Transcultural Healthcare (Personal and Environmental Health) (Nursing) Part 1

Learning Objectives

1.    Define and state the components of culture, subculture, race, minorities, and ethnicity.

2.    Identify major subcultural groups of your community, your state or province, and your country.

3.    Define and give examples of prejudice, ethnocentrism, and stereotyping.

4.    Identify barriers to providing culturally competent nursing care.

5.    List nursing considerations that need to be considered as part of a cultural assessment.

6.    Discuss ways in which each of the following influences nursing care: values and beliefs, taboos and rituals, concepts of health and illness, language and communication, diet and nutrition, elimination, and death and dying.

7.    Assess the importance of religious and spiritual beliefs for clients experiencing illness.

8.    Compare and contrast the following belief systems: magicoreligious, scientific/biomedical, holistic medicine, yin-yang, and hot-cold.

9.    Discuss the common philosophies of mental illness in different cultures and state how these ideas affect nursing care.

10.    Identify important qualifications for a professional interpreter.

11.    Discuss cultural aspects of each of the following: personal space and touching, eye contact, diet and nutrition, elimination, and concepts of death and dying. Relate these aspects to concepts of nursing care.

IMPORTANT TERMINOLOGY
beliefs	karma	race
cultural diversity	minister	rituals
cultural sensitivity	minority	shaman
culture	mullah	stereotype
curandero	nirvana	subculture
ethnicity	norms	taboos
ethnocentrism	prejudice	transcultural nursing
ethnonursing	priest	values
imam	rabbi	yin-yang

In the late 20th century, nurse and anthropologist Madeleine Leininger helped develop the concept that a client has physical, spiritual, psychological, and socioeconomic needs that exist in our complex, diverse world.

As a nurse, you are responsible for becoming acquainted with the predominant cultures in your community. Remember to view each person within a group as an individual and to provide care in a nonjudgmental way. Individuals identify with their cultural, ethnic, racial, and religious backgrounds to various degrees. Nurses must be aware of their own beliefs and be sensitive to the beliefs of others.

CULTURE AND ETHNICITY

Definitions of Culture

Culture is the accumulated learning for generational groups of individuals within structured or nonstructured societies. Individuals experience a cultural heritage with others. Heritage is learned through formal and informal experiences through the life cycle. Culture consists of the combined heritage of language and communication style, health beliefs and health practices, customs and rituals, and religious beliefs and practices. Culture is influenced by environment, expectations of society, and national origin.

Key Concept All cultural information in this topic is general.These generalizations are used for descriptive purposes, and remember that not everyone in a particular group follows all the practices or shares the same beliefs and characteristics.

The way an individual behaves in social groups and as an individual within that group is also part of one’s culture. An individual learns, evaluates, and behaves according to specified values within a culture. Cultural concepts and beliefs provide the blueprints or guides for determining one’s personal and societal values, individual beliefs, and lifelong practices. A pattern of values, attitudes, and social, political, economic, educational, and other behaviors emerges from the learned culture and these values are shared in a defined group over time as an identifiable heritage. Box 8-1 presents some characteristics of culture.

Subcultures are groups within dominant cultures. Subcultures form because individuals share characteristics that belong to an identifiable group, such as occupations (nurse, teacher, politician), religions (Islam, Methodist, Baptist), geographic origins (New Englander, Midwesterner, Californian), or age (infant, teenager, elderly). Nursing students also comprise a subculture because of the unique experiences and growth process that are universal components of all student nursing populations. Table 8-1 describes the major subcultures that exist in the United States.

BOX 8-1.

