CHAPTER 20. Transcultural Nursing
Care of Culturally Diverse Patients
Meg Beturne and Myrna Mamaril
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify key perianesthesia transcultural concepts of cultural competence.
2. Define transcultural nursing.
3. Describe seven major components of a perianesthesia cultural assessment.
4. Discuss the importance of communication as it relates to assessment of culturally diverse patients.
5. Discuss the significance of verbal and nonverbal communication in dealing with culturally diverse patients.
6. Summarize important life events that concern culturally diverse patients in their perianesthesia hospitalizations.
I. DEFINITIONS
A. Culture
1. Integrated system that is shaped by learned values, beliefs, norms, and practices
2. Characteristic of a society
3. Guides individual behavior
a. Thoughts
b. Feelings
c. Actions/patterns of expressions
d. Decision-making that facilitates self-worth and self-esteem
4. Passed down from one generation to the next generation
B. Transcultural nursing
1. Used interchangeably with cross-cultural, intercultural, or multicultural nursing
a. “Trans” means across, “inter” means between, and “multi” means many.
b. Goes across cultural boundaries in search for scientific theory of nursing
2. Integrates the concept of culture into all aspects of nursing
3. A humanistic and scientific area of formal study and practice
a. Focuses on differences and similarities among cultures with respect to:
(1) Human care
(2) Health (or well-being)
(3) Illness
b. Based on individual’s:
(1) Cultural values
(2) Beliefs
(3) Practices
C. Cultural competence
1. Definition
a. Dynamic, continuous process
b. Individual and/or organizational process that continually finds meaningful and useful care delivery strategies based on:
(1) Knowledge of the cultural heritage
(2) Beliefs
(3) Attitudes
(4) Skills
(5) Encounters
(6) Behaviors of those to whom care is rendered
2. Health care professionals need to use knowledge gained from conceptual and theoretical models of culturally appropriate care.
3. Cultural competence assists the nurse to devise meaningful interventions to promote optimal health among individuals regardless of race, ethnicity, gender identity, sexual identity, or cultural heritage.
II. CULTURE
A. Values, norms, beliefs, and practices of a society
B. Develops over time
C. Learned responses, actions, words, and thoughts
D. Passed down through the generations
E. Not genetic in nature
F. Guides behavior
G. Affects health care practices
III. THE TRANSCULTURAL NURSING SOCIETY
A. Founded in 1974: Madeline Leininger, founder
B. Publications on transcultural nursing
C. Annual transcultural nursing conferences
D. Certification available
IV. MAJOR WORLD VIEWS OF HEALTH AND ILLNESS
A. Biomedical (scientific)
1. Life is regulated by biomedical and physical processes.
2. Health is absence of disease.
3. Illness is alteration in structure and function of body.
4. Treatment focuses on physical and chemical interventions.
B. Magicoreligious (supernatural)
1. All that exists is dependent on supernatural forces.
a. Includes good and evil
2. Health means person is blessed or favored by the supernatural.
3. The cause of disease is mystical.
a. Not based on scientific fact
b. Foreign object or spirit enters the body.
c. Sign of punishment or possession by the supernatural
4. Treatment aimed at removing foreign object or spirit
C. Holistic
1. Everything governed by laws of nature
2. Health achieved by adapting to constantly changing environment
3. Illness is imbalance or lack of harmony between forces.
4. Treatment aimed at restoring harmony or balance
V. MAJOR SECTORS OF HEALTH CARE
A. Types
1. Popular
a. Lay; nonprofessional, non–folk healer
(1) Define and treat illness.
b. Determine whether additional care is needed (folk or professional).
c. Activities
(1) Self-care is administered using home remedies.
(2) Consult with family, friends, clergy, neighbors, others who have had same condition.
(3) Remedies include over-the-counter medications.
(4) Care provided by self, family, and/or friends
2. Folk
a. May be consulted when home remedies and self-care methods fail
b. Ethnomedical and traditional
c. Ethnomedical
(1) The study of non-Western, traditional, or folk medicine
(2) Encompasses cultural traditions, beliefs, and practices related to health and illness
(3) Not related to biomedical theory
d. Characteristics
(1) Defines and removes supernatural causes
(2) Works to restore balance
(3) Strives to restore health and prevent illness
e. Activities
(1) Holistic approach
(2) Treatment of illnesses caused by:
(a) Imbalances in individual, physical, social, and metaphysical environments
(b) Supernatural forces
(3) Treatment of:
(a) Culture-specific illnesses
(b) Illnesses not controlled by home remedies or professional medicine
(4) Rituals
(a) Incorporated to prevent illness, misfortune, and to enhance effects of biomedicine
f. Acts as intermediary between popular and professional sectors
g. May be the only sector consulted, depending on cause, signs, and symptoms
h. Care provided by:
(1) Folk healers
(a) Secular
(b) Sacred
(c) Combination of both
3. Professional
a. Types
(1) Biomedicine—United States
(2) Traditional Chinese medicine—China
(3) Ayurvedic medicine—India
b. Goal: to define, treat, and prevent disease and illness
c. May be consulted when home remedies or folk sector treatments are ineffective
d. Initially consulted if acute trauma, surgery, or restoration of body part necessary
B. Characteristics
1. Each explains and treats illness differently.
2. Each defines who should be the health care provider.
3. Each defines how the provider and patient should interact.
4. Sectors are used individually, in combination, or simultaneously.
C. Use of different sectors
1. Folk sector
a. New immigrants and refugees use as primary source.
