Cultural Influences on Nursing Care PDF

4068_Ch04_039-057 15/11/14 12:34 PM Page 39 4 Cultural Influences on Nursing Care BOBBI M. MARTIN LEARNING OUTCOMES 1. Define common concepts related to culture and ethnicity. 2. List examples of cultural characteristics, values, beliefs, and practices. 3. Describe attributes of culturally diverse...

4068_Ch04_039-057 15/11/14 12:34 PM Page 39 4 Cultural Influences on Nursing Care BOBBI M. MARTIN LEARNING OUTCOMES 1. Define common concepts related to culture and ethnicity. 2. List examples of cultural characteristics, values, beliefs, and practices. 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. 4. Identify data you should collect from culturally diverse patients and their families. 5. Apply a holistic approach to patient care that respects cultural characteristics and attributes. KEY TERMS acculturation (uh-KUL-chur-AY-shun) beliefs (bee-LEEFS) cultural (KUL-chur-uhl) cultural assimilation (KUL-chur-uhl uh-SIM-ih-LAY-shun) cultural awareness (KUL-chur-uhl a-WEAR-ness) cultural competence (KUL-chur-uhl KOM-pe-tents) cultural conflict (KUL-chur-uhl KON-flikt) cultural diversity (KUL-chur-uhl dih-VER-sih-tee) cultural sensitivity (KUL-chur-uhl SEN-sih-TIV-ih-tee) cultural shock (KUL-chur-uhl SHOK) culture (KUL-chur) customs (KUS-tums) ethnic (ETH-nick) ethnocentrism (ETH-noh-SEN-trizm) generalizations (JEN-er-al-ih-ZAY-shuns) stereotype (STARE-ee-oh-TIGHP) traditions (tra-DISH-uns) values (VAL-yooz) worldview (WERLD-vyoo) 39 4068_Ch04_039-057 15/11/14 12:34 PM Page 40 40 UNIT ONE Understanding Health Care Issues Your clinical instructor has assigned you to provide care to Mary Waters, a 72-year-old African American woman. Ms. Waters has diabetes and hypertension (high blood pr essure). She was admitted to the hospital for gangr ene of her left foot. When you enter her room, you find Ms. Waters anxious and crying. She tells you that she is scheduled for surgery later in the day. When asked about her foot, she tells you that she has been applying a poultice to draw out the germs, but it has not work ed yet. She adds that she has been praying for the cure that she knows will come. As you are collecting history information about her diabetes, Ms. Waters admits that her doctor told her to attend diabetes classes years ago, but she stopped going because she didn’t like what she heard. She quickly changes the subject, wanting to talk about nothing but her grandchildren. Your attempts to complete preoperative teaching are unsuccessful. Can you think of examples of cultural practices you have seen in your e xperience that were unique or dif ferent from your own? Cultural diversity in the United States is increasing. According to the U.S. Census Bureau, 50.4% of our nation’s population younger than age 1 as of July 1, 2011, were minorities (Bernstein, 2012). Immigration from Spanishspeaking and Asian countries has resulted in dramatic shifts in census numbers. Figure 4.1 illustrates the changes and projections in racial and ethnic makeup in the United States by 2050. As a result, cultural and ethnic differences between nurses and their patients are becoming more evident and must be recognized. More than ever, nurses must develop cultural awareness and apply cultural competence to practice. This chapter provides you with the basics of culture and its impact on health promotion and wellness. CONCEPTS RELATED TO CULTURE Culture refers to the socially transmitted behavior patterns, beliefs, values, customs, arts, and all other characteristics of people that guide their view of the world (worldview). Cultural beliefs, values, customs, and traditions are primarily learned within the family on an unconscious level. They can also be learned from the communities in which we live, from religious organizations, and in schools. As you try to understand more about culture, keep in mind that it contains a number of characteristics (Box 4-1). All individuals and groups have the right to maintain cultural practices that the y feel are appropriate, as long as the y don’t infringe on rights of others. However, as you will learn from this chapter, nurses must be aware of cultural health practices that can cause physical harm and require nursing intervention. Culture has strong influences on a patient’s understanding of health and how he or she will respond to nursing care. You must understand how culture influences health behaviors to better meet the needs of your patients (Fig. 4.2).As you learn more about ethnic and cultural groups, you will be challenged to look at the differences and similarities across cultures. Consider our patient, Ms. Waters. Did she behave as you would have in a similar situation? How do you think the characteristics of her cultur e affected her behavior? Can you think of how you could have used the information she shared to engage her in learning more about her upcoming surgery? Although the terms cultural sensitivity, cultural awareness, and cultural competence are similar, they have different meanings. Cultural sensitivity is knowing politically correct language and not making statements that may offend another person’s cultural beliefs. Cultural awareness focuses on history and ancestry and emphasizes an appreciation for and attention to arts, music, crafts, celebrations, foods, and traditional clothing. Cultural competence includes the skills and knowledge required to provide effective nursing care. To be culturally competent, you need to: • Have an awareness of your own culture and not let it have an undue influence on your patient care. Percent of the Population, by Race and Hispanic Origin: 1990, 2000, 2025, and 2050 (Middle-series projections) 75.7 1990 2000 2025 2050 71.6 62.0 52.5 22.5 16.8 14.2 15.7 12.3 12.8 White, not Hispanic Black 7.5 10.3 0.8 0.9 1.0 1.1 3.0 4.4 American Indian, Eskimo, and Aleut Asian and Pacific Islander 9.0 11.3 Hispanic origin (of any race) FIGURE 4.1 Percent of the population of the United States, by race and Hispanic origin. (Source: U.S. Census Bureau, Population Division; retrieved August 15, 2009, from www.census.gov/population/www/pop-profile/natproj.html.) 4068_Ch04_039-057 15/11/14 12:34 PM Page 41 Chapter 4 Box 4-1 Characteristics of Culture • Culture is learned. Learning occurs through life experiences shared with other members of the culture. • Culture is taught. Cultural values, beliefs, and traditions are passed down from generation to generation either formally (e.g., in schools) or informally (e.g., in families) • Culture is shared by its members. Cultural norms are shared through teachings and social interactions. • Culture is dynamic and adaptive. Cultural customs, beliefs, and practices are not static but change over time and at different rates. Cultural change occurs with adaptation in response to the environment. • Culture is complex. Cultural assumptions and habits are unconscious, which may make them difficult for members of the culture to explain to others. • Culture is diverse. Culture demonstrates the variety that exists between groups and among members of a particular group. • Culture exists at many levels. Culture exists at material (e.g., art, dress, or artifacts) and nonmaterial (as language, traditions, customs, beliefs, and practices) levels. • Culture has common beliefs and practices. Members of a culture share the same beliefs, traditions, customs, and practices as long as they continue