information to people with whom they have little in common. Look at the client, not the interpreter, when asking questions and listening for responses. Eye contact indicates that the client is the primary focus of the interaction and helps the nurse interpret nonverbal clues. If the client speaks some English, speak slowly, not loudly, using simple words and short sentences. Lengthy or complex sentences are barriers when communicating with someone not skilled in a second language. Avoid using technical terms, slang, or phrases with a double or colloquial meaning. The client may not understand the spoken vernacular, especially if he or she learned English from a textbook rather than conversationally. p. 78 p. 79 Ask questions that can be answered by a yes or no. Direct questions avoid the need to provide elaborate responses in English. If the client appears confused by a question, repeat it without changing the words. Rephrasing tends to compound confusion because it forces the client to translate yet another group of unfamiliar words. Give the client sufficient time to respond. The process of interpreting what has been said in English and then converting the response from the native language back to English requires extra time. Use nonverbal communication or pantomime. Body language is universal and tends to be communicated and interpreted quite accurately. Be patient. Anxiety is communicated interpersonally and tends to heighten frustration. Show the client written English words. Some non–English-speaking people can read English better than they can understand spoken English. Work with the health agency’s records committee to obtain consent forms, authorization for health insurance benefits, and copies of client’s rights written in languages other than English. Legally, clients must understand that to which they are consenting. Develop or obtain foreign translations describing common procedures, routine care, and health promotion. One resource is the Patient Education Resource Center in San Francisco, which provides publications in many languages on numerous health topics. All clients are entitled to explanations and educational services. Latinos Latinos are often comfortable sitting close to interviewers and letting interactions unfold slowly. Many Latinos speak English but like native English speakers, have difficulty with medical terminology. They may be embarrassed to ask the interviewer to speak slowly, so the nurse must provide information and ask questions carefully. Latino men are often protective and may be authoritarian regarding women and children. They expect to be consulted in decisions concerning family members. Asian Americans Asian Americans tend to respond with brief or more factual answers and little elaboration, perhaps because traditionally, Asian cultures value simplicity, meditation, and introspection. Asian Americans may not openly disagree with authority figures, such as physicians and nurses, because of their respect for harmony. Such reticence can conceal disagreement or potential noncompliance with a particular therapeutic regimen that is unacceptable from the client’s perspective. Eye Contact Anglo-Americans generally make and maintain eye contact throughout communication. Although it may be natural for Anglo-Americans to look directly at a person while speaking, that is not always true of people from other cultures. It may offend Asian Americans or Native Americans, who are likely to believe that lingering eye contact is an invasion of privacy or a sign of disrespect. Arab Americans may misinterpret direct eye contact as sexually suggestive. Space and Distance Providing personal care and performing nursing procedures often requires intruding upon personal space, which can cause discomfort for some cultural groups. For example, Asian Americans may feel more comfortable with the nurse at more than an arm’s length away. The physical closeness of a nurse in an effort to provide comfort and support may threaten clients from other cultures. Therefore, it is always best to provide explanations when close contact during procedures and personal care is necessary. Touch Some Native Americans may interpret the Anglo-American custom of a strong handshake as offensive. They may be more comfortable with just a light passing of the hands. People from Southeast Asia consider the head to be a sacred body part that only close relatives can touch. Nurses and other health care providers should ask permission before touching this area. Southeast Asians also believe that the area between a female’s waist and knees is particularly private and should not be touched by any male other than the woman’s husband. Before doing so, a male nurse can relieve the client’s anxiety by offering an explanation, requesting permission, and allowing the client’s husband to stay in the room. Emotional Expression Anglo-Americans and African Americans tend to freely