b. Used by individuals from all socioeconomic groups
c. Use dependent on cause of illness and availability of healers in other sectors
D. Nurse’s role
1. Understand why different sectors are used
a. Enables nurse to better explain goals of nursing intervention and treatments
b. Ensures patient understands advantages and disadvantages and potential incompatibilities of treatments from multiple sectors
VI. TRADITIONAL HEALERS
A. Description
1. Not part of popular or professional health sector
2. Specialize in forms of healing characteristic of ethnomedicine
3. Deal with secular, sacred, or both
4. Combine methods from both sacred and secular
B. Secular
1. Use organic and technical means to treat conditions resulting from natural causes
2. Types of healers
a. Herbalist
b. Bone setters
c. Granny midwives
d. Tooth extractors
e. Injectionists
C. Sacred
1. Use nonorganic methods to treat supernatural and natural causes.
2. Nonorganic
a. Semimystical and religious practices
b. Influence mind and faith of individual
c. Examples
(1) Chants
(2) Prayers
(3) Rituals
(4) Amulets—object worn or cherished to ward off evil or attract good fortune
d. Types of healers
(1) Sorcerers
(2) Shamans
(3) Spiritualists
(4) Voodoo priests, priestesses
(5) Diviners
D. Nurse’s role
1. Determine whether patient receiving treatment from traditional healer.
2. Inform patient if traditional treatments and biomedical treatments are incompatible (Table 20-1).
| Healer | Preparation | Practice | |
|---|---|---|---|
| African American (southern urban) | Family members, especially grandmother | Word of mouthPractical experience | Secular:
Common, everyday self-limiting illness that respond to home remedies
Illness prevention
|
| Wise woman (“old day”) |
Practical experience of caring for and raising own children, grandchildren, and other kin
Develops reputation among family, friends, and neighbors of being knowledgeable about home remedies for common illnesses
|
Secular:
Treatment and prevention of common, everyday illnesses
Advice about child care and child rearing
|
|
| Herbalist | No formal training | Secular:
Diagnose a variety of natural illnesses
Dispense herbs to neutralize or eliminate harmful substances that impair the power of body to heal or protect itself
|
|
| Spiritualist |
No formal training
Power may be present at birth (twins) or given by God later in life
Usually associated with fundamentalist Christian religion (Holy Ghost, Pentecostal)
|
Sacred:
Cure illnesses sent by God as punishment
Cure ailments beyond the power of biomedical practitioners (e.g., arthritis, hypertension, diabetes mellitus)
Power of God is present in the body of the spiritualist and transferred to the ill person through laying on of the hands
Draws on the faith of the individual
Sacred or secular: May combine laying on of the hands with herbal therapy, massage, and life counseling
|
|
| Root doctor (root worker, conjure man or woman, voodoo priest or priestess) |
Apprenticeship
May be born with magical powers
|
Sacred or secular:
Serves as intermediary between supernatural and natural worlds
Enact or remove spells
Counteract or protect against witchcraft or sorcery
Combine magical powers with use of herbs
Read omens and signs and prescribe therapy or preventive measures
Counseling and magical powers with use of herbs
|
|
| African Caribbean (Haitian) | Family members, primarily female |
Word of mouth generation to generation
Practical experience
|
Secular:
Prevention and treatment of common, everyday illnesses
|
| Doctor feuilles, bocars, dokte feuilles (leaf doctors, herbalists) |
Apprenticeship training
Hands-on experience
Learn “formulas” for healing
|
Secular:
Treats patients with herbs, roots, medical plants, and rituals
Bone setting, burn treatments, and massage
|
|
| Droquistes | Apprenticeship | Secular:
Make and sell potions to prevent or treat illnesses of natural causation
|
|
|
Houngan (voodoo priest)
Mambo (voodoo priestess)
|
Apprenticeship training in rituals
Knowledge of prayers and herbal remedies from elders
Long training in and study of mythology of spirits
|
Sacred or secular:
Treatment of illnesses due to supernatural causation (angry voodoo spirits; dead ancestors; or magic, witchcraft, or sorcery)
Treatment of illnesses that are long lasting or fail to respond to biomedicine
|
|
| Sages-femme, fam saj, matrone (lay midwife, wise woman) | Apprenticeship | Secular:
Performs deliveries, prepartum and postpartum care, treats other “female” conditions related to reproduction
Uses herbs, massage, rituals, baths, and diet
|
|
| Piqurestes (injections) | Training in missions and other medical facilities | Secular:
Give injections, change dressings
|
|
| Hispanic (Puerto Rican) | Family member, especially oldest female |
Word of mouth
Practical experience
|
Secular:
Common, everyday illnesses that respond to home remedies
|
| Curandero or curandera | Apprenticeship Gift from God | Sacred or secular:
Knowledge of herbs, diet, massage, and ritual
Commune with supernatural
Conduct religious curing ceremonies
|
|
| Partera (lay midwife) | Apprenticeship training from older female relatives | Secular:
Prepartum and postnatal care, herbal remedies, massage, treatment of natural illness affecting women
|
|
| Yerbero (herbalist) | No formal training | Secular:
Preventive and curative care
Treats both ethnomedical and biomedical illnesses
|
|
| Santiguadore (sabador) | Apprenticeship | Secular:
Massage and manipulation of body for illness affecting the musculoskeletal and gastrointestinal systems
Treats both ethnomedical and biomedical illnesses
|
|
| Spiritualist (espiritualista, brujera, santero) |
May be born with gift to fortell future
Perfect skills through apprenticeship
|
Sacred:
Prevention and diagnosis of witchcraft, or sorcery; uses amulets, prayers, and other artifacts
Some limited curative functions
|
|
| Moslem (Iranian) | Family members, especially older women | Knowledge handed down generation to generation | Secular:
Self-care measures such as bed rest, diet, herbs, home remedies, and childbirth assistance
|
| Dais (traditional midwife) |
Apprenticeship
Older women who have raised their own families
|
Secular:
Prepartum and postpartum care
Childbirth
Newborn care
Herbal therapies
Massage
|
|
| Mullah (religious healer) | Religious training | Sacred:
Prevention of illness via preparation of tawiz (amulet with verses from the Koran)
Treat illness due to evil spirits
Treat emotional problems, nervousness, excessive anxiety, and mental illness
|
|
| Injectionists | Self-taught | Secular:
Administer medications prescribed by physicians
Purchase and prescribe injectable medications on their own
|
|
| Hakimji (traditional healer) | Apprenticeship | Sacred or secular:
Combine procedures and medicines from Urani and Greco-Arabic medical traditions
|
|
| Bonesetters | Apprenticeships | Secular:
Sets broken bones
Treats sprains, strains, dislocations, and generalized body pains
|
|
| Native American (Navajo Indian) | Family members | Knowledge handed down from generation to generation | Secular:
Common, everyday illnesses of natural origin
Prevention of illnesses
Herbal remedies
|
| Medicine man |
Born with power to heal
Acquire power to heal via vision or quest
Apprenticeship with medicine man once power to heal is known
|
Sacred or secular:
Diagnosis and treatment of supernatural or natural illness (meditation, trance state, divination, or star gazing)
Use combination of herbs and curing ceremonies
|
|
| Diagnostician | As per medicine man | Sacred:
Diagnose underlying cause of illness via divination
|
|
| Herbalists |
Knowledge passed down generation to generation
Apprenticeship
|
Secular:
Diagnose and treat common illnesses of natural causation
|
3. Consult with traditional healer, if necessary, to ensure all have understanding of same goal: assisting the patient to recovery.