to be adaptive and satisfy their needs. Some members do not always follow all of these, but many do. • Culture is all encompassing. Culture can affect everything its members think and do. • Culture provides identity. Cultural beliefs provide identity for members as long as there is no conflict with the dominant culture or lack of gratification by its members. FIGURE 4.2 The nurse must assess patients’ unique needs related to their cultural backgrounds. Cultural Influences on Nursing Care 41 • Have specific knowledge about your patient’s culture. • Accept and respect cultural differences. • Adapt your nursing care (when appropriate) to your patient’s culture. We will discuss more about cultural competence later in the chapter. Although you may have knowledge about another culture, barriers such as ethnocentrism and stereotyping can keep you from appreciating cultural differences. Ethnocentrism is the tendency for humans to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways. Ethnocentrism perpetrates an attitude that beliefs that dif fer greatly from your own are strange or bizarre and therefore wrong. Additionally, you must be careful not to stereotype your patient. A stereotype is an opinion or belief about a group of people that is ascribed to an individual. For example, the statement “All Chinese people prefer traditional Chinese medicine” is a stereotype. This stereotype is not true. Although many Chinese people may prefer traditional Chinese medicine for some health conditions, not all Chinese people prefer traditional Chinese medicine. Ho wever, you can still make generalizations about an ethnic person without stereotyping. Although a generalization or assumption may be true for the group, it does not necessarily f it every individual. Therefore, you must seek additional information to determine whether the generalization fits the individual. The challenge is for you to understand the patient’s cultural perspective. If you have specific cultural knowledge, you can improve therapeutic interventions by becoming a coparticipant with patients and their families. To do this, it is important that you develop a personal, open style of communication and be receptive to learning from patients from cultures other than your own (Fig. 4.3). A few additional terms important for your understanding of culture relate to the socialization process of those who are learning to become a member of a society or group. When FIGURE 4.3 Health care providers and patients may come from a variety of cultural backgrounds. 4068_Ch04_039-057 15/11/14 12:34 PM Page 42 42 UNIT ONE Understanding Health Care Issues people immigrate to a new country, many gradually accept the new culture through a learning process. They learn to accept their own beliefs as well as those of their new country. This is known as acculturation. Acculturation is commonly seen in second-generation immigrants because the y not only understand the necessity of learning their new culture, but also see the value of it. Learning the new culture helps individuals survive, and more importantly, thrive in their new environment. Cultural assimilation occurs when a new member takes on the dominant culture’s values, beliefs, and practices, sometimes at the cost of losing some of his or her cultural heritage. This process is often viewed as negative. Imagine for a moment that you ha ve moved to China. At first you eat the food and try to understand the language of your new country. Over time, you may learn to cook the food, speak the language, and perhaps blend some of the Chinese beliefs, traditions, and practices with your own. This is acculturation. However, this process is not al ways smooth. When one’s own culture conflicts with a new culture, cultural conflict occurs. Worse than that, cultural shock can happen when values, beliefs, and practices sanctioned by the ne w culture are very different from the ones of the native culture. Let’s look at another example. Ling Chi is a 4-year-old boy who is a recent immigrant enrolled in a ne w school. He is alone and afraid, although he is surrounded by other boys and girls his age. It is lunchtime, and while his teacher is trying to help him with his food, he starts crying. The fork and spoon are foreign to him. At home he is used to eating his lunch with chopsticks. In addition, he does not understand the words spoken to him. Ling Chi is experiencing cultural shock. HEALTH CARE VALUES, BELIEFS, AND PRACTICES Cultural values, beliefs, and practices about the nature of disease and the human body are central in the deli very of health services, treatments, and pre ventive interventions (Office of Minority Health, 2010). A value can be defined as a principle or standard that has meaning or worth to an individual (Purnell & P aulanka, 2008). Values can help shape one’s beliefs and practices. Do you kno w what your values are regarding health and illness? “Cleanliness” is an example of a value. A belief is something that a person accepts as true (e.g., “I believe that germs cause illness and disease”). A practice is a set of behaviors that one follows—for example, washing hands before eating. It is important for you to un derstand the differences between these terms because we will be discussing them as they relate to cultural groups. Consider our patient Mrs. Waters again. Can you think of cultural values, beliefs, or practices she has that may influence why she may not want to attend diabetes classes or learn more about her upcoming surgery? To provide culturally competent care, you need to kno w how the people you encounter def ine health and illness. In general, people follow one of three major health belief systems: scientific (Western medicine or biomedical), spiritual, or holistic. You are already familiar with the scientific health system, which dominates health care in Western societies. Belief in supernatural forces dominates the spiritual system, which is considered by many to be an alternative health care system. (Some experts call this magico-religious, but this is an offensive term to some religious persons.) The holistic belief system focuses on the need for balance and harmon y of the body and spirit with nature. Health care typically focuses on health promotion, the prevention of illness, and acute illness care while considering traditional, religious, and biomedical (scientif ic) beliefs. Additionally, individual responsibility for health, self-medicating practices, views toward mental illness, response to pain, and the sick role are shaped by one’s culture. Most societies combine biomedical health care with traditional, folk, and religious practices such as praying for good health or wearing charms or amulets to ward off illness. There are many examples of folk practices for curing or treating specific illnesses. Think for a minute about such practices that you may per form. What do you do for a fe ver or a sore throat? Does chicken noodle soup come to mind? Many times folk therapies are handed down from family members and may ha ve their roots in religious beliefs. Examples of folk therapies include covering a boil with axle grease or wearing copper bracelets for arthritic pain. As you will see in Chapter 5, many people use complementary therapies such as acupressure or herbal remedies in addition to traditional Western therapies. Often folk practices are not harmful and can be added to the