Culture and Ethnicity Chapter 6 PDF

Culture and Ethnicity Chapter 6 INTRODUCTION Clients vary by age, gender, race, health status, education, religion, occupation, and economic level. Although equal treatment is politically correct, ignoring differences can contradict the best interests of clients. Therefore, nurses are advised to alw...

Culture and Ethnicity Chapter 6 INTRODUCTION Clients vary by age, gender, race, health status, education, religion, occupation, and economic level. Although equal treatment is politically correct, ignoring differences can contradict the best interests of clients. Therefore, nurses are advised to always consider cultural needs from an individual’s perspective. 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. 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, people from various cultural groups have settled, lived, and worked in the United States. Race 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. 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 . 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. 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. One or both groups may experience cultural shock (bewilderment over behavior that is culturally unfamiliar). Consequently, many ethnic groups have been victimized because 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 about age, gender, race, sexual preference, and/or ethnicity. 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. 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. 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. CULTURES IN THE UNITED STATE Although it is an 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. 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 •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. •Most 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. 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 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. 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. 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. The use of untrained interpreters, volunteers, or family is considered inappropriate because it undermines confidentiality and privacy. It also violates family roles and boundaries. 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. 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). 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 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. 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. Cultural characteristics involving aspects of communication may ease the transition toward culturally sensitive care. Native Americans Native Americans have traditionally been fearful of the health care establishment (Satter et al., 2014). They tend to be private and may hesitate to share personal information with health care providers they do not know. 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. If possible, the nurse should write notes after, rather than during, the interview. African Americans 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. 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. Latinos Latinos are often comfortable sitting close to interviewers and letting interactions unfold slowly. 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 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. 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 Asian Americans may feel more comfortable with the nurse at more than an arm’s length away. 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. People from Southeast Asia consider the head to be a sacred body part that only close relatives can touch. 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. 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, especially among unfamiliar people. Stoicism should not be interpreted as a lack of feeling or caring. Latino men may not demonstrate their feelings or readily discuss their symptoms because they may interpret doing so as less masculine. The Latino cultural response can be attributed to machismo, a belief that men are physically strong and must deal with emotions privately. Religious practices within some cultures impose certain rules and restrictions such as times for fasting and foods that can and cannot be consumed. Nutrition Notes         Some traditional foods are rejected, and new foods are added or used as substitutes for traditional foods. Availability and cost influence dietary acculturation. 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 a lot of, 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. Alot is also consumed during la cuarentena, a 40day 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 encounter meat may not be used with dairy and vice versa. Utensils that have encounter non kosher food may not be used with kosher food, among other rule. Time Throughout the world, people view clock time and social time differently. 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. Beliefs Concerning Illness 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. Adding or subtracting heat or cold to restore balance can also restore health. 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. As long as a culturally held health belief or practice is not harmful, the nurse should incorporate it into the client’s care. Skin Characteristics 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. 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. They are thought to form from a genetic tendency to produce excessive transforming growth factor-beta (TGFβ), a substance that promotes fibroblast proliferation during tissue repair. Hypopigmentation and hyperpigmentation are conditions in which the skin is not of a uniform color. Hypopigmentation may result when the skin becomes damaged. Vitiligo, a disease that affects white clients as well as those with darker skin, produces irregular white patches on the skin because of an absence of melanin. 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. 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. Mongolian spots will not produce pain when pressure is applied. Hair Characteristics Dark-skinned people usually have dark brown or black hair. Hair texture results from the amount of protein molecules within the hair. 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. 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. 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. 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. If the production of new red blood cells cannot match the rate of destruction, anemia develops. Alcohol Dehydrogenase Deficiency 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. 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 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. 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 Health beliefs, in turn, affect health practices. 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. 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. 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. Culturally sensitive nurses respect the client’s belief system and integrate scientifically based treatment along with folk and quasi-medical practices. 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. Examples of Alternative Medical Therapy •Homeopathy is based on the principle of similar; it uses diluted herbal and medicinal substances that cause similar symptoms of a particular illness in 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.