4. Modify plan of care if no compromise is reached.
VII. PREOPERATIVE INTERVIEW AND NURSING ASSESSMENT (see Chapter 15)
A. Develop culture sensitivity.
1. Clarify own culture and value systems.
a. Reflect on actions, thoughts, communications, and beliefs of own culture.
2. Examine personal negative opinions of different cultures.
3. Increase awareness of other cultures through churches and schools.
B. Do not project own views on patients through verbal and nonverbal communication cues (Box 20-1).
1. Verbal communication
a. Voice quality
b. Intonation
c. Rhythm
d. Speed
e. Pronunciation used
2. Nonverbal communications
a. Facial expressions
b. Gestures
c. Posture
BOX 20-1
VERBAL AND NONVERBAL COMMUNICATION
Language or Verbal Communication
▪ Vocabulary
▪ Grammatical structure
▪ Voice qualities
▪ Intonation
▪ Rhythm
▪ Speed
▪ Pronunciation
▪ Silence
Nonverbal Communication
▪ Touch
▪ Facial expression
▪ Eye movement
▪ Body posture
Communications That Combine Verbal and Nonverbal Elements
▪ Warmth
▪ Humor
From Giger JN, Davidhizar RE: Transcultural nursing: Assessment and intervention, ed 4, St Louis, 2004, Mosby.
C. Observe client’s family and support system.
D. Respect the patient.
1. All cultures are unique.
2. All individuals are unique.
E. Tips for effective communication
1. Introduce yourself.
a. Exhibit confidence; avoid arrogance.
b. Shake hands if appropriate.
c. Explain reason for your presence.
d. Explain upcoming sequence of events (admission assessment, preoperative holding, intraoperative, postoperative).
2. Avoid assuming where the patient comes from; the patient will tell you if he or she wants you to know.
3. Show respect, especially to males.
a. Males are often the decision-makers.
b. If patient is child or woman, male may be the one making decisions regarding care and follow-up.
4. In some cultures, it is customary for children to go everywhere with parents.
a. Poorer families may not have childcare options available to them.
b. Include children in perioperative experience.
5. Understand traditional health-related practices.
a. Do not show disapproval of them.
b. If practice is potentially harmful, inform patient.
6. Be cognizant of folk illnesses and remedies for the cultural population in your service area.
7. When possible, involve leaders of local groups.
a. Leader may have understanding of problem.
b. May be able to assist in offering acceptable interventions
c. Ensure confidentiality is maintained.
8. Accept diversity as an asset, not a liability.
a. Listening and verbal interactions need to be made with an appreciation of cultural differences (Box 20-2).
BOX 20-2
GUIDELINES FOR CULTURALLY SENSITIVE INTERACTIONS
Nonverbal Strategies
▪ Invite family members to choose where they would like to sit or stand, allowing them to select a comfortable distance.
▪ Observe interactions with others to determine which body gestures (e.g., shaking hands) are acceptable and appropriate. Ask when in doubt.
▪ Avoid appearing rushed.
▪ Be an active listener.
▪ Observe for cues regarding appropriate eye contact.
▪ Learn appropriate use of pauses or interruptions for different cultures.
▪ Ask for clarification if nonverbal meaning is unclear.
Verbal Strategies
▪ Learn proper terms of address.
▪ Use a positive tone of voice to convey interest.
▪ Speak slowly and carefully, not loudly, when families have poor language comprehension.
▪ Encourage questions.
▪ Learn basic words and sentences of family’s language, if possible.
▪ Avoid professional terms.
▪ When asking questions, tell families why the questions are being asked, the way in which the information they provide will be used, and how it might benefit their child.
▪ Repeat important information more than once.
▪ Always give the reason or purpose for a treatment or prescription.
▪ Use information written in family’s language.
▪ Offer the services of an interpreter when necessary.
▪ Learn from families and representatives of their culture methods of communicating information without creating discomfort.
▪ Address intergenerational needs (e.g., family’s need to consult with others).
▪ Be sincere, open, and honest and, when appropriate, share personal experiences, beliefs, and practices to establish rapport and trust.
From Wong DL: Wong’s essentials of pediatric nursing, ed 8, St Louis, 2009, Mosby.