patient’s plan of care. However, some therapies may conflict with prescription medications, or cause a toxic ef fect. Other folk practices may actually cause physical harm to a patient. It is essential to inquire about the full range of therapies being used by your patients, such as food items, teas, herbal remedies, nonfood substances, over-the-counter (OTC) medications, medications prescribed by others, and medications borrowed from others. If patients sense that you do not accept their beliefs and practices, they may be less open to sharing information and less adherent to prescribed treatment. Your goal is to try to encourage your patients’ practices that could be helpful and discourage those that may be harmful. Before encouraging or discouraging such practices, you will need to discuss them with the appropriate health care team member. Think about Ms. Waters. Does she use any folk pr actices? Where can you find more information about her specific folk practices? How would you addr ess this specific situation? Before moving on, we need to discuss the subjects of mental illness and cultural responses to pain and the sick role. Mental illness may be seen by some as being unimportant compared with physical illness. Mental illness is culture bound. What may be perceived as a mental illness in one society may not be considered a mental illness in another society. Among some cultures, ha ving a mental illness or an emotional difficulty is considered a disgrace and is taboo.As a result, a family is likely to keep a person who is mentally ill at home as long as they possibly can. 4068_Ch04_039-057 15/11/14 12:34 PM Page 43 Chapter 4 Cultural Influences on Nursing Care 43 Cultural responses to pain and the sick role can v ary among cultures. For example, some people are e xpected to openly express their pain. Others are expected to suffer their pain in silence. F or some, the sick role is readily accepted, and any excuse is accepted for not fulfilling daily obligations. Others minimize their illness and mak e extended efforts to fulfill their obligations despite being ill. that they are listening and can be trusted. Ho wever, in other societies, as a sign of respect, people should not maintain eye contact with superiors such as teachers and those in positions of higher status. Nursing Assessment • By what name do you prefer to be called? • What language do you speak at home? • Are you able to read and write in English? • If not, what language is preferred? To begin your assessment of your patient’s health beliefs, ask the following questions: • What do you usually do to maintain your health? • What do you usually do when you are sick? • What kind of home treatments do you use when you are sick? • Who is the first person you see when you are sick? • What do you do when you have pain? • Do you wear charms or bracelets to ward off illness? • Do you take herbs or drink special teas when you are sick? If so, what are they? • Do you practice special rituals or prayers to maintain your health? CHARACTERISTICS OF CULTURAL DIVERSITY Primary and secondary characteristics of diversity affect how people view their culture. Primary characteristics of cultural diversity include nationality, race, skin color, gender, age, and religious affiliation. Secondary characteristics include socioeconomic status, education, occupation, military e xperience, political beliefs, length of time away from the country of origin, urban versus rural residence, marital status, parental status, physical characteristics, sexual orientation, and gender issues. Culturally appropriate care needs to tak e into account eight cultural phenomena that may vary with use but can be seen in all cultural groups: 1. communication styles 2. space 3. time orientation 4. social organization 5. environmental control/health beliefs 6. choice of health care providers (HCPs) 7. biological variations 8. death and dying issues. Communication Styles Communication occurs both verbally and nonverbally. Verbal communication includes spoken language, dialects, and voice volume. Dialects are variations in grammar, word meanings, and pronunciation of spoken language. Nonverbal communication includes the use and degree of eye contact, the perception of time, and physical closeness when talking with peers and perceived superiors. In some societies, people are e xpected to maintain eye contact without staring, which shows Nursing Assessment and Strategies Ask the following questions: Be sure to do the following: • Take cues from the patient for voice volume. • Be an active listener, and become comfortable with silence. • Avoid appearing rushed. • Be formal with greetings until told to do otherwise. • Take greeting cues from the patient. • Speak slowly and clearly. Do not speak loudly or with exaggerated mouthing. • Explain why you are asking specific questions. • Give reasons for treatments. • Repeat questions if needed. • Provide written instructions in the patient’s preferred language. • Obtain an interpreter if needed. HCPs should refrain from relying on untrained individuals to interpret, especially family members (see “Evidence-Based Practice”). Although it may seem logical that a patient’ s best advocate is his or her family, it is risky to rely on family members to interpret medical or health information for the following reasons: • Family members may not be proficient in medical terminology. • They may not possess the skills needed to interpret. • They may unintentionally or intentionally omit or alter important information. • Using family members to interpret may raise privacy issues protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). • If children are used, they may not be emotionally mature enough to handle the information being conveyed. EVIDENCE-BASED PRACTICE Clinical Question Do patients with limited English proficiency who have professional interpreters experience improved clinical care over those who use ad hoc or family member interpreters? Evidence The likelihood of medical errors is significantly reduced by the use of professional interpreters 4068_Ch04_039-057 15/11/14 12:34 PM Page 44 44 UNIT ONE Understanding Health Care Issues versus not using interpreters or the use of ad hoc interpreters. Ad hoc interpreters were much more likely to make errors that led to serious medical problems than professionally trained interpreters (Flores, Abreu, Barone, Bachur, & Lin, 2012). Implications for Nursing Practice National Standards on Culturally and Linguistically Appropriate Services recommends that cultural and linguistic appropriate services should be integrated throughout an organization (Office of Minority Health, 2012). Additionally, organizations are required by law to provide language access services to individuals with limited English proficiency (Joint Commission, 2008). Addressing communication barriers is an important task for nurses as caregivers and patient advocates. Nurses can be aware of the populations they serve and have interpreters available to facilitate communication. This is done through face-to-face interpretation, via phone, or via video. Nurses can also ensure there are written materials in the patients’ native language, especially for discharge instructions. The Joint Commission provides direction and support for HCPs to use health information technology to bridge the cultural gap between HCPs and patients. They note that