express both positive and negative feelings. Asian and Native Americans, however, tend to restrict their emotional expression and expressions of physical discomfort (Zborowski, 1952, 1969), especially among unfamiliar people. Stoicism should not be interpreted as a lack of feeling or caring (Eliopoulos, 2013). Similarly, Latino men may not demonstrate their feelings or readily discuss their symptoms because they may interpret doing so as less masculine (Andrews & Boyle, 2011). The Latino cultural response can be attributed to machismo, a belief that virile men are physically strong and must deal with emotions privately. Because this behavior is atypical from an Anglo-American perspective, nurses may overlook the emotional and physical needs of people from these cultural groups. p. 79 p. 80 Dietary Customs and Restrictions Food is necessary for survival: it relieves hunger, promotes health, and prevents disease. Eating also has social meanings that relate to communal togetherness, celebration, reward and punishment, and relief of stress. Culture may dictate the types of food and how frequently a person eats, the types of utensils used, and the status of individuals, such as who eats first and who gets larger servings. Religious practices within some cultures impose certain rules and restrictions such as times for fasting and foods that can and cannot be consumed (Table 6-4). If dietary teaching disregards cultural and religious food preferences, nurses can jeopardize a client’s adherence to a therapeutic diet for a medical disorder. Nutrition Notes Dietary acculturation occurs when people change their eating behaviors after moving to a new area. Some traditional foods are rejected and new foods are added or used as substitutes for traditional foods. Availability and cost influence dietary acculturation. Acculturation can have a positive or negative effect on eating habits. Generally, as immigrants adopt the “typical American diet” their intake of fat, sugar, and calories increases, and their intake of fruit, vegetables, fiber, and protein decreases. New Americans should be encouraged to retain any healthy eating practices. Hispanics and those from Central America drink atole, a heated mixture of masa harina (corn meal), piloncillo (Mexican brown sugar), cinnamon, vanilla, and sometimes chocolate or fruit, as a traditional celebration and comfort food. Atole is also consumed during la cuarentena, a 40-day period following the delivery of an infant, in the belief that it will help the new mother recover and increase the volume of breast milk. The diet of some African Americans may include greens, grits, cornbread, and beans cooked with a generous amount of fat or fatty meats, reflecting Southern American roots. Some common foods in Asian American diets include rice and rice noodles; mixtures containing beef, chicken, fish, and soybean products; bok choy; and bean sprouts. Flavors are enhanced with monosodium glutamate (MSG); soy; oyster, bean, and fish sauce; and peppers, resulting in food that is both spicy and salty. Native Americans may consume what is grown locally like fry bread made from corn; meat that is hunted on land or fished from nearby rivers; and chicken, pigs, and cattle that are raised within the community. They may also rely on products available from commercial markets. Many Muslims buy halal meat from Muslim shopkeepers who sell only to Muslims. Islam also includes rules about not eating at a table where alcohol is served (Islamic-laws.com, 2019). Jewish people have kosher rules for food, which must be certified as such by a rabbi. Utensils (including pots and pans and other cooking surfaces) that have come into contact with meat may not be used with dairy and vice versa. Utensils that have come into contact with nonkosher food may not be used with kosher food, among other rules (Rich, 2011). Time Throughout the world, people view clock time and social time differently (Giger, 2013). Calendars and clocks define clock time, dividing it into years, months, weeks, days, hours, minutes, and seconds. Social time reflects attitudes concerning punctuality that vary among cultures. Punctuality is sometimes less important to people from other cultures than it is to Anglo-Americans. Tolerating and accommodating cultural differences related to time facilitates culturally sensitive care. Beliefs Concerning Illness Generally, people embrace one of three cultural views (or some combination of these views) to explain illness or disease. The biomedical or scientific perspective is often shared by those from developed countries who base their beliefs about health and disease on research findings. An example of a scientific perspective is that microorganisms cause infectious diseases, and frequent hand hygiene reduces the potential for infection. The naturalistic or holistic perspective espouses that humans and nature must be in balance or harmony to remain