both genders are kept free of axillary and pubic hair. The left hand is used for cleaning the genitals and the right one is reserved for eating, hand shaking, and other hygienic activ- ities. Muslims fast during Ramadan from sunrise to sunset, and this can include abstinence from all things (including medications or intravenous fluids). Illness can be an excep- tion to this rule, but public health nurses should consult with a family elder or Muslim leader to encourage the client to continue with any necessary treatments. Also, Muslims pray several times daily, facing toward Mecca. Home visits should be planned so that prayers are not interrupted (Elec- tronic Resource Center, 2007e).
When caring for Arabs in clinics or at home, a nurse of the same sex as the client should be assigned. Many topics (e.g., menstruation, family planning, pregnancy, and child- birth) must be discussed only with and by women; men are not included in these discussions.
Additional guidelines for nurses working with all immigrant groups include the following:
◆ Do not make assumptions about a client’s understanding of health care issues.
◆ Permit more time for interviewing; allow time to evaluate beliefs and provide appropriate interven- tions.
◆ Provide educational programs to correct any misconceptions about health issues; this can occur in clinics, mosques, schools, or homes.
◆ Provide an appropriate interpreter to improve com- munication with immigrants who do not speak English well.
TRANSCULTURAL COMMUNITY HEALTH
further awareness of the nurse’s unconscious, culturally based responses. Finally, ask selected clients to critique nursing actions in light of the clients’ own culture. Feedback from clients’ perspectives can reveal many of the nurse’s own cultural responses.
Because culture is mostly tacit, as discussed earlier, it takes conscious effort and hard work to bring the nurse’s own cultural biases or influence to the surface. Doing so, however, rewards the nurse with a more effective understanding of self and enhanced ability to provide culturally relevant service to clients (Leonard, 2001; Narayanasamy, 2003).
Cultivate Cultural Sensitivity
The second transcultural nursing principle seeks to expand the nurse’s awareness of the significance of culture on behav- ior. Nurses’ beliefs and ways of doing things frequently con- flict with those of their clients. A first step toward bridging cultural barriers is to recognize those differences and develop cultural sensitivity. Cultural sensitivity requires recognizing that culturally based values, beliefs, and practices influence people’s health and lifestyles and need to be considered in plans for service (Campinha-Bacote, 2003; Leininger, 2006).
Mrs. Juarez’s values and health practices sharply contrasted with those of the clinic’s staff. Failure to recognize these dif- ferences led to a breakdown in communication and ineffec- tive care. Once differences in culture are recognized, it is important to accept and appreciate them. A nurse’s ways are valid for the nurse; clients’ ways work for them. The nurse visiting the Kim family in the third case file discussion avoided the dangerous ethnocentric trap of assuming that her way was best, and she consequently developed a fruitful rela- tionship with her clients.
As a part of developing cultural sensitivity, nurses need to try to understand clients’ points of view. They need to stand in their clients’ shoes and try to see the world through their eyes. By listening, observing, and gradually learning other cultures, the nurse must add a further step of choosing to avoid ethnocentrism. Otherwise, the nurse’s view of a dif- ferent culture will remain distorted and perhaps prejudiced (Leonard, 2001; Leininger, 2006). The ability to show inter- est, concern, and compassion enabled one nurse to win the trust and respect of the Native American women in the sec- ond case file example and told the Kims that their nurse cared about them. These nurses attempted to understand the feelings and ideas of their clients; in this way, they estab- lished a trusting relationship and opened the door to the pos- sibility of their clients’ adopting healthier behaviors.
Assess the Client Group’s Culture
A third transcultural nursing principle emphasizes the need to learn clients’ cultures. All clients’ actions, like one’s own, are based on underlying culturally learned beliefs, values, and ideas (Ludwick & Silva, 2000; Spector, 2009). Mrs.
Kim did not like milk because her culture had taught her that it was distasteful and many Asians are lactose intolerant. The Native American women’s response to waiting or keeping someone else waiting was influenced by their valuing patience. There usually is some culturally based reason that causes clients to engage in (or avoid) certain actions. Instead of making assumptions or judging clients’ behavior, the
nurse first must learn about the culture that guides that behav- ior (Giger & Davidhizar, 2002). During a cultural assessment, the nurse obtains health-related information about the values, beliefs, and practices of a designated cultural group. Learning the culture of the client first is critical to effective nursing practice. The Giger and Davidhizar Transcultural Assessment Model (2002) denotes six interrelated factors for assessing differences between people in cultural groups (Figure 5.2).