9. Culturally sensitive interactions
VIII. HEALTH HABITS
A. Western
1. Care providers
a. Physician is most common care provider.
b. Physician assistants
c. Nurse practitioners
d. Chiropractors
e. Doctors of osteopathy
f. Doctors of podiatry
2. Causes for illness
a. Genetic
3. Toxins
a. Cigarettes
b. Asbestos
c. Environmental
4. Dietary
a. Inappropriate diet
b. Excessive fat intake
c. Excessive alcohol intake
5. Illness is treatable or curable.
6. Focus on prevention of illness
B. Non-Western (folk medicine)
1. Care providers
a. Indigenous healers
(1) Surgeons
(2) Spiritualists
(3) Herbalists
2. Causes for illness
a. Evil spirits
b. Witches
c. Dysfunction within the harmony of the body
IX. CULTURAL BELIEFS OF ASIANS (CHINESE AMERICANS)
A. Basis for health culture beliefs and practices is holistic.
1. Oneness of all things with nature, the universe, and the divine
B. Health
1. Results when body works in rhythmic and finely balanced manner
2. Body adjusts to external environment.
3. Functions and emotions are in harmony.
C. Traditional Chinese medicine (TCM)
1. System of preventive medicine
2. Components
a. Tao
(1) Way of life, virtue, heaven, and death
(2) Individuals should:
(a) Flow with nature.
(b) Avoid excesses and extremes.
(c) Maintain a middle position.
(d) Practice moderation.
b. Ch’i (vitality)
(1) “Universal energy”
(2) Fundamental concept of entire system of TCM
(3) Origin of all disease
(4) Health is balance of harmony in the flow of ch’i; illness results from imbalance.
c. Yin and yang
(1) Represents duality and unity of universe and Tao
(2) Balance of yin and yang
(a) The negative and positive energy forces
(b) Gift from prior generations
(c) Harmony and balance of physical and spiritual with nature
d. Law of five elements
(1) Association between external physical worlds and internal milieu of body
(2) Includes fire, earth, metal, water, and wood
e. Meridians and pulses
(1) Invisible systems or pathways that carry ch’i through the body
(2) Regulate organs, blood flow, and connect internal and external organs
(3) Pulses
(a) Present in each organ
(b) Pulse indicates status of organ.
(i) Balance
(ii) Imbalance
(c) No difference among pulses indicates perfect balance.
f. Causative factors of disease
(1) Internal
(a) Excess or lack of emotion
(b) Constitution
(c) Anxiety
(d) Irregularity of food and drink
(2) External
(a) Cold, heat, humidity, fire, dryness, dampness, and wind
(3) Illness results from:
(a) Excess or deficiency of internal or external causative factors
(b) Interruption in flow of ch’i
(c) Loss of ch’i
(d) Imbalance of yin and yang
D. Illness
1. Prevented by:
a. Conforming with nature
b. Wearing of jade charms to prevent harm
2. Disruption of yin and yang energy forces caused by:
a. Overexertion
b. Lying or sitting for prolonged periods
3. Treatment
a. Herbs such as ginseng
b. Acupuncture
c. Curing methods
(1) Cold treatments
(2) Hot treatments (moxibustion—application of heat to skin)
E. Grief handled stoically and internalized
F. Family
1. Is valued
2. Act as caregivers
3. Respect and value elders
G. Language and communication
1. Official language: Mandarin
2. Many dialects; not all are understood by other groups
3. Silence is valued.
4. Do not verbalize disagreements.
5. Unacceptable to display affection to opposite sex in public
6. Excessive eye contact may be interpreted as rude.
H. Death: viewed as religious experience
I. Medical conditions linked to Asians
1. Thalassemia
2. Lactose intolerance
J. Medical care provided by healers
K. Nursing implications
1. Expect use of multiple sectors; attempt to accommodate alternative therapies.
2. Patient will use self-care measures; support and encourage patient.
3. Incorporate family in planning care.
4. Patient tends to be submissive, quiet, and agreeable.
a. Ability to maintain harmonious relationship supersedes disagreement.
b. Impolite to disagree with authority figures
c. Will say “yes” even when patient does not fully understand to prevent disruption in harmony
d. Will not openly express pain
e. Will not ask for assistance
5. Do not draw large amounts of blood from patient.
a. Blood contains ch’i.
b. Vital energy for TCM
6. Avoid lengthy conversations and questioning of patient.
a. May confuse patient or convey incompetence
b. Combine health teaching with interactive techniques and demonstration.
X. CULTURAL BELIEFS OF HISPANICS (PUERTO RICAN AMERICANS)
A. Basis for health culture beliefs and practices is holistic.
B. Health
1. Luck or gift from God
2. Balance and harmony among mind, body, spirit, and nature
a. Forces of “hot” and “cold,” “wet” and “dry”
3. Maintain equilibrium through:
a. Proper balanced diet
b. Avoiding conflict
c. Moderate lifestyle
d. Sharing resources with others
e. Honoring God
4. Maintain health by:
a. Praying to God
b. Consumption of herbs and spices
c. Wearing amulets
d. Keeping religious materials in home
e. Proper conduct
f. Proper nutrition
C. Illness
1. Caused by God as punishment for misconduct
2. Cause may be natural or supernatural
3. Cause determined by:
a. Previous social behavior
b. Religious behavior
4. Spiritism
a. Supernatural illness
b. Cause is external force.
c. Individual is “passive” instrument in treatment.
d. Failure of patient to respond to biomedical treatment may confirm presence of supernatural cause.
D. Family
1. Respect for one another is important.
2. Plays key role in health care
3. Strong sense of family, both nuclear and extended
a. Needs of family supersede needs of individual.
b. Men are dominant providers; women are homemakers.
c. Female health consultant is oldest female in family.
E. Treatment
1. Medical care provided by healers
2. Healer (curandero)
a. Cures hot illness with cold medicine and vice versa
b. Uses massage and cleanings
c. May use herbs and spices for prevention and healing
3. Brujo: uses witchcraft for healing illnesses related to jealousy and envy
F. Medical conditions linked to Hispanics
1. Diabetes mellitus
2. Tuberculosis
G. Language and communication
1. Primary language: Spanish
2. Direct confrontation considered rude and disrespectful
H. Death
1. Predominantly Catholic
2. Believe in heaven and hell
3. Administration of sacraments of the sick is important.
I. Nursing implications
1. Key cultural concepts
a. Respect
(1) Treat others and expect to be treated with dignity and respect.