healthy; illness is an outcome of disharmony. Some Native Americans believe that positive outcomes result from living in congruence with Mother Earth. Another example includes Asian Americans who consider the yin/yang theory, which refers to the belief that balanced forces promote health. Latinos embrace a similar concept referred to as the hot/cold theory. It implies that illness is an imbalance between components ascribed as having hot or cold attributes. Adding or subtracting heat or cold to restore balance can also restore health. This is also a consideration in Ayurveda, which has its origins in India. Finally, there is the magico–religious perspective in which there is a cultural belief that supernatural forces contribute to disease or health. Some examples of the magico–religious perspective include faith healing or practice forms of witchcraft or voodoo that may be practiced by Haitians. Native Americans have a strong reverence for the Great Creator’s influence on health and illness. They use herbs and spiritual rituals performed by tribal leaders or medicine men or women known as shamans to relieve illness (Eliopoulos, 2013). Although nurses may disagree with a client’s beliefs concerning the cause of health or illness, respect for the individual client helps achieve health care goals. As long as a culturally held health belief or practice is not harmful, the nurse should incorporate it into the client’s care. Concept Mastery Alert Client Health Beliefs Always incorporate a client’s health beliefs in his or her care. Because some Native Americans have a strong belief in the Great Creator’s influence on health and illness, a tribal medicine man or woman may play a major role in the care of a Native American client’s illness. p. 80 TABLE 6-4 Examples of Religious Beliefs and Practices That Affect Health Care RELIGION EXAMPLES NURSING IMPLICATIONS Orthodox Judaism and some nonorthodox Jews (i.e., Conservative, Reform, and Reconstructionist) Circumcision is a sacred ritual performed on the 8th day of life. Provide information on care following circumcision before discharge. Kosher dietary laws allow consumption of animals that chew their cud and have cloven hoofs (e.g., cattle, sheep, goats, deer, and bison). Animals are slaughtered according to defined procedures; dairy products and meat are not eaten together. Seafood with fins and scales are permitted (i.e., no shellfish, like crabs and shrimp). Notify dietary department of the client’s food preferences. Packaged food labeled kosher indicates it was “properly preserved.” Pareve means “made without meat or milk.” Sabbath begins on Friday at sundown and ends on Saturday at sundown. Avoid scheduling nonemergency tests or procedures during this time. Autopsies are not allowed unless required by law. All organs that are removed and examined during an autopsy must be returned to the body so that the body may remain intact for burial. Burial is preferred within 24 hours of death; Judaic law requires that the body not be left alone. Contact the family to stay with the dying client. Orthodox family members may ask a son or other relative to close the mouth and eyes of the deceased. Catholicism Statues and medals of religious figures provide spiritual comfort. Leave such items on or near the client; keep items safe and return promptly if removed. Artificial birth control and abortion are forbidden. Explain how to avoid pregnancy through methods such as checking basal body temperature and characteristics of cervical mucus. Baptism is necessary for salvation. In an emergency, any baptized Christian should perform baptism by pouring water over the head three times and saying, “I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.” Jehovah’s Witnesses Blood transfusions are refused even in life-threatening situations because they believe blood is the source of the soul. Refer to physicians who practice blood conservation strategies such as autotransfusions and intravenous volume expanders (e.g., dextran). Seventh Day Adventist Strict dietary laws are followed based on the Old Testament. Request a consult with the dietitian to facilitate a vegetarian diet without caffeine. Saturday is the Sabbath. Avoid scheduling medical appointments or procedures at this time. Christian Scientist Prayer is the antidote for any illness. Expect that these clients will contact lay practitioners to assist with healing. Legal procedures may be used as an option when the well-being of minor children are threatened by parental refusal for medical care. Church of Jesus Christ of Latter-Day Saints (Mormonism) Coffee, tea, alcohol, tobacco, illegal drugs, and overuse of prescription drugs are prohibited. Notify the dietary department to provide noncaffeinated beverages. Male members may anoint the sick with consecrated olive oil. Facilitate anointing rituals before surgery or at the client’s request. Amish Clients may be reluctant to spend