74 U N I T 2 ● Integrating Basic Concepts
Cambodia, Laos, and Vietnam) make up the third subcul- ture. Native Americans (Indian nations found in North America including the Eskimos and Aleuts) include approximately 2.3 million American Indians and Alaskan Natives belonging to 545 federally recognized tribes in the
BOX 6-1 ● Examples of U.S. Cultural Characteristics
❙ English is the language of communication.
❙ The pronunciation or meaning of some words varies according to regions within the United States.
❙ The customary greeting is a handshake.
❙ A distance of 4 to 12 feet is customary when interacting with strangers or doing business (Giger and Davidhizar, 1995).
❙ In casual situations, it is acceptable for women as well as men to wear pants;
blue jeans are a common mode of dress.
❙ Most Americans are Christians.
❙ Sunday is recognized as the Sabbath.
❙ Government is expected to remain separate from religion.
❙ Guilt or innocence for alleged crimes is decided by a jury of one’s peers.
❙ Selection of a marriage partner is an individual’s choice.
❙ Legally, men and women are equals.
❙ Marriage is monogamous (only one spouse); fidelity is expected.
❙ Divorce and subsequent remarriages are common.
❙ Parents are responsible for their minor children.
❙ Aging adults live separately from their children.
❙ Status is related to occupation, wealth, and education.
❙ Common beliefs are that everyone has the potential for success and that hard work leads to prosperity.
❙ Daily bathing and use of a deodorant are standard hygiene practices.
❙ Anglo-American women shave the hair from their legs and underarms; most men shave their faces daily.
❙ Licensed practitioners provide health care.
❙ Drugs and surgery are the traditional forms of medical treatment.
❙ Americans tend to value technology and equate it with quality.
❙ As a whole, Americans are time oriented and, therefore, rigidly schedule their activities according to clock hours.
❙ Forks, knives, and spoons are used, except when eating “fast foods,” for which the fingers are appropriate.
SUBCULTURAL GROUPS IN THE UNITED STATES*
TABLE 6-2
PERCENT OF REPRESENTATIVE AMERICAN
GROUP COUNTRIES POPULATION
African American Africa, Haiti, Jamaica, 12.3 West Indies,
Dominican Republic
Latino Mexico, Puerto Rico, 12.5
Cuba, South and Central America
Asian American China, Japan, Korea, 4.3 Philippines, Thailand,
Cambodia, Laos, Vietnam, Pacific Islands
Native American North American Indian 0.9 nation and tribes,
Eskimos, Aleuts
*As reported by the U.S. Census Bureau, 2004.
Language and Communication
Because language is the primary way to share and gather information, the inability to communicate is one of the biggest deterrents to providing culturally sensitive care.
Foreign travelers and many residents in the United States do not speak English, or they have learned it as their sec- ond language and do not speak it well. Estimates are that 13.8% of those who live in the United States speak a lan- guage other than English at home (Perkins et al., 2003).
Those who can communicate in English may still prefer to use their primary language, especially under stress.
EQUAL ACCESS. Federal law, specifically Title IV of the Civil Rights Act of 1994, states that people with limited English proficiency are entitled to the same health care and social services as those who speak English fluently.
In other words, all clients have a right to unencumbered communication with a health provider. Using children as interpreters or requiring clients to provide their own interpreters is a civil rights violation. The Joint Com- mission on Accreditation of Healthcare Organizations requires that hospitals provide effective communication for each client.
The use of untrained interpreters, volunteers, or fam- ily is considered inappropriate because it undermines confidentiality and privacy. It also violates family roles and boundaries. It increases the potential for modifying, condensing, omitting, or adding information or project- ing the interpreter’s own values during communication between client and health care provider. To comply with the laws and accreditation requirements, health care agencies are strongly encouraged to train professional interpreters. A competently trained interpreter demon- strates the skills listed in Box 6-2.
NURSE–CLIENT COMMUNICATION. If the nurse is not bilin- gual(able to speak a second language), he or she must use an alternative method for communicating. See Nursing Guidelines 6-1 for more information.
Understanding some unique cultural characteristics involving aspects of communication may ease the tran- sition toward culturally sensitive care. It is helpful to be aware of general communication patterns among the major U.S. subcultures.
Native Americanstend to be private and may hesitate to share personal information with strangers. They may interpret questioning as prying or meddling. The nurse should be patient when awaiting an answer and listen carefully because people of this culture may consider impatience disrespectful (Lipson, Dibble & Minarik, 2002). Navajos, currently the largest tribe of Native Amer- icans, believe that no person has the right to speak for another and may refuse to comment on a family mem- ber’s health problems.
Because Native Americans traditionally preserved their heritage through oral rather than written history, they may be skeptical of nurses who write down what they say. If possible, the nurse should write notes after, rather than during, the interview.