(a) Professional attire
(b) Correct tone of voice
(c) Professional image
(d) Providing proper explanations for treatments
(e) Answering all questions completely
(f) Allowing patient opportunity to express his or her feelings
(2) Personalismo: treating each patient as an individual
(a) Establish rapport with patient initially.
(b) Touch arm, shoulder, or back during interactions.
(c) Allow patient opportunity to express concerns.
(d) Take initiative to learn a few words in Spanish.
2. Expect full physical for any complaint or problem.
3. Very expressive, dramatic
a. Cultural norm
4. Difficult to express degree or location of pain
5. Prefer Hispanic health care professional
a. Understand and respect traditional health care beliefs.
XI. CULTURAL BELIEFS OF NATIVE AMERICANS (NAVAJO INDIANS)
A. Basis of traditional Navajo health culture beliefs and practices is holistic.
1. Health achieved by living in harmony with universe
2. Individuals have spiritual and physical dimensions.
3. Physical dimension
a. Individuals treat bodies and nature with respect.
4. Spiritual dimension
a. Individuals participate in development of own potential through will or volition.
5. World governed by supernatural powers and holy people
a. Failure to honor supernatural results in lack of harmony.
b. Harmony essential for good health
B. Cultural traditions
1. Emphasize cooperation rather than competitiveness.
2. Share and give to others.
3. Continue to develop self throughout lifetime.
4. Believe nature is more powerful than humans.
5. Respect elders.
6. Welfare and security of family more important than individual success
7. Strive to live in balance with nature.
C. Health
1. Harmony within self and environment
2. Ability to survive under difficult circumstances
D. Illness
1. Caused by disharmony within self and environment
a. Action of witches
b. Disturbing physical world
c. Angering the spirit world
d. Failure to follow established rituals
e. Not taking care of self
f. Failure to observe moderation and balance in all things
g. Being disrespectful
2. Do not believe in infection, communicable agents, or physiological processes.
3. Do not believe in germ theory.
4. Prevention by rituals
E. Healing
1. Occurs when ill person becomes one with holy people
2. Establishes harmony with universe
F. Treatment
1. Biomedical and ethnomedical systems sought for treatment
2. Medical care provided by Medicine Man
a. Healing achieved only through ethnomedicine
b. Healing cannot be separated from religion and individual spirituality.
c. Chanting used at traditional healing ceremonies
(1) Used to diagnose and restore balance
3. Nature is powerful force.
4. Medicine, rest, diet, isolation, and sweat baths
5. Medications made of herbs and plants
6. For medication to be effective, it must be administered according to proper ceremony.
G. Family
1. Should be included for nursing care
2. Strong sense of community and extended family
H. Prevention of illness
1. Wearing of amulets to ward off illness or witchcraft
2. Amulets can be bags of herbs, fetishes, or other symbolic objects that are believed to have curative or protective powers.
3. Blessing occurs at important events.
a. Enhance good fortune, happiness, and health
I. Medical conditions associated with Native Americans
1. Lactose intolerance
2. Tuberculosis
J. Language and communication
1. Navajo or English
2. Silence shows respect.
3. Eye contact avoided
XII. CULTURAL BELIEFS OF AFRICAN AMERICANS
A. Basis of health culture beliefs and practices is magicoreligious and holistic.
1. Perceptions about health and illness come from popular, ethnomedical, and biomedical health culture.
2. Little distinction between science and religion, or body and mind
3. Good health equates to good fortune.
4. Illness viewed as misfortune
B. Health is:
1. Synonymous with good luck
2. Harmony with nature
C. Illness
1. Causes
a. Disharmony with nature
b. Demons
c. Personal tragedy
2. Classified as natural and unnatural
3. Natural illness caused by failure to follow three laws of nature (God’s law)
a. Humans are bound by same laws of nature.
b. Humans are to know, love, and serve God.
c. Humans are to love each other.
4. Unnatural illness caused by God withdrawing divine protection
a. Makes person vulnerable to evil influences
b. Devil is in control.
c. Evil influences not responsive to treatment
5. Individuals vulnerable to illness
a. Elderly
b. Young
c. Women
d. Unborn fetus
D. Treatment
1. Medical care by healers
2. Cannot be separated from religious beliefs and practices
3. Occurs around practice of religious ceremonies
4. Prevention by:
a. Proper nutrition
b. Adequate rest
c. Taking care of relationship with God, nature, and others
E. Family
1. Strong family ties
2. Extended family assists with health care
F. Medical conditions linked to African Americans
1. Sickle cell anemia
2. Hypertension
XIII. CULTURAL BELIEFS OF HAITIAN AMERICANS (CARIBBEAN)
A. Basis of health culture beliefs is magicoreligious and holistic.
1. Believe in healing power of Christian God
2. Believe in traditional folk religion such as voodoo
a. Maintaining health and recovery from illness depends on faith.
b. Power of supernatural works in conjunction with traditional healers and biomedical health care providers.
c. Usually seek biomedical care after appropriate rituals performed
B. Health
1. Ability to carry out activities of daily living
a. Looks well
b. Good appetite
c. Shiny skin
d. Bright eyes
e. Good color
f. Able to move about without pain
C. Illness
1. Natural
a. Dominant illnesses
2. Supernatural
a. Rare
b. Suspected when:
(1) Child becomes ill or dies.
(2) Home remedies, biomedicine, or treatments from secular healers do not work.
(3) Social conflict occurs before symptoms.
(4) Sudden onset
(5) Illness becomes life-threatening.
(6) Other misfortunes occur at same time.
(7) Occurs after one has good fortune; caused by envy and anger of others
D. Family
1. Rely on family, kin, and friends.
2. Usually use extended family
3. Health care is home managed by grandmother, mother, or maternal aunt.
4. Older siblings care for younger siblings.
E. Nursing implications
1. Patient may regard questions with suspicion.
a. Keep questions to a minimum.
b. Explain reason for questions.
c. If health care practitioner asks too many questions, may be viewed as lacking competence
2. Oral medications not so effective as parenteral
3. View vitamin injections as important for maintaining blood.
4. Explain reason for all blood tests; very concerned about status of their blood.
5. Commonly use purgatives with castor oil.
a. Assess for signs and symptoms of dehydration, especially in children.