money on health care unnecessarily. Assess home remedies and folk healing being used. Home deliveries are preferred; expect brief overnight stays following hospital births. A central belief is that illness must be endured with faith and patience. Offer comfort measures and analgesic medications rather than waiting for clients to request them. Clients are formally educated up to eighth grade. Select written health educational materials at the client’s level of understanding. Photographs are not permitted. Avoid photographing newborns. p. 81 p. 82 Hinduism Clients value modesty and hygiene. Provide a daily bath but not following a meal; add hot water to cold but not the reverse. The application of a pundra, a distinctive mark on the forehead, is religiously symbolic. Avoid removing or replace it as soon as possible. Hindus value self-control. Offer comfort measures and analgesic medications rather than waiting for Hindu clients to request them. Men do not participate during labor and delivery. Keep men informed of the birthing progress. Cleansing of the body after death symbolizes cleansing of the soul. Inquire if the family wishes to wash a deceased client’s body. Most clients are vegetarians; beef is forbidden, and some do not consume eggs. Request a consult with the dietitian. Clients may refuse medication in gelatin capsules because gelatin is made from animal byproducts. Islam (Muslim) Prayer and washing are required five times a day. Plan care around prayer and washing rituals, which occur at sunrise, midmorning, noon, afternoon, and sunset. Help clients face Mecca for prayer. Pork and alcohol are forbidden. Clients may refuse medication in capsules and pork insulin. Request that the pharmacist omit alcohol in liquid medications, which usually contain this ingredient. Clients prefer to die at home. Expect that life support will be unacceptable if there is no hope for a reasonable recovery. Only relatives may touch or wash the body of a deceased Muslim. Consult the family before performing postmortem care. Adapted from Andrews, J. D. (2014). Cultural, ethnic and religious reference manual (4th ed.). Winston-Salem, NC: JAMARDA Resources. Stop, Think, and Respond 6-1 How might a culturally sensitive nurse respond to a Vietnamese client who practices coining, which involves rubbing the skin in a symptomatic area with a heated or oiled coin to draw an illness out of the body? Coining is not painful, but it produces redness of the skin and superficial ecchymosis (bruising). Biologic and Physiologic Variations The biologic characteristics of primary importance to nurses are those that involve the skin, hair, and certain physiologic enzymes. Skin Characteristics Skin assessment techniques that are commonly taught are biased toward white clients. To provide culturally sensitive care, nurses must modify their techniques to obtain accurate data on people of color. The best technique for observing baseline skin color in a dark-skinned person is to use natural or bright artificial light. Because the palms of the hands, the feet, and the abdomen contain the least pigmentation and are less likely to have been tanned, they are often the best areas to inspect. According to Giger (2013), all skin, regardless of a person’s ethnic origin, contains an underlying red tone. Its absence or a lighter appearance indicates pallor, a characteristic of anemia or inadequate oxygenation. The color of the lips and nail beds, common sites for assessing cyanosis in white clients, may be highly pigmented in other groups, and nurses may misinterpret normal findings. The conjunctiva and oral mucous membranes are likely to provide more accurate data. The sclera or the hard palate, rather than the skin, is a better location for assessing jaundice. In some people of color, however, the sclera may have a yellow cast from carotene and fatty deposits; nurses should not misconstrue this finding as jaundice (Andrews & Boyle, 2011). Rashes, bruising, and inflammation may be less obvious among people with dark skin. Palpating for variations in texture, warmth, and tenderness is a better assessment technique than inspection. Keloids (irregular, elevated thick scars) are more common among dark-skinned clients (Fig. 6-4). They are thought to form from a genetic tendency to produce excessive transforming growth factor-beta (TGF-β), a substance that promotes fibroblast proliferation during tissue repair. FIGURE 6-4 Keloids are raised, thick scars as is seen in this client’s ear lobe originally punctured to accommodate pierced earrings. (Photo by B. Proud.) p. 82 p. 83 FIGURE 6-5 Vitiligo of the forearm in an African American. (Courtesy of Neutrogena Care Institute.) Some nurses, when bathing a dark-skinned person, may misinterpret the brown discoloration on a washcloth as a sign of poor hygiene. However, this is due to the normal shedding of dead skin cells, which retain their pigmentation. Hypopigmentation