Characteristics of Culture

A World of Difference When one individual meets another individual, they may fail to understand each other because of differences in language, education, values, rules, understanding of health and illness, gestures, emotional expressions, body language, cultural norms, family backgrounds, age-related norms, religious or family rituals, expectations of the male or female, as well as previous life experiences. Here are some common characteristics of what society considers to be culture.
	A way of life for a group of individuals
	The sum of socially inherited characteristics, handed down from generation to generation
	A group’s design for living—socially transmitted assumptions about the physical and social world
	Learned from birth
	Roles change with an individual’s age, sex, and family position
	Influenced by social groups not genetics
	Unique to each ethnic group
	Shared by members of the same group who identify with each other
	Complex and all-encompassing
	Often an unconscious process An adaptation to various conditions, such as environment, educational background, and available resources
	Dynamic and always changing

The term race is used to differentiate large groups of humankind that share common biological and sociological characteristics. Race implies genetic characteristics associated with having ancestors from a specific part of the world. Race should not be confused with ethnicity or culture. Racial mixing has blurred the physical characteristics of individuals. The nurse must be aware that obvious physical attributes, such as skin, hair, or eye color, are not accurate indicators of race. Genetic diseases are not limited to individuals who physically appear to be of a particular race.

Physical and cultural characteristics of a group may differ from those of the predominant group of a particular region. These minority groups within a population may be identified as subcultures. African Americans, Latinos (or Hispanics), Asian Americans, and Native Americans are four identified subcultures of the United States, according to the Centers for Disease Control (CDC). Each group has specific and distinctive features and is also part of larger cultural groups. These groups can be divided into smaller groups; for example, Latinos include Mexicans, Puerto Ricans, Cubans, Guatemalans, and others. Minorities can also be identified according to religion, occupation, sexual orientation, or gender. In the United States, a census is taken every 10 years and some terms of race or ethnicity may be revised.

The term minority can be misleading. For example, a Texas rancher in the skyscrapers of Manhattan can be seen as a minority. A Vietnamese immigrant can be part of the majority of a population in one geographic location, just as a descendant of early European settlers can be part of a minority in parts of the United States. Global shifts of multiple groups of individuals are continually revising cultures and subcultures and remaking majority and minority groups. This phenomenon is happening on all continents. The results of these shifts can be beneficial to society or may lead to fervent nationalism and hostility.

Special Considerations : CULTURE & ETHNICITY

Cultures and subcultures are not stagnant or unchanging. Race and ethnicity are also words with evolving definitions. Economics, migrations of populations, and politics influence these concepts.

Ethnicity is the common heritage shared by a specific culture. Now many people work hard to retain their cultural and ethnic identification. This is demonstrated in Scandinavian celebrations in the Midwest; Hispanic celebrations of Cinco de Mayo in the Southwest; traditional Mardi Gras celebrations in Louisiana; Native American pow wows; and Chinese New Year celebrations. Many ethnic groups celebrate special occasions, such as weddings, with traditional activities and foods. Tacos and burritos are examples of types of food in the southwestern United States that are shared with other ethnic backgrounds. Some people strongly identify with their culture of origin and make an effort to pass traditions along to their children. Cultures are often associated with religious beliefs, and religion may be a strong factor in a person’s ethnicity.

Groups show ethnic pride in various ways. For example, a celebration of religious and cultural heritage is demonstrated by the St. Patrick’s Day Parade in New York City. Some ethnic groups retain links to their country of origin by wearing specific items, such as an Asian Indian sari, clothing with African patterns, or Native American jewelry.

