A PATIENT'S BEHAVIOR is influenced in part by his cultural background. However, although certain attributes and attitudes are associated with particular cultural groups as described in the following pages, not all people from the same cultural background share the same behaviors and views.
When caring for a patient from a culture different from your own, you need to be aware of and respect his cultural preferences and beliefs; otherwise, he may consider you insensitive and indifferent, possibly even incompetent. But beware of assuming that all members of any one culture act and behave in the same way; in other words, don't stereotype people.
The best way to avoid stereotyping is to view each patient as an individual and to find out his cultural preferences. Using a culture assessment tool or questionnaire can help you discover these and document them for other members of the health care team.
Keeping the caveat about stereotyping in mind, let's take a look at how people from various cultural groups tend to perceive some common behaviors and key health care issues.
Space and distance
People tend to regard the space immediately around them as an extension of themselves. The amount of space they prefer between themselves and others to feel comfortable is a culturally determined phenomenon.
Most people aren't conscious of their personal space requirements—it's just a feeling about what's comfortable for them—and you may be unaware of what people from another culture expect. For example, one patient may perceive your sitting close to him as an expression of warmth and caring; another may feel that you're invading his personal space.
Research reveals that people from the United States, Canada, and Great Britain require the most personal space between themselves and others. Those from Latin America, Japan, and the Middle East need the least amount of space and feel comfortable standing close to others. Keep these general trends in mind if a patient tends to position himself unusually close or far from you and be sensitive to his preference when giving nursing care.
Eye contact is also a culturally determined behavior. Although most nurses are taught to maintain eye contact when speaking with patients, people from some cultural backgrounds may prefer you don't. In fact, your strong gaze may be interpreted as a sign of disrespect among Asian, American Indian, Indo-Chinese, Arab, and Appalachian patients who feel that direct eye contact is impolite or aggressive. These patients may avert their eyes when talking with you and others they perceive as authority figures.
An American Indian patient may stare at the floor during conversations. That's a cultural behavior conveying respect, and it shows that he's paying close attention to you. Likewise, a Hispanic patient may maintain downcast eyes in deference to someone's age, sex, social position, economic status, or position of authority. Being aware that whether a person makes eye contact may reflect his cultural background can help you avoid misunderstandings and make him feel more comfortable with you.
Time and punctuality
Attitudes about time vary widely among cultures and can be a barrier to effective communication between nurses and patients. Concepts of time and punctuality are culturally determined, as is the concept of waiting.
In U.S. culture, we measure the passing and duration of time using clocks and watches. For most health care providers in our culture, time and promptness are extremely important. For example, we expect patients to arrive at an exact time for an appointment—despite the fact that they may have to wait for health care providers who are running late.
For patients from some other cultures, however, time is a relative phenomenon, and they may pay little attention to the exact hour or minute. Some Hispanic people, for example, consider time in a wider frame of reference and make the primary distinction between day and night but not hours of the day. Time may also be marked according to traditional times for meals, sleep, and other routine activities or events.
In some cultures, the “present” is of the greatest importance, and time is viewed in broad ranges rather than in terms of a fixed hour. Being flexible in regard to schedules is the best way to accommodate these differences.
Value differences also may influence someone's sense of time and priorities. For example, responding to a family matter may be more important to a patient than meeting a scheduled health care appointment. Allowing for these different values is essential in maintaining effective nurse/patient relationships. Scolding or acting annoyed when a patient is late would undermine his confidence in the health care system and might result in more missed appointments or indifference to patient teaching.
The meaning people associate with touching is culturally determined to a great degree. In Hispanic and Arab cultures, male health care providers may be prohibited from touching or examining certain parts of the female body; similarly, females may be prohibited from caring for males. Among many Asian Americans, touching a person's head may be impolite because that's where they believe the spirit resides. Before assessing an Asian American patient's head or evaluating a head injury, you may need to clearly explain what you're doing and why.