and hyperpigmentation are conditions in which the skin is not of a uniform color. Hypopigmentation may result when the skin becomes damaged. Regardless of ethnic origin, damaged skin characteristically manifests temporary redness, which then fades to a lighter hue; in dark-skinned clients, the effect may be more obvious. Vitiligo, a disease that affects white clients as well as those with darker skin, produces irregular white patches on the skin as a result of an absence of melanin (Fig. 6-5). Other than hypopigmentation, there are no physical symptoms, but the cosmetic effects may create emotional distress. Clients concerned about uneven skin tone may use a pigmented cream to disguise noticeable areas. Mongolian spots, an example of hyperpigmentation, are dark blue areas on the lower back and sometimes on the abdomen, thighs, shoulders, or arms of darkly pigmented infants and children (Fig. 6-6). Mongolian spots are due to the migration of melanocytes into the fetal epidermis. They are rare among white children and tend to fade by the time a child is 5 years old. Nurses unfamiliar with ethnic differences can mistake Mongolian spots as a sign of physical abuse or injury. They can differentiate between the two by pressing the pigmented area: Mongolian spots will not produce pain when pressure is applied. Hair Characteristics Hair color and texture are also biologic variants. Dark-skinned people usually have dark brown or black hair. Hair texture results from the amount of protein molecules within the hair. Variations range from straight to very curly. The curlier the hair, the more difficult it may be to comb. In general, using a wide-toothed comb or pick, wetting the hair with water before combing, or applying a moisturizing cream makes grooming more manageable. FIGURE 6-6 Mongolian spots. These bluish pigmented areas are common in dark-skinned infants. (Photo by K. Timby.) Enzymatic Variations Three inherited enzymatic variations are prevalent among members of various U.S. demographic groups. They involve an absence or insufficiency of the enzymes lactase, glucose-6-phosphate dehydrogenase (G-6-PD), and alcohol dehydrogenase (ADH). Lactase Deficiency Lactase is a digestive enzyme that converts lactose, the sugar in milk, into the simpler sugars, glucose and galactose. A lactase deficiency, common among African Americans, Hispanics, and Chinese people, causes intolerance to dairy products. Without lactase, people have cramps, intestinal gas, and diarrhea approximately 30 minutes after ingesting milk or foods that contain it. Symptoms may continue for 2 hours (Dudek, 2017). Eliminating or reducing sources of lactose in the diet may prevent the discomfort. Liquid tube-feeding formulas and those used for bottle-fed infants can be prepared using milk substitutes. Because milk is a good source of calcium necessary for health, nurses should teach affected clients to obtain calcium from other sources, such as green leafy vegetables, dates, prunes, canned sardines and salmon with bones, egg yolks, whole grains, dried peas and beans, and calcium supplements. Client and Family Teaching Box 6-1 provides additional points for education. G-6-PD Deficiency G-6-PD is an enzyme that helps red blood cells metabolize glucose. African Americans and people from Mediterranean countries commonly lack this enzyme. The disorder is manifested in males because the gene is sex-linked, but females can carry and transmit the faulty gene. A G-6-PD deficiency makes red blood cells vulnerable during stress, which increases metabolic needs. When this happens, red blood cells are destroyed at a much greater rate than in unaffected people. If the production of new red blood cells cannot match the rate of destruction, anemia develops. p. 83 Client and Family Teaching 6-1Reducing or Eliminating Lactose In order to reduce or eliminate lactose, the nurse teaches the client or the family: Avoid milk, dairy products, and packaged foods that list dry milk solids or whey among their ingredients (e.g., some breads, cereals, puddings, gravy mixes, caramels, chocolate). Use nondairy creamers, which are lactose-free, instead of cream or milk. Consume only small amounts of milk or dairy products at a time. Substitute milk that has been cultured with the Acidophilus organism, which converts lactose into lactic acid. Drink Lactaid, a commercial product in which the lactose has been preconverted into other absorbable sugars. Use kosher foods, which are prepared without milk; they can be identified with the word pareve on the label. Because several drugs can precipitate the anemic process (Table 6-5), it is important for the nurse to intervene if these drugs or those that depress red blood cell production are prescribed for clients who are at greatest risk. The nurse must monitor susceptible clients and advocate for laboratory tests, such as red blood cell count and hemoglobin levels, which will indicate