caregivers who have access to health information technology systems provide better care with improved outcomes (Lopez, Green, Tan-McGrory, King, & Betancourt, 2011). Tips for Using Interpreters Address the patient, not the interpreter. Do not interrupt the patient and the interpreter. Ask the interpreter to give you exact translations. Avoid using medical jargon. Office of Minority Health, U.S. Department of Health and Human Services. (2012). National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Retrieved May 15, 2013 from www .thinkculturalhealth.hhs.gov/pdfs/EnhancedNational CLASStandards.pdf Space Space refers to one’s “personal space.” Are you aware of your comfort zone? In other words, how close can someone get to you before you feel less safe and secure? Like you, most people have such a comfort zone. Personal space tends to be different when speaking with close friends versus strangers, and it also differs across cultures. For example, people from the Middle East tend to stand close together when talking, whereas those from European countries, such as German y, require a much larger space. The need for space is important for the patient’s privacy, autonomy, security, and self-identity. Understanding what space means for your patients can be important when you are trying to assess, treat, and teach them. Nursing Assessment and Strategies Ask the following questions: • Are you comfortable? • Do you have any concerns you would like to discuss? Be sure to do the following: • Make sure your patients are comfortable before you interview them. • Maintain appropriate physical distance (observe for cues). • Be aware of cultural differences. • Be aware of physical objects that may be a barrier to comfort. • Make sure that the patient’s physical environment is arranged to ensure safety, security, and familiarity. REFERENCES Time Orientation Flores, G., Abreu, M., Barone, C. P., Bachur, R., & Lin, H. (2012). Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus as hoc versus no interpreters. Annals of Emergency Medicine, 50, 545–553. Time orientation can vary among people from different cultures. The perception of time has tw o dimensions. The first dimension is related to clock time versus social time. For example, some cultures have a flexible orientation to time and events, and appointments take place when the person arrives. An event scheduled for 1400 may not be gin until 1430 or when a majority of the participants arrive. For others, time is less flexible, and appointments and social events are expected to start at the agreed-on time. For many, social events may be flexible, whereas medical appointments and business engagements start on time. The second dimension of time relates to whether the culture is predominantly concerned with the past, present, or future. Past-oriented individuals maintain traditions that were meaningful in the past and may w orship ancestors. Presentoriented people accept the day as it comes, with little regard for the past; the future is unpredictable. Future-oriented Joint Commission. (2008). Promoting effective communication: Language access services in health care. Joint Commission Perspectives, 28, 811. Retrieved March 24, 2009, from www.jointcommission.org/NR/rdonlyres /ACAFA57F-5F50-427A-BB98-73431D68A5E4/0 /Perspectives_Article_Feb_2008.pdf López, L., Green, A. R., Tan-McGrory, A., King, R., & Betancourt, J. R. (2011). Bridging the digital divide in health care: The role of health information technology in addressing racial and ethnic disparities. Joint Commission Journal on Quality and Patient Safety, 37, 437–445. 4068_Ch04_039-057 15/11/14 12:34 PM Page 45 Chapter 4 people anticipate a bigger and better future and place a high value on change. Some people balance all three views—they respect the past, enjoy living in the present, and plan for the future. Hospitals, clinics, and HCPs’ offices maintain a tight time schedule. It is therefore important that you understand patients’ time orientation so you can prepare them for the timing of appointments, tests, and treatments. In addition, it is important that you assess their usual routines so that you can incorporate these as much as possible into their daily care. Nursing Assessment and Strategies Ask the following questions to understand your patients’time orientation: • Are you normally on time for appointments? • Are there any routines that you need to follow? • What time do you usually eat your meals? Take your bath? Be sure to do the following: • Have a clock in the patient’s room. • Assess for orientation, and reorient to time as needed. • Prepare patients before a procedure or test. • Give time options when appropriate. (“Would you like to take a walk now or in an hour?”) Social Organization Family organization includes the percei ved head of the household, gender roles, and roles of the older and extended family members. The household may be patriarchal (male dominated), matriarchal (female dominated), or e galitarian (shared equally between men and women). An awareness of the family dominance pattern is important for determining which family member to speak to when health care decisions have to be made. Confidentiality issues can complicate this issue. Be sure to follow your institution’s policies when communicating with family members. You may need to obtain the patient’s permission before planning care with f amily members. In some cultures, specific roles are outlined for men and women. Men are expected to protect and provide for the family, manage finances, and deal with the outside world. Women are expected to maintain the home en vironment, including child care and household tasks. You must accept that not all societies share or even desire an egalitarian family structure. Roles for older adults and e xtended family vary among culturally diverse groups. In some cultures, older adults are seen as being wise, are deferred to for making decisions, and are held in high esteem. Their children are expected to provide for them when they are no longer able to care for themselves. In other cultures, although older people may be loved by family members, they may not be given such high regard and may be cared for outside the home when self-care becomes a concern. The extended family is very important in some groups, and a single household may include several generations living together out of desire rather than out of necessity . The Cultural Influences on Nursing Care 45 extended family may include both blood-related and non– blood-related persons who are gi ven family status. In other families, each generation lives in a separate home or li ving space. You can assist your patients with their treatment plans when you have a better understanding of their family dynamics. It is important to know whom to include for planning of care, discharge planning, and patient teaching. Nursing Assessment and Strategies Ask the following questions: • Who makes the decisions in your household? • Who takes care of money matters, does the cooking, or is responsible for child care? • Who decides when it is time to see a HCP? • Who lives in your household? Are they all blood related? Be sure to do the following: • Observe the use of touch between family members. • Let family members decide where they want to stand or sit for comfort. Environmental Control Environmental control consists of three major concepts: people’s