Understanding these phenomena is a first step toward appre- ciating the diversity that exists among people from different cultural backgrounds. Interviewing members of a subcultural group can provide valuable data to enhance understanding (Eggenberger, Grassley, & Restrepo, 2006).
To fully understand a group’s culture, it should be stud- ied in depth, as Bernal maintains (1993, p. 231):
Although a general knowledge base and skills are applicable transculturally, immersion in a given culture is necessary to understand fully the patterns that shape the behavior of indi- viduals within that group. Experience with one group can be helpful in understanding the concept of diversity, but each group must be understood within its own ecologic niche and for its own historical and cultural reality.
Practically speaking, however, it is not possible to study in depth all of the cultural groups that the nurse encounters.
Instead, the nurse can conduct a cultural assessment by questioning key informants, observing the cultural group, CHAPTER 5 Transcultural Nursing in the Community
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113Communication Space Social
organization
Culturally diverse individual
Time Environmental
control
Biological variations
F I G U R E 5.2 Components of the Giger and Davidhizar Tran- scultural Assessment Model, showing the culturally diverse individual through communication, space, social organization, time, environ- mental control, and biologic variations. Adapted from Giger, J.N., &
Davidhizar, R. (2002). Culturally competent care: Emphasis on understanding the people of Afghanistan, Afghan Americans, and Islamic culture and religion. International Nursing Review, 49(2), 79–86, with permission.
LWBK151-3970G-C05_091-120.qxd 11/19/08 12:01 AM Page 113 Aptara Inc.
and reading additional information in the literature. The data can be grouped into six categories:
1. Ethnic or racial background: Where did the client group originate, and how does that influence their status and identity?
2. Language and communication patterns: What is the preferred language spoken, and what are the group’s culturally based communication patterns?
3. Cultural values and norms: What are the client group’s values, beliefs, and standards regarding such things as family roles and functions, education, child rearing, work and leisure, aging, death and dying, and rites of passage?
4. Biocultural factors: Are there physical or genetic traits unique to this cultural group that predispose them to certain conditions or illnesses?
5. Religious beliefs and practices: What are the group’s religious beliefs, and how do they influence life events, roles, health, and illness?
6. Health beliefs and practices: What are the group’s beliefs and practices regarding prevention, causes, and treatment of illnesses?
The cultural assessment guide presented in Table 5.7 gives suggestions for more detailed data collection.
Many cultural assessment guides can be found throughout the nursing literature. Nonetheless, a thorough cultural assessment may be too time-consuming and costly.
114
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UNIT 1 Foundations of Community Health NursingTABLE 5.7
Cultural Assessment Guide
Category Sample Data
Ethnic/racial background Countries of origin
Mostly native-born or U.S. born?
Reasons for emigrating if applicable Racial/ethnic identity
Experience with racism or racial discrimination?
Language and communication patterns Languages of origin
Languages spoken in the home Preferred language for communication
How verbal communication patterns affected by age, sex, other?
Preferences for use of interpreters
Nonverbal communication patterns (e.g., eye contact, touching) Cultural values and norms Group beliefs and standards for male and female roles and functions
Standards for modesty and sexuality
Family/extended family structures and functions Values re: work, leisure, success, time
Values re: education and occupation Norms for child-rearing and socialization Norms for social networks and supports Values re: aging and treatment of elders Values re: authority
Norms for dress and appearance
Biocultural factors Group genetic predisposition to health conditions (e.g., hypertension, anemia) Socioculturally associated illnesses (e.g., AIDS, alcoholism)
Group attitudes toward body parts and functions Group vulnerability or resistance to health threats?
Folk illnesses common to group?
Group physical/genetic differences (e.g., bone mass, height, weight, longevity) Religious beliefs and practices Religious beliefs affecting roles, childbearing and child-rearing, health and illness?
Recognized religious healers?
Religious beliefs and practices for promoting health, preventing illness, or treatment of illness
Beliefs and rituals re: conception and birth Beliefs and rituals re: death, dying, grief Health beliefs and practices Beliefs re: causes of illness
Beliefs re: treatment of illness
Beliefs re: use of healers (traditional and Westem) Health promotion and illness prevention practices Folk medicine practices
Beliefs re: mental health and illness Dietary, herbal, and other folk cures Food beliefs, preparation, consumption Experience with Westem medicine LWBK151-3970G-C05_091-120.qxd 11/19/08 12:01 AM Page 114 Aptara Inc.