African Americansmay be mistrustful of the medical establishment, possibly because of poor practices em- ployed in past research projects such as the Tuskegee syphilis experiment (Fourtner et al., 1994; Jones, 1993).
They also have sometimes been treated as second-class cit- izens when seeking health care. The nurse must demon- strate professionalism by addressing clients by their last names and introducing himself or herself. He or she should follow-up thoroughly with requests, respect the client’s privacy, and ask open-ended rather than direct questions until trust has been established. Because of their experiences as victims of discrimination, African Ameri- cans may hesitate to give any more information than what is asked.
Latinosare characteristically comfortable sitting close to interviewers and letting interactions unfold slowly. Many Latinos speak English but still have difficulty with medical terminology. They may be embarrassed to ask the inter- viewer to speak slowly, so the nurse must provide infor- mation and ask questions carefully. Latino men generally are protective and authoritarian regarding women and children. They expect to be consulted in decisions con- cerning family members.
Asian Americans tend to respond with brief or more factual answers and little elaboration, perhaps because traditionally they value simplicity, meditation, and intro- spection. Asian Americans may not openly disagree with authority figures, such as physicians and nurses, because of their respect for harmony. Such reticence can conceal disagreement or potential noncompliance with a partic- ular therapeutic regimen that is unacceptable from their perspective.
Eye Contact
Anglo-Americans generally make and maintain eye con- tact throughout communication. Although it may be BOX 6-2 ● Characteristics of a Skilled Interpreter
❙ Learns the goals of the interaction
❙ Demonstrates courtesy and respect for the client
❙ Explains his/her role to the client
❙ Positions himself/herself to avoid disrupting direct communication between the health care worker and client
❙ Has a good memory for what is said
❙ Converts the information in one language accurately into the other without commenting on the content
❙ Possesses knowledge of medical terminology and vocabulary
❙ Attempts to preserve the emphasis and emotions that both people express
❙ Asks for clarification if verbalizations from either party are unclear
❙ Indicates instances in which a cultural difference has the potential to impair communication
❙ Maintains confidentiality
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76 U N I T 2 ● Integrating Basic Concepts
natural for Anglo-Americans to look directly at a person while speaking, that is not always true of people from other cultures. It may offend Asian Americans or Native Americans who are likely to believe that lingering eye con- tact is an invasion of privacy or a sign of disrespect. Arabs may misinterpret direct eye contact as sexually suggestive.
Space and Distance
Providing personal care and performing nursing pro- cedures often reduce personal space, which causes dis- comfort for some cultural groups. For example, Asian Americans may feel more comfortable with the nurse at more than an arm’s length away. The physical closeness of a nurse in an effort to provide comfort and support may threaten clients from other cultures. It is best, there-
fore, to provide explanations when close contact during procedures and personal care is necessary.
Touch
Some Native Americans may interpret the Anglo- American custom of a strong handshake as offensive.
They may be more comfortable with just a light passing of the hands. People from Southeast Asia consider the head to be a sacred body part that only close relatives can touch.
Nurses and other health care workers should ask permis- sion before touching this area. Southeast Asians also believe that the area between a female’s waist and knees is particularly private and should not be touched by any male other than the woman’s husband. Before doing so, a male nurse can relieve the client’s anxiety by offering an
NURSING GUIDELINES 6-1
Communicating With Non–English-Speaking Clients
❙ Greet or say words and phrases in the client’s language, even if carrying on a conversation is impossible. Using familiar words indicates a desire to communicate with the client even if the nurse lacks the expertise to do so extensively.
❙ Use Web sites with the client that translate English to several foreign languages and vice versa. Examples are found at http://ets.freetranslation.com and http://babel.altavista.com/tr.
A computer with Internet access provides sites with easy-to-use, rapid, free translations of up to 150 words at a time.
❙ Refer to an English/foreign language dictionary or use appendices in references such as Tabers’ Cyclopedic Medical Dictionary. Some dictionaries provide medical words and phrases that may provide pertinent information.
❙ Compile a loose-leaf folder or file cards of medical words in one or more languages spoken by clients in the community. Place it with other reference books on the nursing unit. A homemade reference provides a readily available language resource for communicating with others in the local area.
❙ Request a trained interpreter. If that option is impossible, call ethnic organizations or church pastors to obtain a list of people who speak the client’s language and may be willing to act as emergency translators.
Someone proficient at speaking the language is more effective in obtaining necessary information and explaining proposed treatments than is someone relying on a rough translation.
❙ Contact an international telephone operator in a crisis, if there is no other option for communicating with a client. International telephone operators are generally available 24 hours a day; however, their main responsibility is the job for which they were hired.
❙ When several interpreters are available, select one who is the same gender and approximately the same age as the client. Some clients are embarrassed relating personal information to people with whom they have little in common.