perception of their ability to control what happens to them and their health, their beliefs about health and illness, and their beliefs in alternative health care therapies such as folk medicine. For example, if a person does not believe he has control of his health, he may not be receptive to nursing interventions that require self-confidence, such as self-administration of insulin. Regarding health beliefs, if a person belie ves that illness is due to a spiritual cause and not bacteria, he or she may not understand the need to take antibiotics. Third, many people put great faith in folk healing practices. Nurses need to consider their patient’s cultural values and beliefs, especially if they are different from the dominant Western health care view. Distinctions are made between health and illness and what people do to promote or maintain health and to pre vent and treat illnesses. Not all of your patients will turn to a Western health care system or provider. Many people try some form of alternative therapy before seeking treatment. People also use alternative therapies and religious systems such as prayer in combination with the scientific medical system. Religious beliefs and practices may be important to patients (Fig. 4.4). Nursing Assessment and Strategies Ask the following questions: • How do you define health? Illness? • Do you have any special beliefs about health and illness? • What do you do to keep well? • When you feel ill, what is the first thing you do to get better? • How do you deal with pain? • How do you and your family express grief? • Are there any cultural beliefs or practices that I need to know about to plan your care? 4068_Ch04_039-057 15/11/14 12:34 PM Page 46 46 UNIT ONE Understanding Health Care Issues FIGURE 4.4 Religious artifacts are central to many people’s health and illness practices. Be sure to do the following: • Be aware of possible cultural beliefs and practices. • Never stereotype based on what you know about different cultures; always ask for specific information. • Perform a cultural assessment on all of your patients. • Ask if patients have received treatments of any kind for their illness. • Ask about religious beliefs and practices. • Encourage helpful practices and discourage those that are harmful. Health Care Providers HCP choices are made based on the patient’s perceived status and previous use of traditional, religious, and biomedical HCPs. In Western societies, educated HCPs are treated with great respect. However, some people prefer traditional healers because they are known to the patient, family, and community. It is important to respect dif ferences in gender relationships when providing care. Some people may be especially modest because of their religion, seeking out same-gender nurses and HCPs for intimate care. Respect these patients’ modesty by providing privacy and assigning a same-gender care provider when possible. Nursing Assessment and Strategies Ask the following questions of your patients: • What HCPs besides physicians and nurses do you see when you are ill? • Do you object to male or female HCPs giving physical care to you? Be sure to do the following: • Observe for alternative care providers who may visit the patient in the health care facility. Biological Variations The term biological variations refers to ways in which people are different from one another physiologically and genetically. These differences can make them more susceptible to certain illnesses and diseases and may also influence the effectiveness of different medications. Biological variations can include differences in (1) body build and structure, (2) skin color, (3) vital signs, (4) laboratory values, (5) susceptibility to disease, and (6) nutrition. Darker skin color can challenge you to be more observant when you are assessing the skin color of your patient. Laboratory test results can also be different in a number of cultures. F or example, American Indians and Hispanic Americans may have higher blood glucose levels than whites. The term biological variations also refers to differences in nutritional practices. Nutritional practices are currently being scrutinized in our society. These practices include the personal meaning of food, food choices and rituals, food taboos, and how food and food substances are used for health promotion and wellness. Cultural beliefs influence what people eat or avoid. In addition to being important for survi val, food offers security and acceptance, plays a signif icant role in socialization, and can serve as an expression of love. Culturally congruent dietary counseling, such as adapting preparation practices and including ethnic food choices, can reduce health risks. Whenever possible, you should determine a patient’s current dietary practices. Culturally di verse patients may refuse to eat on a schedule ofAmerican mealtimes or to eat American foods. Counseling about food group requirements or dietary restrictions must respect an individual’s cultural background. Most cultures have their own nutritional practices for health promotion and disease pre vention. For many, a balance of dif ferent types of foods is important for maintaining health and preventing illness. A thorough history and assessment of dietary practices can be an important diagnostic tool to guide health promotion. Nursing Assessment and Strategies Ask the following questions of your patients: • Are you at risk for any diseases or genetic disorders related to your cultural background? • Are you satisfied with your weight? • Are you active? What is your normal exercise pattern? • Do you protect your eyes and skin from the sun? From possible injuries? • Do you have any drug or food allergies? • Has anyone in your family had any major illnesses? • What do you eat to stay healthy? • What do you eat when you are ill? • Are there certain foods that you do not eat? Why? • Do certain foods cause you to become ill? What are they? • Who purchases the food in your household? • Who prepares the food in your household? Be sure to do the following: • Teach about biological variations that may pertain to your patient. • Determine and respect usual eating patterns whenever possible. • Teach good nutrition habits, taking into account patient preferences. Refer to a dietitian if appropriate. Death and Dying and End-of-Life Issues Death rituals of cultural groups are the least likely to change over time. To avoid cultural taboos, you must become knowledgeable 4068_Ch04_039-057 15/11/14 12:34 PM Page 47 Chapter 4 about rituals surrounding death and bereavement. For some, the body should be b uried whole. Therefore, an amputated limb may be buried in the amputee’s future gravesite, and organ donation would probably not be acceptable. Cremation may be preferred for some, whereas for others, it is taboo and burial is the preferred practice. Views on autopsy vary. Some cultural groups have elaborate ceremonies that last for days in commemoration of the dead. To some these rituals appear to be a celebration, and in a sense, the y are a celebration of the person’s life rather than a mourning of the person’s death. If you are uncertain, find out from the family if there is anything that the health care team can do to f acilitate cultural practices. The expression of grief in response to death varies within and among cultural and ethnic groups. For example, in some cultures, loved ones are