Instead, the two-phase assessment process is proposed, as outlined in Table 5.8. Categories to explore in the assess- ment include values, beliefs, customs, and social structure components. Two methods that have proved highly effective for in-depth study of cultural groups are ethnographic inter- viewing and participant observation. Classic models of these methods have been published by Spradley (1979, 1980).
Show Respect and Patience While Learning About Other Cultures
The fourth transcultural nursing principle emphasizes key behaviors for the nurse to practice during the cultural learning process. Respect is the first behavior, and it is shown in many ways. When Sandra Josten involved the Native American women in decisions and gave them choices, she was showing respect. When the nurse gave positive recognition to the importance of the Kims’ culture, she was showing respect.
Attentive listening is a way to show respect and to learn about a client’s culture. Within the United States, people of minority groups particularly need respect (Cowan & Norman, 2006). At times, for groups with limited English skills and a community health nurse who is not bilingual, an interpreter who can assist with communication becomes a necessity (Display 5.7).
A minority group is part of a population that differs from the majority and often receives different and unequal treatment. Their ways contrast with those of the dominant culture. It is difficult for them to retain pride in their lifestyles, or in themselves, when the majority culture sug- gests that they are inferior (Leininger, 2006; Spector, 2009).
This message may be only implied or even unintentional, as was the case for Mrs. Juarez in From the Case Files IV. The clinic’s routine and the manner of the staff were not intended to show disrespect. They did, nevertheless, and Mrs. Juarez was intimidated and was unable to receive the help that she needed. Everyone needs respect to enhance pride, dignity, and self-esteem; it is an important contributor to good men- tal health. Showing respect also is an important means for breaking down barriers in cross-cultural communication. For community health nurses, culturally relevant care means practicing cultural relativism. Cultural relativism is recog- nizing and respecting alternative viewpoints and understand- ing values, beliefs, and practices within their cultural context.
In addition to respect, patience is essential. It takes time to build trust and effect cultural change. It can be difficult to
establish the nurse–client relationship when it involves two different cultures. Trust must be won, and winning it may take weeks, months, or years. Time must be allowed for both nurse and clients to learn how to communicate with one another, to test one another’s trustworthiness, and to learn about one another. Change in behavior (learned aspects of the culture) occurs gradually. Some aspects of both the nurse’s and the clients’ cultures can, and probably will, change. The Kims’ nurse, Paula Morrow, for example, modified CHAPTER 5 Transcultural Nursing in the Community
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115TABLE 5.8
Two-Phased Cultural Assessment Process
Phase I—Data Collection
Stage 1 Assess values, beliefs, and customs (e.g., ethnic affiliations, religion, decision-making patterns).
Stage 2 Collect problem-specific cultural data (e.g., cultural beliefs and practices related to diet and nutrition). Make nursing diagnoses.
Stage 3 Determine cultural factors influencing nursing intervention (e.g., child-rearing beliefs and practices that might affect nurse teaching toilet training or child discipline).
Phase II—Data Organization
Step 1 Compare cultural data with
Standards of client’s own culture (e.g., client’s diet compared with cultural norms) Standards of the nurse’s culture
Standards of the health facility providing service.
Step 2 Determine incongruities in above standards.
Step 3 Seek to modify one or more systems (client’s, nurse’s, or the facility’s) to achieve maximum congruity.
DISPLAY 5.7
1. Unless the community health nurse is thoroughly effective and fluent in the client’s language, an interpreter should be used.
2. Speak at a normal to slow pace and make eye con- tact with the client.
3. Confidentiality must be maintained by the interpreter, who divulges nothing without the full approval of the client and community health nurse.
4. Evaluate the interpreter’s style, approach to clients, and ability to develop a relationship of trust and respect. Try to match the interpreter to the client.
5. Be patient. Careful interpretation often requires that the interpreter use long, explanatory phrases.
6. Interpreters must interpret everything that is said by all of the people in the interaction but should inform the community health nurse if the content might be perceived as offensive, insensitive, or harmful to the dignity and well-being of the client.
7. When appropriate, encourage interpreters to explain cultural differences to the client and to yourself.
8. Interpretation conveys the content and spirit of what is said, with nothing omitted or added.
9. Volunteer interpreters receive no fee. Employed interpreters receive their fee or salary from the hir- ing agency. They should not accept money or favors from clients or the community health nurse.
A sincere “thank you” is most appropriate (Kaufert
& Putsch, 1997; Putsch, 1985. University of Washington Medical Center, 2008).