6. Have difficulty expressing location of pain.
a. Have patient point to area.
b. Give opportunity for patient to describe pain.
c. Not accustomed to using pain rating scales to describe intensity.
XIV. CULTURAL BELIEFS OF WHITE AMERICANS OR ANGLO-AMERICANS
A. Basis of health culture beliefs and practices is scientific.
1. Incorporate variety of self-care measures and home remedies.
2. Number of illness episodes brought to health care practitioner is limited.
3. Faith in God
a. Assists in protecting from illness
b. Aids in recovery
c. Assists in coping with illness
d. May consider illness as punishment from God
4. Supernatural causes
a. Evil eye and curses
B. Health
1. Absence of illness
2. Ability to function in acceptable manner
C. Illness
1. Interferes with ability to function in acceptable manner
2. Experienced when:
a. Pain occurs.
b. Changes in bodily feelings or functions occur.
3. Most illnesses result from natural causes.
4. Dominant theory is germ theory.
D. Prevention
1. Diet and nutrition
2. Taking vitamins, minerals, and tonics
3. Exercising
4. Maintaining normal bowel function
5. Moderate lifestyle
6. Adequate sleep and rest
E. Family
1. Structure usually nuclear family only
2. Spouse generally main health consultant
3. Mother or wife as primary caregiver
a. Diagnoses of illness when it occurs
F. Nursing implications
1. Wide variation among groups
2. Some groups have difficulty expressing signs and symptoms.
3. May not openly express pain
XV. ASPECTS OF COMMUNICATION
A. Factors that can have an effect on communication (Box 20-3)
1. Although communication is universal, styles and types of feedback may be unique to certain cultural groups.
BOX 20-3
FACTORS INFLUENCING COMMUNICATION
▪ Physical health and emotional well-being
▪ The situation being discussed and its meaning
▪ Distractions to the communication process
▪ Knowledge of the matter being discussed
▪ Skill at communicating
▪ Attitudes toward the other person and toward the subject being discussed
▪ Personal needs and interests
▪ Background, including cultural, social, and philosophical values
▪ The senses involved and their functional ability
▪ Personal tendency to make judgments and be judgmental of others
▪ The environment in which the communication occurs
▪ Past experiences that relate to the current situation
From Giger JN, Davidhizar RE: Transcultural nursing: Assessment and intervention, ed 5, St Louis, 2008, Mosby.
B. Communication techniques
1. Use open-ended questions.
2. Approach in nonthreatening manner.
3. Allow time for patient’s responses.
4. Do not hurry through interview.
5. Use professional interpreters whenever possible; patient may be more willing to give important health history information through stranger than family member (especially information regarding sexual matters).
6. Avoid use of medical terms.
7. Use language appropriate to patient’s level of understanding.
8. Use language dictionary appropriate to culture.
9. Use pictures and gestures.
10. Speak slowly.
C. Culture specific—verbal
1. Chinese Americans
a. Soft tone
b. Slow speech with silence at times
c. Silence valued
2. Hispanics
a. Loud tone
b. Rapid speech
3. Native Americans
a. Soft tone
b. Slow speech with silence at times
4. African Americans
a. Loud tone
b. Rapid speech
D. Culture specific—nonverbal
1. Chinese Americans
a. Avoid eye contact.
b. Discomfort expressed privately
c. Avoid excessive touch.
2. Hispanics
a. Maintain eye contact.
b. Discomfort expressed openly
c. Tactile culture
3. Native Americans
a. Respect indicated by avoiding eye contact
b. Respect indicated by periods of silence
c. Discomfort expressed privately
d. Light touch or hand passing
4. Orthodox Jews
a. Eye contact may have sexual connotation.
b. Older male to female other than wife
c. Tactile culture
5. African Americans
a. Maintain eye contact (avoid prolonged eye contact).
b. Open display of discomfort
XVI. NUTRITIONAL CONCERNS
A. Ethnic and religious food preferences
1. Chinese Americans
a. Prefer rice with all meals
2. Native Americans
a. Usually consists of corn, beans, and squash
3. African Americans
a. Prefer salted and spiced foods
b. High intake of yellow and dark green leafy vegetables
4. Hispanics
a. Foods and illness have varying degrees of “hot” and “cold” (not related to temperature of food).
b. Easier to digest hot foods—chili peppers, onions, garlic
c. Cold foods include fresh vegetables, corn, beans, squash, tropical fruits.
5. Jehovah’s Witnesses
a. No food that contains blood as an additive, such as lunch meats
6. Seventh-Day Adventists
a. Avoid meat or foods with shells.
b. Avoid caffeine.
c. Vegetarian diet encouraged
d. Protein deficiency may need to be considered.
7. Jews
a. Consider pigs unholy or unclean
b. Pork products not allowed
c. Cannot mix meat with milk
d. Kosher products
8. Muslim
a. No pork or food products made with pork
b. No animal fat shortening
B. Manner of preparation
1. Identify any cultural preconditions.
C. Frequency
1. Identify any cultural requisites.
D. Nursing implications
1. Incorporate normal diet into postoperative plan of care.
2. Consult with nutritionist if areas of concern are identified.
XVII. SPIRITUAL AND RELIGIOUS NEEDS
A. Practices pertaining to health care
1. Availability of spiritual resources
2. Pray before meals
3. Religious articles made available
B. Chinese
1. Taoism
2. Buddhism
3. Islam
4. Christianity
C. Hispanics
1. Catholicism
D. Christian Science
1. Prayer heals the body.
2. Children treated by Christian Science practitioners only
E. Jehovah’s Witnesses
1. Opposed to homologous blood transfusions
2. May submit to autologous blood transfusions
3. May refuse surgery if blood transfusion is required
4. Do not partake in national holidays including Christmas
F. Seventh-Day Adventists
1. Belief that their bodies are temples of God
2. Avoidance of meat, caffeine, drugs, tobacco, and alcohol
3. May refuse foods with shells (lobster, crab)
G. Nursing implications
1. Be cognizant of patient’s religious needs.
2. Patient may request private time before procedure (preoperative holding).
XVIII. PERIOPERATIVE NURSING CONSIDERATIONS
A. Preoperative teaching
1. Be alert and sensitive to cultural differences (Box 20-4).
BOX 20-4
GUIDELINES FOR RELATING TO PATIENTS FROM DIFFERENT CULTURES
1. Assess your personal beliefs surrounding persons from different culture.
a. Review your personal beliefs and past experiences.
b. Set aside any values, biases, ideas, and attitudes that are judgmental and may negatively affect care.