expected to suffer the grief of death in silence, with little display of emotion. In other cultures, loved ones are expected to display elaborate emotions to show that they cared for the deceased. These variations in the grieving process may cause confusion if you perceive some people as overreacting and others as not caring.You must accept that culturally diverse behaviors are associated with the grie ving process. Bereavement support strategies include being physically present, encouraging reality orientation, openly acknowledging the family’s right to grieve as they need to, helping the family express their feelings, encouraging interpersonal relationships, promoting interest in a ne w life, and making referrals to other staff and spiritual leaders as appropriate. At times you may be involved with end-of-life decisions. Some of these may include advance directives, resuscitation status, and organ transplantation. Collaborate with the RN or HCP to ensure cultural preferences are respected. Nursing Assessment and Strategies Ask the following questions of your patients: • What are the usual burial practices in your family? • What are your feelings about autopsy? Be sure to do the following: • Observe expressions of grief. Support the family in their expression of grief. • Observe for differences in the expression of grief among family members. • Offer to obtain a religious counselor/spiritual leader if the family wishes. ETHNIC AND CULTURAL GROUPS IN THE UNITED STATES This section describes selected attributes of some of the cultural groups in the U.S. These groups include European American (white), Spanish/Hispanic/Latino, African American (black), American Indian/Alaskan Native, Arab American, Asian American, and Native Hawaiian or Other Pacific Islander. The groups described here by no means represent all the cultural groups in North America; they do, however, represent the largest Cultural Influences on Nursing Care 47 population percentages in the United States. As of the 2010 census, the U.S. federal government initiated new terminology for classifying people of diverse racial and ethnic backgrounds. This terminology is used in this section. Attributes presented for each group include communication styles, space, time orientation, social or ganization, environmental control, biological variation, health care beliefs, traditional HCPs, and death and dying issues. Racial and ethnic biological v ariations, susceptibility to disease, and genetic diseases are co vered to a greater e xtent elsewhere in this textbook (see “Gerontological Issues”). Gerontological Issues Aging, Ethnicity, Health, and Illness Compared with white or European American older adults, ethnic minorities are more likely to: • Live in poverty • Experience debilitating disease processes or functional disability at a higher rate and at an earlier age • Have greater difficulty accessing health care services • Be underserved for physical and mental health problems. By 2030, the number of older adults will double. The largest growth will be among minorities. Remember that to provide culturally competent care older adults need to be assessed within their personal cultural context. Avoid generalizing cultural practices to indi viduals or families without first assessing whether this practice or belief is true for the individual. For example, it would be wrong to assume that an older Me xican American woman who lives with her extended family will receive the family’s support for assistance with bathing and other activities of daily living. If an older Chinese woman uses herbs and folk treatments for common complaints, it does not mean that she will not use the services, treatments, or medications of Western medicine. Always assess individual and family preferences. European American European American is the term used to describe people living in the United States whose heritage is from western, southern, and northern Europe. European American groups include the white ethnic groups. Many of the descendants of these original European immigrants practice the unique attrib utes of the subcultures from which the y originate. There is much diversity in the primary and secondary characteristics of diversity within this cultural group. Many European Americans maintain the value of individualism over group norms and are activity-oriented. Most European Americans practice Western medicine, which v alues advanced technology and evidence-based practice (Table 4.1). (Text continued on page 53) Space Communication Spanish/ Hispanics/ Latino Primary language English, Spanish, or Portuguese (many dialects). Dramatic body language. Some believe direct eye contact can cause illness (“evil eye”). Value physical closeness and touching. European American (White) Primary language is usually English; often speak own national language. Eye contact should be maintained, without staring. Loud voice volume is the norm. Readily shares personal information. Depends on area; tend to avoid physical closeness. Handshake proper. Close personal space. Touch frequently with friends, less so with strangers. Touching another’s hair considered improper. African American (Black) Primary language is usually English. May speak “black English” occasionally depending on the situation. Usually loud voice volume. Nonverbal communication important; direct eye contact may be interpreted as aggression. Space very important; has no boundaries. Touch is not acceptable from strangers. Pointing and direct eye contact may be considered rude. American Indian/ Alaskan Native English, tribal languages. Talking loudly may be considered rude. Use body language. Avoid eye contact. Comfortable with long periods of silence. Information should be given over time, allowing adequate time to process information. Stand very close when talking. Touch only between same gender. Arab American Primary language is Arabic. Most speak some English. May use spirited, loud voice. May be reluctant to disclose personal information. Maintain intense eye contact. TABLE 4.1 HEALTH CARE CONSIDERATIONS FOR SPECIFIC CULTURAL GROUPS IN THE U.S.* Avoid physical closeness and touching. Asian Americans English (may prefer national language and specific to each country); many dialects. Loud talking is considered rude. Silence is acceptable. Avoid eye contact. Avoid use of “no.” Avoid physical closeness and touching. Native Hawaiian/ Pacific Islander English (may prefer national language); many dialects Prefer indirect communication style (feelings such as disappointment or anger may not be appropriate for expression). Do not use first names unless invited. It is appropriate to express ignorance about their culture and show concern for a meaningful interaction. A simple greeting in the native language goes a long way to open the relationship. 