❙ Look at the client, not the interpreter, when asking questions and listening for responses. Eye contact indicates that the client is the
primary focus of the interaction and helps the nurse to interpret nonverbal clues.
❙ If the client speaks some English, speak slowly, not loudly, using simple words and short sentences. Lengthy or complex sentences are barriers when communicating with someone not skilled in a second language.
❙ Avoid using technical terms, slang, or phrases with a double or colloquial meaning. The client may not understand the spoken vernacular, especially if he or she learned English from a textbook rather than conversationally.
❙ Ask questions that can be answered by a yes or no. Direct questions avoid the need to provide elaborate responses in English.
❙ If the client appears confused by a question, repeat it without changing the words. Rephrasing tends to compound confusion because it forces the client to translate yet another group of unfamiliar words.
❙ Give the client sufficient time to respond. The process of interpreting what has been said in English and then converting the response from the native language back to English requires extra time.
❙ Use nonverbal communication or pantomime. Body language is universal and tends to be communicated and interpreted quite accurately.
❙ Be patient. Anxiety is communicated interpersonally and tends to heighten frustration.
❙ Show the client written English words. Some non–English-speaking people can read English better than they can understand it spoken.
❙ Work with the health agency’s records committee to obtain consent forms, authorization for health insurance benefits, and copies of client’s rights written in languages other than English. Legally, clients must understand what they are consenting to.
❙ Develop or obtain foreign translations describing common procedures, routine care, and health promotion. One resource is the Patient Education Resource Center in San Francisco, which provides publications in many languages on numerous health topics. All clients are entitled to explanations and educational services.
explanation, requesting permission, and allowing the client’s husband to stay in the room.
Emotional Expression
Anglo-Americans and African Americans, in general, freely express positive and negative feelings. Asian Amer- icans, however, tend to control their emotions and expres- sions of physical discomfort (Zborowski, 1952, 1969), especially among unfamiliar people. Similarly, Latino men may not demonstrate their feelings or readily discuss their symptoms because they may interpret doing so as less than manly (Andrews & Boyle, 2003). The Latino cul- tural response can be attributed to machismo, a belief that virile men are physically strong and must deal with emo- tions privately. Because this behavior is atypical from an Anglo-American perspective, nurses may overlook the emotional and physical needs of people from these cul- tural groups.
Dietary Customs and Restrictions
Basically, food is a means of survival: it relieves hunger, promotes health, and prevents disease. Eating also has social meanings that relate to communal togetherness, celebration, reward and punishment, and relief of stress.
Culture dictates the types of food and how frequently a person eats, the types of utensils used, and the status of individuals, such as who eats first and who gets the most.
Religious practices within some cultures impose certain rules and restrictions such as times for fasting and foods that can and cannot be consumed (Table 6-3). Nurses can jeopardize the compliance of clients with a therapeutic diet for medical disorders if dietary teaching disregards cultural and religious food preferences.
Time
Throughout the world, people view clock time and social time differently (Giger & Davidhizar, 2004). Calendars and clocks define clock time, dividing it into years, months, weeks, days, hours, minutes, and seconds. Social time reflects attitudes concerning punctuality that vary among cultures. Punctuality is often less important to people from other cultures than it is to Anglo-Americans. Tolerating and accommodating cultural differences related to time facilitates culturally sensitive care.
Beliefs Concerning Illness
Generally, people embrace one of three cultural views to explain illness or disease. The biomedicalorscientific per- spectiveis shared by those from developed countries who base their beliefs about health and disease on research findings. An example of a scientific perspective is that microorganisms cause infectious diseases, and frequent handwashing reduces the potential for infection.
Thenaturalisticorholistic perspective espouses that humans and nature must be in balance or harmony to
remain healthy; illness is an outcome of disharmony.
Native Americans share this view. Another example is Asian Americans who uphold the Yin/Yang theory,which refers to the belief that balanced forces promote health.
Latinos embrace a similar concept referred to as the hot/
cold theory.It implies that illness is an imbalance between components ascribed as having hot or cold attributes.
Adding or subtracting heat or cold to restore balance also can restore health.
Finally, there is the magico-religious perspectivein which there is a cultural belief that supernatural forces con- tribute to disease or health. Some examples of the magico- religious perspective include cultural groups that accept faith healing or practice forms of witchcraft or voodoo.
Although nurses may disagree with a client’s belief’s con- cerning the cause of health or illness, respect for the per- son helps to achieve health care goals.
Stop • Think + Respond BOX 6-1 How might a culturally sensitive nurse respond to a Vietnamese client who practices coining, which involves rubbing the skin in a symptomatic area with a heated or oiled coin to draw an illness out of the body? Coining is not painful, but it produces redness of the skin and superficial ecchymosis (bruising).
Biologic and Physiologic Variations
The biologic characteristics of primary importance to nurses are those that involve the skin, hair, and certain physiologic enzymes.