2. Assess communication variables from a cultural perspective.
a. Determine the ethnic identity of the patient, including generation in America.
b. Use the patient as a source of information when possible.
c. Assess cultural factors that may affect your relationship with the patient and respond appropriately.
3. Plan care based on the communicated needs and cultural background.
a. Learn as much as possible about the patient’s cultural customs and beliefs.
b. Encourage the patient to reveal cultural interpretation of health, illness, and health care.
c. Be sensitive to the uniqueness of the patient.
d. Identify sources of discrepancy between the patient’s and your own concepts of health and illness.
e. Communicate at the patient’s personal level of functioning.
f. Evaluate effectiveness of nursing actions and modify nursing care plan when necessary.
4. Modify communication approaches to meet cultural needs.
a. Be attentive to signs of fear, anxiety, and confusion in patients.
b. Respond in a reassuring manner in keeping with the patient’s cultural orientation.
c. Be aware that, in some cultural groups, discussion concerning the patient with others may be offensive and may impede the nursing process.
5. Understand that respect for the patient and communicated needs is central to the therapeutic relationship.
a. Communicate respect by using a kind and attentive approach.
b. Learn how listening is communicated in the patient’s culture.
c. Use appropriate active listening techniques.
d. Adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by culture.
6. Communicate in a nonthreatening manner.
a. Conduct the interview in an unhurried manner.
b. Follow acceptable social and cultural amenities.
c. Ask general questions during the information-gathering stage.
d. Be patient with a respondent who gives information that may seem unrelated to the patient’s health problem.
e. Develop a trusting relationship by listening carefully, allowing time, and giving the patient your full attention.
7. Use validating techniques in communication.
a. Be alert for feedback that the patient is not understanding.
b. Do not assume meaning is interpreted without distortion.
8. Be considerate of reluctance to talk when the subject involves sexual matters.
a. Be aware that in some cultures, sexual matters are not discussed freely with members of the opposite sex.
9. Adopt special approaches when the patient speaks a different language.
a. Use a caring tone of voice and facial expression to help alleviate the patient’s fears.
b. Speak slowly and distinctly, but not loudly.
c. Use gestures, pictures, and play-acting to help the patient understand.
d. Repeat the message in different ways if necessary.
e. Be alert to words the patient seems to understand and use them frequently.
f. Keep messages simple and repeat them frequently.
g. Avoid using medical terms and abbreviations that the patient may not understand.
10. Use interpreters to improve communication.
a. Ask the interpreter to translate the message, not just the individual words.
b. Obtain feedback to confirm understanding.
c. Use an interpreter who is culturally sensitive.
From Giger JN, Davidhizar RE: Transcultural nursing: Assessment and intervention, ed 4, St Louis, 2004, Mosby.
2. Differences may:
a. Dictate type of teaching method based on patient’s learning style
b. Show variation in patient’s educational needs
c. Cause variation in patient’s response to teaching
d. Cause variations in patient’s discharge plan
B. Consent
1. Decision for surgery may be made by head of family or group of elders in a religious community.
2. Decision-maker and patient must understand importance of surgery.
3. Ensure consent forms signed appropriately, according to facility policy.
C. Body hair
1. Shaving may violate some cultural beliefs and practices.
a. Sikh religion (East India): forbids shaving of hair
b. Greece: manhood is linked to body hair.
c. Native Americans: body hair sign of health and strength
D. Removal of jewelry
1. Some cultures view as religious articles.
2. Not permitted to be removed from body
a. If site interferes with surgery, may consent to placement of article on another part of body
b. May need to be secured (taped) on person before procedure
c. Document presence of article in nursing record.
E. Pain
1. Emphasize that it is acceptable to express pain.
a. Patient may not verbalize or may continue to deny pain.
b. Incorporate nonverbal patient reactions into nursing assessment of pain.
c. Medicate as necessary.
2. Cultural belief to express stoic attitude toward pain
a. Patient may refuse pain medication.
3. Meditation
a. Used by Eastern religions
b. Relaxation techniques may be helpful in minimizing postoperative pain.
F. Postoperative dietary needs
1. Incorporate cultural food practices into dietary teaching for the postoperative patient.
G. Geriatric considerations
1. Nursing approach
a. Elderly person is unique individual.
b. Avoid imposing own attitude and belief toward aging on the patient.
XIX. LOSS OF PRIVACY THROUGHOUT PERIOPERATIVE EXPERIENCE
A. History and physical (Table 20-2)
1. Use of touch during assessment: respect individual’s cultural practice.
2. Need to remove clothing: respect individual’s cultural practice; accommodate patient’s requests.
3. Communication with physician regarding “taboo” topics
a. Incorporate cultural practices into plan of care if appropriate.
| ADLs, Activities of daily living. | ||
| Traditional Western Health Care History Model | Interview Example: Blending Explanatory Model and Traditional Model | Culture-Sensitive Listening: Listening for Illness (Cultural Perception) and Disease (Biomedical Perception) |
|---|---|---|
| Introduction | Mr. Smith? Hi, I’m J. P., a primary care clinician. I will be working with you today. How would you like to be addressed? or What name would you like me to use? | In every culture, your name has special significance, and the way you are addressed may have great meaning. Never assume that it is acceptable to use the person’s first name, or for them to use yours. Age, gender, and cultural norms all play a role in how individuals wish to be addressed. |
| Chief complaint | What brought you in today? (Ascertain what symptom is of concern.) What is the name of your problem? | Asking a patient to name the problem will give you clues to the patient’s beliefs about the origin of the illness. |
| SYMPTOM ANALYSIS | ||
| Onset/duration |
When did it start? Can you think of anything that brought this on? What do you think caused your problem?