4068_Ch04_039-057 15/11/14 12:34 PM Page 48 Future over present. Nuclear family basic, extended family important. Man dominant figure. JudeoChristian religions. Community social organizations important. Many concerned with status. Rely mainly on modern health care system. Value individual responsibility for health. Believe humans can control nature. Have strong belief and value in technology. Most use alternative remedies or OTCs before seeing an HCP. Use prayers and religious symbols for good health. Time Orientation Social Organization Environmental Control/Health Beliefs HCPs Traditional health and illness beliefs. Folk medicine traditions. Health beliefs are strongly affected by religion, believing in God’s will. May have shrines or statues in the home to pray for good health. Theory of hot and cold foods used for health maintenance and treatment of disease. Nuclear family basic, extended family highly valued. Man is decision maker; woman is homemaker. Catholicism. Present. Traditional health and illness beliefs. General distrust of health care professionals, providers, and the health care system. Folk medicine tradition. May believe that serious illness sent from God. Use prayers for prevention and health recovery. Pain is seen as a sign of illness. Many female single-parent families, often matriarchal. Large, extended families important. Strong social and church affiliations. Protestant (often Baptist). Present over future. Traditional health and illness beliefs. Folk medicine traditions. Promote harmony with nature. Inanimate objects ward off evil spirits. Older adults may request samegender directcare provider. Pain is something to be endured. Sick role not usually supported. Extended family basic unit. Very family oriented. Elders honored. Strong community affiliations. Sacred myths and legends. Usually present. Focus on acute care over prevention. Illness may be considered punishment for sins. May pray five times a day for health. Acceptable to purchase organs for transplantation. Sick role supported. Food is eaten with the right hand, which is considered “clean.” May fast while hospitalized. Patriarchal household, with well-defined gender roles. Elders respected and cared for by family. Extended family important; may live in close proximity to each other. May be Christian, Jewish, or Muslim. Present or future. Traditional health and illness beliefs. Traditional medicine traditions. Good health is a gift from ancestors. Imbalances in the yin and yang cause illness. Believe blood is the source of life and is not replenished. Amulets worn to ward off disease. High value on immediate and extended family. Hierarchical family structure. Family honor and loyalty honored. Tradition important. Male has power; woman is obedient. High value placed on children and education. Christianity, Buddhism, Taoism, and Islamic religions. Present. Continued Traditional health and illness beliefs. Some societies have great respect for physicians. Physician visits are infrequent; it may be difficult to gain compliance with follow up care for chronic illness. High emphasis on group and the hierarchy within the group. Rights of the group outweigh rights of the individual. Always demonstrate respect as elders are revered. Elders will defer to their adult children to make healthrelated decisions or judgments. Present. 4068_Ch04_039-057 15/11/14 12:35 PM Page 49 Biological Variations American Indian/ Alaskan Native Traditional healers: shamans, medicine man, diviners, crystal gazers. Nutritional preferences vary greatly depending on location and tribe. Nontraditional diets tend to be high in fat and commonly lack fruits and vegetables. Herbs used to cleanse the body of evil spirits and poison. African American (Black) Sick role not seen as a burden. Folk healers. A respected older adult female community member commonly sought for initial health care. Traditional healers: spiritualists, voodoo priest or priestess, root doctor. Nutritional preferences include fried foods, barbecued foods, greens, legumes. Diet commonly high in fat and sodium. Food selections may vary according to socioeconomic status and rural versus urban residence. Being overweight is seen as positive. Spanish/ Hispanics/ Latino Expressive with pain. Easily enter the sick role. Traditional healers: curandero, espiritista, patera, señora. Nutritional preferences include spicy and fried foods, beans, and rice. Important for food to be served warm. May subscribe to hot and cold theory of illness (e.g., caused when body is exposed to imbalance of hot/cold substances). European American (White) Have controlled expression of pain but need little encouragement to accept pain relief. Sick role not well accepted except with a major illness. Traditional healers: Western-educated HCPs; recent trend to use complementary therapists. Nutritional preferences include meats (especially red) and carbohydrates. Diets tend to be high in fat and sodium. Eating and drinking may be social rituals. Culture stresses thinness as attractive. Nutritional preferences include fresh meats and vegetables; may avoid pork and alcohol (Islam). Less likely than general population to smoke, drink alcohol, or use illicit drugs. High risk for diabetes, hypertension, hypercholesterolemia. Arab American Eating and drinking at the same time is considered unhealthy. Traditional healers: Westerneducated HCPs; may prefer same sex caregivers. Nutritional preferences include raw fish and rice. Foods are balanced between yin and yang. Diet is high in salt. Food is fundamental form of socialization. Susceptibility: lactose intolerance, thalassemia, liver and stomach cancer, hypertension, coccidioidomycosis. Asian Americans Traditional healers: doctors, herbalists, acupuncturists who use such therapies as acupuncture, acumassage, coining, and cupping. TABLE 4.1 HEALTH CARE CONSIDERATIONS FOR SPECIFIC CULTURAL GROUPS IN THE U.S.*—cont’d Nutritional preferences include tubers, fruit, fish and coconut. Susceptibility includes: obesity, type 2 diabetes, hypertension and their resulting cardiovascular and cerebrovascular diseases. Heart valve disorders may be present as rheumatic fever and rheumatic heart Native Hawaiian/ Pacific Islander Older patients from specific Pacific regions my use cultural guides or clan leaders such as a “Kahuna lapa’au” (priest who heals with medicines). A belief illness is due to an imbalance in physical, mental/ emotional, and spiritual. 4068_Ch04_039-057 15/11/14 12:35 PM Page 50 Death and Dying Issues Susceptibility: heart disease, alcoholism, liver disease, diabetes mellitus, tuberculosis, arthritis, glaucoma. Believe body should go into the afterlife whole. Some engage in a cleansing ceremony after touching a dead body. Tribal laws may dictate cremation versus burial. Openly express grief. Food is seen as a symbol of health and wealth. Susceptibility: keloid formation, lactose intolerance, sickle cell anemia, glucose6-phosphate dehydrogenase deficiency, thalassemia, sarcoidosis, hypertension, coccidioidomycosis, esophageal and stomach cancers. Death does not end connection between people; body is kept intact after death; prefer no autopsy. Relatives may communicate with the dead person. Food choices vary by specific country. Being overweight may be considered healthy. Susceptibility: lactose intolerance, diabetes mellitus, parasites, coccidioidomycosis, gout. Burial is the usual practice, rarely cremation; many resist autopsy, the body should be buried whole. May have elaborate ceremonial burial. Women very expressive with grief; men are expected to maintain control. Susceptibility: heart disease, breast cancer, diabetes mellitus, thalassemia, Tay-Sachs disease (Eastern European Jewish). Autopsy and burial or cremation usually connected with religious practices or individual preferences. Have varied expressions of grief. Men are expected to be in more control during grief than women. Believe death is God’s will. At time of death, bed should face the holy city of Mecca (for Muslims). May perform ritual washing of the body after death. Cremation or autopsy not acceptable. May weep with grief, but limited. Autopsy not understood by many. Cremation acceptable, but burial also common. Extended grieving time (7 to 30 days) for the more traditional. Expression of grief is highly varied between men and women and among specific countries. Continued Adapt to change and death is seen as a part of life. There is a belief of a combined body, mind, and spiritual existence. disease continue to remain problems in the Pacific Islands. Alcohol and drug abuse is prevalent. 