any adverse effects. Alcohol Dehydrogenase Deficiency When a person consumes alcohol, a process of chemical reactions involving enzymes, one of which is alcohol dehydrogenase (ADH), eventually breaks down the alcohol into acetic acid and carbon dioxide. Asian Americans and Native Americans often metabolize alcohol at a different rate than other groups because of physiologic variations in their enzyme system. The result is that affected clients experience dramatic vascular effects, such as flushing and rapid heart rate, soon after consuming alcohol. In addition, middle metabolites of alcohol (those formed before acetic acid) remain unchanged for a prolonged period. Many scientists believe that the middle metabolites, such as acetaldehyde, are extremely toxic and subsequently play a primary role in causing organ damage. The rate of alcoholism among Native Americans is six times higher than the U.S. average. One in 10 Native American deaths is alcohol-related (Ghosh, 2012). Pharmacologic Considerations Pharmaceutical studies demonstrate that genetic variations in racial groups can influence medication outcomes. For example, certain drug classes used for psychological illnesses such as those for depression or schizophrenia reduce symptoms more effectively in African American and Asian clients than other classes of drugs. Protein variations in the genetic code are thought to influence these differences. Disease Prevalence Several diseases, including sickle cell anemia, hypertension, diabetes, and stroke, occur with much greater frequency among ethnic minority groups than in the general population. The incidence of chronic illness affects morbidity differently as well (Table 6-6). The incidence of some chronic diseases and their complications may be related partly to variations in social factors, such as poverty. Minority cultural groups tend to be less affluent; consequently, their access to expensive health care is often limited. Without preventive health care, early detection, and treatment, higher death rates are bound to occur. The United States, therefore, has committed itself to reducing disparities in health care among all Americans (see Chapter 4). With the knowledge that special populations are at increased risk for chronic diseases, culturally sensitive nurses focus heavily on health education, participate in community health screenings, and campaign for more equitable health services. Health Beliefs and Practices Many differences in health beliefs exist among U.S. demographic groups. They persist as a result of strong ethnic influences. Health beliefs, in turn, affect health practices (Table 6-7). Folk medicine (health practices unique to a particular group of people) has come to mean the methods of disease prevention or treatment outside mainstream conventional practice. Generally, lay providers rather than formally educated and licensed individuals give such treatments. In addition to culturally specific health practices, such as those sought from a curandero (Latino practitioner who is thought to have spiritual and medicinal powers), a shaman, or an herbalist, many people in the United States also turn to complementary and alternative medicine (CAM), those therapies that are used in addition to or instead of conventional medical treatment for which there is some scientific evidence of safety and effectiveness. Consequently, CAM is now being referred to as integrative therapy (Weil, 2012) (Fig. 6-7, Box 6-3). TABLE 6-5 Examples of Drugs That Precipitate Glucose 6-Phosphate Dehydrogenase Anemia DRUG CATEGORY EXAMPLE USE Aspirin Acetylsalicylic acid (Aspirin) Treatment of pain, inflammation, and fever Nonsteroidal antiinflammatory drugs (NSAIDs) Ibuprofen (Advil) Naproxen (Aleve) Treatment of pain, inflammation, and fever Sulfonamides Trimethoprim/sulfamethoxazole (Bactrim) Treatment of urinary infections p. 84 p. 85 TABLE 6-6 Leading Causes of Death Among U.S. Cultural Groups National Vital Statistics Reports. (2013). Deaths, percentage of total deaths, and rank order for causes of death, by race per 100,000 population, United States, 2010. Retrieved April 1, 2015, from http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf CAM attracts people for various reasons; mainstream medical care is expensive, there may be dissatisfaction with prior treatment or progress, family or acquaintances may provide testimonials about their efficacy, or individuals may feel intimidated by the health care establishment. Just because a health belief or practice is different does not make it wrong. Culturally sensitive nurses respect the client’s belief system and integrate scientifically based treatment along with folk and quasi-medical practices. Refer to Table 6-7 for additional examples of health beliefs and practices as they relate to various cultural groups. Gerontologic Considerations Older adults may prefer their own culture’s traditional healing practices