Table 8.1 Cultural Factors that influence care of clients

SUBCULTURE	COUNTRIES OF ORIGIN	FAMILY	FOLKAND TRADITIONAL HEALTHCARE	HEALTH BELIEF	VALUES AND BELIEFS	COMMON HEALTH CONCERNS
Anglo American	• Western Europe	•    Nuclear family highly valued •    Consideration for the individual is highly valued as compared with group or family values. •    Elderly family members may live in a nursing home when they can no longer care for themselves.	•    Self-diagnosis of illness •    Use of over-the-counter drugs (especially vitamins and analgesics) •    Dieting (especially fad diets) •    Exercise and nutrition used to prevent illness.	• Illness is caused by infectious microorganisms, organ degeneration, and unhealthy lifestyles.	•    Youth is valued over age. •    Cleanliness •    Orderliness •    Attractiveness •    Individualism •    Achievement •    Punctuality	•    Cardiovascular diseases •    Gastrointestinal diseases •    Obesity •    Some forms of cancer •    Motor vehicle accidents •    Suicides •    Mental illness •    Chemical abuses •    Diabetes mellitus and its complications
African American	•    Africa •    Dominican Republic •    Haiti •    Jamaica •    West Indian Islands	•    Close and supportive extended family relationships •    Develop strong kinship ties with non-blood relatives from church or organizational and social groups •    Family unity, loyalty, and cooperation are important. •    Frequently matriarchal	• Varies extensively and may include traditional Western medicine, spiritualists, herb doctors, root doctors, conjurers, skilled elder family members, voodoo, and faith healing	• Supernatural forces can cause disease and influence recovery.	•    Present oriented •    Members of the African American clergy are highly respected in the community. •    Frequently highly religious	•    Hypertension •    Sickle cell anemia •    Skin disorders: inflammation of hair follicles, various types of dermatitis, and excessive growth of scar tissue (keloids) •    Lactose enzyme deficiency •    Tuberculosis
Hispanic or Latino	•    Central and South America (e.g., Mexico, Guatemala) •    Cuba •    Puerto Rico	•    Familial role is important. •    Special bond between a child’s parents and his or her grandparents (compadrazgo) •    Family is the primary unit of society.	•    Frequently consult folk healers (curanderas/ curanderos). •    The secret of good health is to balance hot and cold within the body; therefore, most foods, beverages, herbs, and medications are classified as hot (caliente) or cold (fresco, frio) (e.g., a cold disease will be cured with a hot treatment).	• Illness and misfortune occur as punishment from God, referred to as castigo de Dios, or by an imbalance of “hot” or “cold” forces within the body.	•    Respect is given according to age (older) and sex (male). •    Roman Catholic Church may be very influential •    God gives health and allows illness for a reason; therefore, may perceive illness as a punishment from God. •    Atonement and forgiveness are important parts of therapy •    Time is relative and flexible; little attention may be given to the exact times of day. •    Reticent to share personal and family affairs; therefore, psychotherapy may not be accepted. •    Proper consideration should be given to cultural rituals, such as shaking hands and standing up to greet and saying goodbye to people. •    Personal integrity is important.	•    Diabetes mellitus and its complications •    Nutritional concerns (e.g., obesity or deficits) •    Lactose enzyme deficiency •    Infant morbidity or mortality

Asian American	•    Cambodia •    China •    Indonesia •    Japan •    Korea •    Laos •    Pacific Islands •    Philippines •    Thailand •    Vietnam	•    Welfare of the family is valued above the individual. •    Extended families are common. •    A person’s lineage (ancestors) is respected. •    Sharing among family members is expected.	•    Theoretical basis is in Taoism, which seeks a balance in all things. •    Good health is achieved through the proper balance of yin and yang. •    Diseases and foods are classified as hot or cold and a proper balance between them will promote wellness (e.g., treat a cold disease with hot foods). •    Use herbs, diet, and the application of hot or cold therapy	•    Health is the result of a balance between yin and yang energy; illness results when equilibrium is disturbed. •    Meridians or energy pathways are points located on the body; if the energy flow is out of balance, treatment of the pathway may be necessary to restore the energy equilibrium. •    Acupressure is a technique for compressing the energy pathway points. •    Acupuncture is a technique in which fine needles are inserted into the body at energy pathway points.	•    Strong sense of self-respect and self-control •    High respect for age •    Respect for authority •    Respect for hard work •    Praise of self to others is considered poor manners. •    Strong emphasis on harmony and the avoidance of conflict	•    Tuberculosis •    Communicable diseases •    Malnutrition •    Suicide •    Various forms of mental illness •    Lactose enzyme deficiency
Native American (many differences can occur among tribes.)**	•    North American continent •    More than 500 Indian nations and tribes contribute to the American cultures, including Apache, Hopi, Inuit, Mohawk, Navajo, Seminole, and Zu ni	•    Families are large and extended. •    Grandparents are official and symbolic leaders and decision-makers. •    A child’s namesake may assume equal parenting authority with biological parents.	•    Medicine men/women (shamans) are frequently consulted •    Heavy use of herbs and psychological treatments, ceremonies •    Fasting, meditation, heat, and massages	• Illness occurs when the harmony of nature (Mother Earth) is disturbed.	• A shaman, or medicine man or woman, who has both spiritual and physical healing powers, is consulted to restore harmony.	•    Alcoholism •    Suicide •    Tuberculosis •    Malnutrition •    Communicable diseases •    Maternal and infant morbidity and mortality •    Diabetes mellitus and its complications •    Hypertension •    Gallbladder disease