4068_Ch04_039-057 15/11/14 12:35 PM Page 51 Negotiate acceptable weight. When possible, encourage participation of similar ethnic minorities in planning care and to promote healthy interactions. Ask who makes decisions for the family. Reinforce need to be on time for appointments. Collaborate on decision of what is an acceptable weight. Respect personal space. Encourage health screening and preventive health care strategies. Encourage lowfat, low-cholesterol, high-fiber diet. *Although many other cultural groups are represented in the United States, the most common are presented here. Source: Bernstein, 2008. Nursing Considerations African American (Black) Offer eulogy at burial with religious songs. Usually prefer burial. Express grief openly. Spanish/ Hispanics/ Latino European American (White) Incorporate time for processing information. Use silence therapeutically. Monitor body language. American Indian/ Alaskan Native Respect nutritional requests, and try to obtain specific dietary requests. Attempt to provide same-sex caregiver. Screen for domestic violence. Arab American Monitor for cues of expression and body language. Inquire in a nonjudgmental manner regarding use of traditional medicine. Provide same-sex care provider when possible. Asian Americans TABLE 4.1 HEALTH CARE CONSIDERATIONS FOR SPECIFIC CULTURAL GROUPS IN THE U.S.*—cont’d Treat elders with respect. Rank is very important. Pacific Islanders may not understand the concept of triage as the severity of illness is less important than the rank of the patient. Engage family members and traditional healers in management of chronic illness since this population tends to accept chronic illness even when treatment to manage the illness is available. Native Hawaiian/ Pacific Islander 4068_Ch04_039-057 15/11/14 12:35 PM Page 52 4068_Ch04_039-057 15/11/14 12:35 PM Page 53 Chapter 4 Cultural Influences on Nursing Care 53 Spanish/Hispanic/Latino The term Spanish/Hispanic/Latino is used to describe people whose cultural heritage has a strong Spanish influence. Ho wever, many people in this group prefer to identify themselves as Chicano or with terms that provide a country of origin, such as Mexican, Peruvian, Puerto Rican, and Cuban (Purnell & Paulanka, 2008). The population breakdo wn of Spanish/ Hispanic/Latino populations in the U. S. is Mexican Americans (63%), Puerto Rican (9.2%), Central and South Americans (13.4%), Cuban (3.5%), and other groups, including the Dominican Republic (23.3%; U.S. Census, 2011). Hispanics immigrate from an y number of Central and South American countries, the Caribbean, and other Spanish-speaking countries. Thus, there is much di versity in this population in the United States. Some Spanish/Hispanics/Latinos speak only Spanish, only English, or both Spanish and English, whereas others speak neither Spanish nor English but rather an Indian dialect. The spoken language depends on individual circumstances and the length of time spent in the United States. Spanish is the second most commonly spoken language in the United States. Spanish/Hispanics/Latinos comprise approximately 17% of the U.S. population (U.S. Census Bureau, 2011); they recently became the majority minority population. They live in all 50 states with more than 90% living in and around cities. Four of every five Spanish/Hispanics/Latinos are born and raised in the United States. Man y of these individuals have come from poverty and have few opportunities for advancement. They sacrifice for their basic needs (Figs. 4.5 and 4.6). Most Spanish/Hispanics/Latinos practice adaptations of the Roman Catholic religion. Their close relationship with God makes it acceptable for people to have visions and dreams in which God or the saints speak directly to them. Thus, HCPs must be careful not to attribute these culture-bound visions to FIGURE 4.5 Honduran couples wait to get married until they can afford a celebration—at 100 years young in this case. FIGURE 4.6 Many mission workers have helped with health care needs in Central and South American countries. hallucinations that indicate a need for psychiatric services (see Table 4.1) African American/Black African Americans/blacks are the third lar gest ethnic group in the United States and represent more than 100 racial strains. They make up 13% of the population (U.S. Census Bureau, 2011). Although African Americans/blacks live in all 50 states, more than half live in the South. It is important to understand that not all people with dark skin identify themselves as African American. Many black-skinned people from the Caribbean use terms more specific to their identity, such as Haitian, Jamaican, or West Indian. African Americans/blacks have been called by many names. Their ancient African name is Nehesu or Nubian. During slavery days in America, they were called Negro, a SpanishPortuguese word meaning “black.” After emancipation in 1863, they were called colored, a term adopted by the First Colored Men’s Convention in the United States in 1831. The U.S. Bureau of the Census adopted the word Negro in 1880. During the civil rights movements in the 1960s, the term black was used to signify a philosophy of life instead of color. In the 1970s, these ethnic peoples referred to themselv es as African Americans because they were proud of both their African and American heritages. In 1988, the term African American was widely adopted in the United States by those 4068_Ch04_039-057 15/11/14 12:35 PM Page 54 54 UNIT ONE Understanding Health Care Issues whose ancestry originated from Africa. These terms continue to cause confusion when people try to use the “politically correct” term in this country . Additionally, titles such as the National Black Nurses Association and the National Association for the Advancement of Colored People (NAACP) still exist. African Americans/blacks are underrepresented in colleges and universities, managerial and administrative positions, and the health care professions. They are overrepresented in highrisk, hazardous occupations such as the steel and tire industries, construction industries, and high-pollution factories (see Table 4.1) The 2008 election of Barack Obama, the f irst African American U.S. president, and his reelection in 2012, brought about education initiatives including outreach programs for low-income families and increased a vailability of advance placement classes nationwide. This will likely have an impact on such issues in the future. CRITICAL THINKING Ms. Waters ■ Now that you have learned more about culture, let’ s look at Ms. Waters again. Review Table 4.1 and answer the following questions: 1. What does your interaction with Ms. Waters tell you about her time orientation? 2. What is evident about her social organization? 3. What biological variations may Ms. Wat