Always consider a patient's culturally defined sense of modesty when giving nursing care. For example, some Jewish and Islamic women believe that modesty requires covering their head, arms, and legs with clothing. Respect their tradition and help them remain covered while in your care.
In some aspects of care, the perspectives of health care providers, patients, and families may be in conflict. One example is the issue of informed consent and full disclosure. For example, you may feel that each patient has the right to full disclosure about his disease and prognosis and advocate that he be informed. But his family, coming from another culture may believe they're responsible for protecting and sparing him from knowledge about a serious illness. Similarly, patients may not want to know about their condition, expecting their relatives to “take the burden” of that knowledge and related decision making. If so, you need to respect their beliefs; don't just decide that they're wrong and inform the patient on your own.
You may face similar dilemmas when a patient refuses pain medication or treatment because of cultural or religious beliefs about pain or his belief in divine intervention or faith healing. You may not agree with his choice, but competent adults have the legal right to refuse treatment, regardless of the reason. Thinking about your beliefs and recognizing your cultural bias and world view will help you understand differences and resolve cultural and ethical conflicts you may face. But while caring for this patient, promote open dialogue and work with him, his family, and health care providers to reach a culturally appropriate solution. For example, a patient who refuses a routine blood transfusion might accept an autologous one.
People from all cultures celebrate civil and religious holidays. Get familiar with major holidays for the cultural groups your facility serves. You can find out more about various celebrations from religious organizations, hospital chaplains, and patients themselves. Expect to schedule routine health appointments, diagnostic tests, surgery, and other major procedures to avoid such holidays. If their holiday rituals aren't contradicted in the health care setting, try to accommodate them.
The cultural meanings associated with food vary widely. For example, sharing meals may be associated with solidifying social or business ties, celebrating life events, expressing appreciation, recognizing accomplishment, expressing wealth or social status, and validating social, cultural, or religious ceremonial functions. Culture determines which foods are served and when, the number and frequency of meals, who eats with whom, and who gets the choicest portions. Culture also determines how foods are prepared and served, how they're eaten (with chopsticks, fingers, or forks), and where people shop for their favorite food.
Religious practices may include fasting, abstaining from selected foods at particular times, and avoiding certain medications, such as pork-derived insulin. Practices may also include the ritualistic use of food and beverages. (See Prohibited Foods and Beverages of Selected Religious Groups.)
Many groups tend to feast, often with family and friends, on selected holidays. For example, many Christians eat large dinners on Christmas and Easter and traditionally consume certain high-calorie, high-fat foods, such as seasonal cookies, pastries, and candies. These culturally based dietary practices are especially significant when caring for patients with diabetes, hypertension, gastrointestinal disorders, and other conditions in which dietary modifications are important parts of the treatment regimen.
Along with psychosocial adaptations, you also need to consider culture's physiologic impact on how patients respond to treatment, particularly medications. Data have been collected for many years regarding different effects some medications have on persons of diverse ethnic or cultural origins. For example, because of genetic predisposition, patients may metabolize drugs in different ways or at different rates. For one patient, a “normal dose” of a medication may trigger an adverse reaction; for another, it might not work at all. (Think of how antihypertensive drugs don't work as well for African Americans as they do for white ones.) Culturally competent medication administration requires you to consider ethnicity and related factors—including values and beliefs about herbal supplements, dietary intake, and genetic factors that can affect how effective a treatment is and how well patients adhere to the treatment plan.
Various cultural groups have wide-ranging beliefs about man's relationship with the environment. A patient's attitude toward his treatment and prognosis is influenced by whether he generally believes that man has some control over events or whether he's more fatalistic and believes that chance and luck determine what will happen. If your patient holds the former view, you're likely to see good cooperation with health care regimens; he'll see the benefit of developing behavior that could improve his health. Some American Indians and Asian Americans are likely to fall into this category.