*For more information about the U.S. population, including race and cultural data, estimates of growth, genealogy or other facts: http://www.census.gov or http://factfindercensus.gov,

**For more information about Native American nations and tribes: www.doi.gov/bureau-indian-affairsorwww.nativeculturelinks.com/nations,

Cultural Diversity

Cultures have become so interwoven and blended that specific identification of cultural groups can be difficult. Currently, the Hispanic community is the fastest-growing group in the United States. The Asian/Pacific Islander group is also expanding rapidly, with a 95% growth rate expected in the early 21st century. To date, as many as 150 different ethnic groups and more than 500 tribes of Native Americans have been identified in the United States. In addition to expanding birth rates among specific ethnic groups, immigrants from many countries are entering the United States in large numbers. Migrations of populations worldwide are influencing demographics, culture, and economics in many countries.

As you can see from the nightly news and from your own experience, cultural diversity has become part of our world. Individuals will meet people of many ethnic groups, both as citizens and as nurses. When a nurse cares for clients from her own culture, she will likely understand their language, values, and beliefs. When a nurse encounters clients from cultures that are unfamiliar, however, understanding and communication may become difficult. To be effective, the nurse must transcend cultural barriers and approach every client with patience, empathy, concern, and competence. A high level of self-awareness is also important. Before you can understand another person’s culture, you must first understand and accept your own.

NCLEX Alert Components of test questions may include a variety of cultural concerns. For example, you may be asked to identify common cultural food needs (pork, alcohol, vegetarian) as well as nursing concerns related to diseases that may be found in certain racial and ethnic groups (hypertension, diabetes, genetic disorders).

Barriers to Culturally Competent Care

Prejudice is a belief based on preconceived notions about certain groups of people. Prejudices can be unfair, biased beliefs. Many people have been the victims of prejudice. Overweight individuals, homosexuals, racial groups, and others have been the victims of prejudice. Prejudice exists in subtler forms, an example being a fixed negative opinion against authority figures that some people harbor. Many individuals are prejudiced without realizing it. Consider that you may be prejudiced against men with beards, women in short skirts, individuals with high IQs, and so forth. Are you pre-judging others on the basis of personal appearance or a unique trait?

Key Concept Individuals can be overly sensitive to a cultural reference, which, in itself, can be a form of perceived prejudice. If you hear or use the word Mexican, Filipino, or Muslim in a sentence, does that mean that the statement reflects prejudice? For example, if your instructor states that country XYZ has a high mortality rate ofTB, is that a statement of fact or is the statement considered derogatory?

Ethnocentrism is the belief that one’s own culture is the best and only acceptable culture. It shows lack of cultural sensitivity. If a person is ethnocentric, he or she is unable to see the value in other cultures. As a nurse, seeing beyond your own particular ethnic/cultural group is important for effective communication and understanding.

The term stereotype refers to classifying or categorizing people and believing that all those belonging to a certain group are alike. In the movies, the villain is often stereotyped as wearing the black hat, whereas the hero wears the white hat. Stereotyping implies preconceived, but often incorrect, negative notions. It is inappropriate to assign derogatory characteristics (e.g., lazy, dishonest, or stupid) to groups due to stereotyping. Additionally, individuals will always maintain some uniqueness within a group. People are all more alike than they are different.

Cultural Sensitivity

Cultural sensitivity is the understanding and tolerance of all cultures and lifestyles. It is crucial in the delivery of competent nursing care. You should develop cultural sensitivity when working with individuals from every ethnic/cultural group. Cultural sensitivity allows the nurse to understand more accurately and to accept the behavior of others. Nurses are better able to deliver care, being sensitive to cultural factors involved in the client’s health or illness.

No culture is better or worse than another. Additionally, cultures are ever changing; they evolve over many generations. Table 8-1 gives some generalities about some subcultures, and Box 8-2 and Box 8-3 list many nursing considerations that can be used as part of cultural assessments.