Why do you think it started then?
How long do you think it will last?
|
This will provide information about the patient’s insight into the problem and may reveal underlying beliefs. |
| Location |
What parts of your body are affected?
How does it work in your body?
|
Actively listen to understand the patient’s perception of the condition. |
| Frequency/chronology |
How often do you notice it in your body? Have you noticed it before?
Are you generally getting better?
Worse? About the same? What is it like?
|
This may add information regarding previous episodes and treatment modalities as well as patient expectations for treatment. |
| Quality | Is it dangerous? | Show empathy, interest, and respect for the patient’s concerns. |
| Quantity | Will this last a long time? How much of a problem is it? | Encourage the patient to explain. |
| Aggravating or alleviating factors |
Is there anything that makes it better?
Makes it worse? (Ask about various common cultural practices.)
|
This shows interest and gives the patient permission to talk about the illness and his or her conceptualization of the condition. |
| Associated symptoms | Do you have any other symptoms with this? Is this causing any other problems in your body? | Again, this gives insight into the patient’s perceptions. |
| Treatments tried | Have you talked with anyone else about this? Did they make any suggestions? Have you tried any other medicines or home remedies? Did these help? Are there any special remedies that you have been advised to try or that are recommended by your healers? Who recommended the remedies you have tried? | Knowing, understanding, and accepting culturally determined treatments and respecting those who utilize them often enables you to develop treatment plans that blend traditional healing measures with allopathic health care practices. |
| Effects on ADLs | What bothers you most about this illness? How has it affected your daily life? | Provides insight into the patient’s illness and allows interpretation of the disease effects. |
| Patient perceptions | What do you think is going on? Is there anything you fear about your illness? What would you like me to do today? | Positions the clinician to better provide a culturally appropriate plan of care. |
| Conclusion |
Is there anything else I should know or that you would like to tell me?
What would you like me to do today?
|
Patients may or may not be able to tell you what they would like you to do. In some cultures, it may be presumptuous to tell a provider what to do or to express an opinion. |
B. Exposure during perioperative experience
1. Reinforce confidentiality; respect cultural practices; accommodate patient requests.
2. Keep personnel to a safe minimum.
3. Avoid overexposure.
XX. PERSONAL SPACE
A. Determined by individual cultures
1. Close personal space
a. Chinese Americans
b. Hispanics
c. Native Americans
d. African Americans
2. Distant personal space
a. Whites
BIBLIOGRAPHY
1. Andrews, M.M.; Boyle, J.S., Transcultural concepts in nursing. ed 5 ( 2008)Kluwer Lippincott Williams & Wilkins, Baltimore, MD.
2. Campesino, M., Commentary: Problematic issues in cultural comparisons, J Prof Nurs 18 (6) ( 2002) 343–345.
3. Campinha-Bacote, J., The process of cultural competence in the delivery of healthcare services: A model of care, J Transcult Nurs 13 (3) ( 2002) 181–184; discussion 200-201.
4. Chang, M.K.; Harden, J.T., Meeting the challenge of the new millennium: Caring for culturally diverse patients, Urol Nurs 22 (6) ( 2002) 372–376; 390; quiz 377.
5. Cioffi, R.N., Communicating with culturally and linguistically diverse patients in an acute care setting, Int J Nurs Stud 40 (3) ( 2003) 299–306.
6. Dawood, M.; James, J., Cross-cultural care: What are you afraid of?Nurs Times 97 (40) ( 2001) 24–25.
7. Geissler, E.M., Cultural assessment. ed 2 ( 1998)Mosby, St Louis.
8. Giger, J.; Davidhizar, R.E., Transcultural nursing: Assessment and intervention. ed 5 ( 2008)Mosby, St Louis.
9. Kearns, C.J.; Meehan, N.K.; Carr, R.L.; et al., Using cross-cultural definitions of health care, Nurse Pract 28 (1) ( 2003) 61–62.
10. Krau, S.D., Working toward cultural competence in the workplace, SCI Nurs 19 (4) ( 2002) 193–194.
11. Leininger, M., Transcultural nursing: The study and practice field, Imprint 38 (2) ( 1991) 55–59.
12. Leininger, M., Founder’s focus: Transcultural nursing care makes a big outcome difference, J Transcult Nurs 14 (2) ( 2003) 157.
13. Luckman, J., Saunders manual of nursing care. ( 1997)WB Saunders, Philadelphia.
14. Martsolf, D.S., Cultural aspects of orthopaedic nursing, Orthop Nurs 18 (2) ( 1999) 65–71.
15. McEvoy, M., Culture and spirituality as an integrated concept in pediatric care, MCN Am J Matern Child Nurs 28 (1) ( 2003) 39–43; quiz 44.
16. Narayanasamy, A., Transcultural nursing: How do nurses respond to cultural needs?Br J Nurs 12 (3) ( 2003) 185-–194.
17. Sharma, S.B.; Smith, M.K., The importance of cultural assessment, SCI Nurs 19 (4) ( 2002) 177–180.
18. Stacciarini, J.M., Experiencing cultural differences: Reflections on cultural diversity, J Prof Nurs 18 (6) ( 2002) 346–349.
19. Wong, D.L.; Hockenberry-Eaton, M.; Wilson, D.; et al., Wong’s essentials of pediatric nursing. ed 6 ( 2001)Mosby, St Louis.