In contrast, Hispanic and Appalachian patients tend to be more fatalistic about nature, health, and death, feeling that they can't control these things. Patients who believe that they can't do much to improve their health through their actions may need more teaching and reinforcement about how diet and medications can affect their health. Provide information in a nonjudgmental way and respect their fatalistic beliefs.
Recipe for success
Clearly, you can't take a “cookbook” approach to caring for patients based on their cultural heritage or background. Transcultural nursing means being sensitive to cultural differences as you focus on individual patients, their needs, and their preferences. Show your patients your respect for their culture by asking them about it, their beliefs, and related health care practices. They'll respond to your honesty and interest, and most will be happy to tell you more about their culture.
Overcoming barriers to communication
Establishing an environment where cultural differences are respected begins with effective communication. This occurs not just from speaking the same language, but also through body language and other cues, such as voice, tone, and loudness. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires facilities to have interpreters available, so your facility should make a list available. But at times you'll be on your own, interacting with patients and families who don't speak English. To overcome the barriers you'll face, use these tips.
- Greet the patient using his last name or his complete name. Avoid being too casual or familiar. Point to yourself, say your name, and smile.
- Proceed in an unhurried manner. Pay attention to any effort the patient or his family makes to communicate.
- Speak in a low, moderate voice. Avoid talking loudly. Remember, we all have a tendency to raise the volume and pitch of our voice when a listener appears not to understand. But he may think that you're angry and shouting.
- Organize your thoughts. Repeat and summarize frequently. Use audiovisual aids when feasible.
- Use short, simple sentences and speak in the active voice.
- Use simple words, such as “pain” rather than “discomfort.” Avoid medical jargon, idioms, and slang.
- Avoid using contractions, such as don't, can't, or won't.
- Use nouns instead of pronouns. For example, ask your patient's parent, “Does Juan take this medicine?” rather than “Does he take this medicine?”
- Pantomime words, using gestures such as pointing or drinking from a cup, and perform simple actions while verbalizing them.
- Give instructions in the proper sequence. For example, rather than saying, “Before you take the medicine, get into bed,” you should say, “Get into your bed, then take your medicine.”
- Discuss one topic at a time and avoid giving too much information in a single conversation. For example, instead of asking, “Are you cold and in pain?” separate your questions and gesture as you ask them: “Are you cold?” “Are you in pain?”
- Validate whether the patient understands by having him repeat instructions, demonstrate the procedure you've taught him, or act out the meaning.
- Use any appropriate words you know in the person'slanguage. This shows that you're aware of and respect his native language.
- See if you have another language in common. For example, many Indo-Chinese people speak French, and many Europeans know three or four languages. Try Latin words or phrases, if you're familiar with the language.
- Do what you can to pick up a language that many patients in your area speak. Get phrase books from a library or bookstore, make or buy flash cards, or make a list for your bulletin board of key phrases everyone on staff can use. Your patients will appreciate your efforts, and you'll be prepared to provide better care.
Prohibited foods and beverages of selected religious groups
Alcoholic products and beverages (including extracts containing alcohol, such as vanilla and lemon)
Gelatin made with pork, marshmallow, and other confections made with gelatin
Shellfish and scavenger fish (shrimp, crab, lobster, escargot, catfish). Fish with fins and scales are permissible.
Mixing milk and meat dishes at same meal
Blood by ingestion (blood sausage, raw meat); blood by transfusion is acceptable.
Note: Packaged foods will contain labels identifying kosher (“properly preserved” or “fitting”) and pareve (made without meat or milk) items.
Mormonism (Church of Jesus Christ of Latter-Day Saints)
Beverages containing caffeine stimulants (coffee, tea, colas, and selected carbonated soft drinks)
Certain seafood, including shellfish
Note: Optional vegetarianism is encouraged.
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Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th edition, S. Smeltzer and B. Bare, Lippincott Williams & Wilkins, 2003.
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Understanding transcultural nursing
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Giger, J., and Davidhizar, R.: Transcultural Nursing: Assessment & Intervention
, 3rd edition St. Louis, Mo., Mosby, 1999.