Skin Characteristics
Skin assessment techniques commonly taught are biased toward white clients. To provide culturally sensitive care, nurses must modify their techniques to include obtaining accurate data on nonwhite clients.
The best technique for observing baseline skin color in a dark-skinned person is to use natural or bright arti- ficial light. Because the palms of the hands, the feet, and the abdomen contain the least pigmentation and are less likely to have been tanned, they are often the best struc- tures to inspect.
According to Giger and Davidhizar (2004), all skin, regardless of a person’s ethnic origin, contains an under- lying red tone. Its absence or a lighter appearance indi- cates pallor, a characteristic of anemia or inadequate oxygenation. The color of the lips and nail beds, common sites for assessing cyanosis in whites, may be highly pig- mented in other groups, and nurses may misinterpret normal findings. The conjunctiva and oral mucous mem- branes are likely to provide more accurate data. The sclera or the hard palate, rather than the skin, is a better location
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78 U N I T 2 ● Integrating Basic Concepts
EXAMPLES OF RELIGIOUS BELIEFS AND PRACTICES THAT AFFECT HEALTH CARE
TABLE 6-3
RELIGION EXAMPLES NURSING IMPLICATIONS
Orthodox Judaism
Catholicism
Jehovah’s Witnesses
Seventh Day Adventists
Christian Scientists
Church of Jesus Christ of Latter-Day Saints (Mormonism) Amish
Hinduism
Provide information on care following circumcision before discharge.
Notify dietary department of the client’s food pref- erences. Packaged food labeled kosherindicates it was “properly preserved.” Parevemeans “made without meat or milk.”
Avoid scheduling nonemergency tests or procedures during this time.
All organs removed and examined during an autopsy must be returned to the body.
Contact the family to stay with the dying client.
Expect a son or relative to close the mouth and eyes of the deceased.
Leave such items on or near the client; keep safe and return promptly if removed.
Explain how to avoid pregnancy through methods such as checking basal body temperature and characteristics of cervical mucus.
In an emergency, any baptized Christian should per- form baptism by pouring water over the head three times and saying, “I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.”
Refer to physicians who practice blood conserva- tion strategies such as autotransfusions and IV volume expanders (e.g., Dextran).
Request a consult with the dietitian to facilitate vegetarian diet without caffeine.
Avoid scheduling medical appointments or procedures at this time.
Expect that these clients will contact lay practitioners to assist with healing. Legal procedures may be used as an option when the well-being of minor children is threatened by parental refusal for medical care.
Notify the dietary department to provide non- caffeinated beverages.
Facilitate anointing rituals before surgery or upon the client’s request.
Assess home remedies and folk healing being used.
Home deliveries are preferred; expect brief overnight stays following hospital births.
Offer comfort measures and analgesic medications rather that waiting for clients to request them.
Select written health educational materials at the client’s level of understanding.
Avoid the custom of photographing newborns.
Provide a daily bath but not following a meal; add hot water to cold but not the reverse.
Avoid removing or replace it as soon as possible.
Offer comfort measures and analgesic medications rather than waiting for Hindu clients to request them.
Keep men informed of birthing progress.
Inquire if the family wishes to wash a deceased client’s body.
Request a consult with the dietitian. Client may refuse medication in gelatin capsules because gelatin is made from animal by-products.
Circumcision is a sacred ritual performed on the 8th day of life.
Kosher dietary laws allow consumption of ani- mals that chew their cud and have cloven hoofs. Animals are slaughtered according to defined procedures; dairy products and meat are not eaten together.
Sabbath begins on Friday at sundown and ends on Saturday at sundown.
Autopsy is not allowed unless required by law.
Burial is preferred within 24 hours of death; Judaic law requires that the body not be left alone.
Statues and medals of religious figures provide spiritual comfort.
Artificial birth control and abortion are forbidden.
Baptism is necessary for salvation.
They refuse blood transfusions even in life- threatening situations because they believe that blood is the source of the soul.
They follow strict dietary laws based on the Old Testament.
Saturday is the Sabbath.
Prayer is the antidote for any illness.
Coffee, tea, alcohol, tobacco, illegal drugs, and overuse of prescription drugs are prohibited.
Male members may anoint the sick with consecrated olive oil.
These clients may be reluctant to spend money on health care unnecessarily.
A central belief is that illness must be endured with faith and patience.
Clients are formally educated up to 8th grade.
Photographs are not permitted.
These clients highly value modesty and hygiene.
The application of a pundra,a distinctive mark on the forehead, is religiously symbolic.
Hindus value self-control.
Men do not participate during labor and delivery.
Cleansing of the body after death symbolizes cleansing of the soul.
Most clients are vegetarians: beef is forbidden;
some do not consume eggs.
(continued)