with which they have been familiar since childhood. They may implement these practices instead of or along with care recommended by Western-based health care providers. TABLE 6-7 Examples of Common Health Beliefs and Practices CULTURAL GROUP HEALTH BELIEF HEALTH PRACTICES Anglo-Americans Illness results from infectious microorganisms, organ degeneration, and unhealthy lifestyles. Physicians are consulted for diagnosis and treatment; nurses provide physical care. African Americans Supernatural forces can cause disease and influence recovery. Individual and group prayer is used to speed recovery. Asian Americans Health results from a balance between yin and yang energy; illness results when equilibrium is disturbed. Acupuncture, acupressure, food, and herbs are used to restore balance. Latinos Illness and misfortune are punishment from God (referred to as castigo de Dios) or results from an imbalance of “hot” or “cold” forces within the body. Prayer and penance are performed to receive forgiveness; the services of lay practitioners who are believed to possess spiritual healing power are used; foods that are “hot” or “cold” are consumed to restore balance. Native Americans Illness occurs when the harmony of nature (Mother Earth) is disturbed. A shaman, or medicine man or woman, who has both spiritual and healing power, is consulted to restore harmony. p. 85 p. 86 FIGURE 6-7 Treatment with herbal remedies may be more common among Asian American and Pacific Islander clients. (From Mohr, W. [2012]. Psychiatric-mental health nursing. Philadelphia, PA: Lippincott Williams & Wilkins.) CULTURALLY SENSITIVE NURSING Accepting that the United States is multicultural is the first step toward culturally sensitive/competent nursing care. The following recommendations are ways to demonstrate culturally sensitive nursing care: Use culturally sensitive techniques to improve interactions such as sitting in the client’s comfort zone and making appropriate eye contact. Become familiar with physical differences among ethnic groups. Perform physical assessments, especially of the skin, using techniques that provide accurate data. Learn or ask clients about cultural beliefs concerning health, illness, and techniques for healing. Consult the client on ways to solve health problems. Never verbally or nonverbally ridicule a cultural belief or practice. Integrate helpful or harmless cultural practices within the plan of care. Modify or gradually change culturally unsafe health practices. Avoid removing religious medals or clothes that hold symbolic meaning for the client. If they must be removed, keep them safe and replace them as soon as possible. Provide culturally preferred food. Advocate for routine screening for diseases to which clients are genetically or culturally prone. Facilitate rituals by the person the client identifies as a healer within his or her belief system. Apologize if cultural traditions or beliefs are violated. Learn to speak a second language. BOX 6-3 Examples of Alternative Medical Therapy • Homeopathy is based on the principle of similars; it uses diluted herbal and medicinal substances that cause similar symptoms of a particular illness in healthy people. For example, quinine is used to treat malaria because it causes chills, fever, and weakness (symptoms of malaria) when administered to healthy people. • Naturopathy uses botanicals, nutrition, homeopathy, acupuncture, hydrotherapy, and manipulation to treat illness and restore a person to optimum balance. • Chiropractic is based on the belief that illnesses and pain result from spinal misalignment; it uses manipulation and readjustments of joint articulations, massage, and physiotherapy to correct dysfunction. • Environmental medicine proposes that allergies to environmental substances in the home and workplace affect health, particularly for highly sensitive people. It advocates reduced exposure to chemicals to control conditions that mainstream physicians have failed to diagnose or underdiagnosed. KEY POINTS Culturally sensitive nursing care: Care that respects and is compatible with each client’s culture Culture: The values, beliefs, and practices of a particular group Race: Biologic variations Ethnicity: A bond or kinship a person feels with his or her country of birth or place of ancestral origin Factors that interfere with achieving culturally sensitive nursing: Stereotypes: Fixed attitudes about all people who share a common characteristic Generalization: Supposition that a person shares cultural characteristics with others of a similar background Ethnocentrism: Belief that one’s own ethnicity is superior to all others Transcultural nursing: Providing nursing care within the context of another’s culture Assessments of a cultural nature Acceptance of each client as an individual Knowledge of health problems that affect particular cultural groups Planning of care within the client’s health belief syst