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Perspective on cultural competency

A review of Chinese culture

Cannon, Melodie, DNP, MSC/FNP, BHSCN, RN(EC), NP-PHC, CEN, GNC(C); Tsang, Clara, MN, RN(EC), NP-PHC, GNC(C)

doi: 10.1097/01.NURSE.0000544215.16159.88

Abstract: With an emphasis on Chinese seniors, this article raises awareness of the importance of cultural competency and how this can impact care delivery, as well as strategies healthcare professionals can use to improve cultural competency in their institution.

Explore how cultural competency can improve nursing care.

Melodie Cannon is an NP at Scarborough and Rouge Health System in Toronto, Ontario, Canada, and an adjunct lecturer at the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto. Clara Tsang is a visiting professor at Life University College of Nursing and Midwifery in Sihanoukville, Cambodia, and a retired NP.

The authors have disclosed no financial relationships related to this article.



DELIVERING “patient first” care can be especially challenging for nurses and other healthcare professionals who care for multicultural populations. Beyond communication and language barriers, healthcare professionals practicing in such environments need to expand their understanding of patients' cultural beliefs and practices. They can better empathize and offer patient-centric care if they do so through a culturally sensitive lens. This article, with an emphasis on Chinese seniors, aims to promote awareness of the importance of cultural competency and how it can impact care delivery.

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A diverse community

According to the 2016 Census for Ontario, Canada, visible minorities comprised 29.3% of the total population. Chinese people represented 19.4% of these minorities.1,2 The city of Scarborough, a Toronto suburb, is especially known for its ethnic diversity. Immigrants made up 63% of the population in Scarborough as of 2011, and more than 40% of them are of Asian descent.3 Therefore, a local hospital in Scarborough was an ideal subject for an informal, culturally sensitive community assessment of how it cared for older Chinese adults. The assessment found that this population has significantly different beliefs and practices that contrast with those of the public at large.

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A lack of data

Despite serving an ethnically diverse population, the hospital did not collect data specific to the ethnicity and primary language of its patient population. Beginning with the initial presentation at triage, staff had difficulty obtaining an accurate history from Chinese patients, often due to a language barrier. Staff typically depended on the availability of Cantonese- or Mandarin-speaking staff or family members to provide collateral information. This inability to obtain pertinent information and thus intervene appropriately persisted throughout the patients' stay. Culturally sensitive treatment options or alternatives to care were not readily available.

Treatment based solely on lab results or diagnostic imaging, although part of the provision of healthcare, is often inadequate because relatively normal investigations do not exclude a potentially serious condition that can result in adverse patient outcomes. Understanding the patient, and having the patient understand the caregivers, is vital to obtaining an accurate health and medication history and providing diagnosis-specific treatment.

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Healthcare gaps in acculturation

Cultural diversity can pose unique challenges for healthcare delivery. A Toronto study found that new immigrants underutilize primary and preventive services. Reasons for this spanned from access barriers such as lack of awareness of available services, immigration status, and transportation to language difficulties and a lack of cultural sensitivity on the part of healthcare providers.4 The impact of these factors on older immigrant patients is particularly concerning because it can lead to a negatively reinforced cycle of health consequences, greater system costs, and poor patient satisfaction. Care providers who are sensitive to other cultures can stem or reverse this effect by enhancing their relationship with their patients.

Toronto residents can generally meet many of their needs, including primary healthcare, in their native language and in their own neighborhood. However, in times of crisis, they may need access to hospital services. Older adults from minority ethnic groups can be most vulnerable in these situations. Language barriers may impede accurate history taking, which in turn affects diagnosis and treatment efficacy. Following prescribed treatments may be influenced by cultural beliefs and traditions that are unfamiliar to healthcare providers, sometimes leading to adverse outcomes (See Traditional Chinese beliefs and practices).

Empowering an acute care hospital to address this unique challenge requires a comprehensive approach. This should start with a discovery process to uncover issues impacting care, assess opportunities for improvement and derive fit-for-purpose strategies that meet the community's unique cultural needs.

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Beliefs and values

Given that the Chinese belief system advocates simplicity, harmony, and order, avoiding conflict is regarded as essential to inner peace and societal reputation (See A brief guide to Chinese ideology). The culture fosters a strong sense of responsibility and obligation to family, with less focus on individual independence. A hierarchy of relationships in family and society is commonly observed, with the oldest male (husband or son) holding decision-making authority on behalf of the family. Emotional restraint, self-control, politeness, and deference to those in authoritative positions are foundational tenets of Chinese culture.5

Protection of the young and the old is an important virtue as well; consequently, withholding negative information from an older relative may be regarded as kind and loving by the family. Many Chinese believe in the concept of good and bad karma. Further, they believe talking or even thinking about death will alter the maintenance of vital inner harmony.6 These should all be important considerations for healthcare providers caring for older Chinese patients.

The Chinese perspective on health is focused on a balance between yin and yang forces, and qi (vital energy) flowing between the body and the environment.7 Five traditional elements—wood, fire, earth, metal, and water—must be kept in equilibrium to maintain health.7 These elements represent a nature cycle that corresponds to bodily functions, stages of human life, and the body's reactions to illness or disease.8 Disorder in that natural process, potentially due to such external forces as weather, emotional trauma, or contaminated food and water, is believed to cause an imbalance that results in illness.

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Healing practices

Using traditional herbs, foods, massage therapy, and folk healers to help prevent illness or supplement prescribed medications is a common practice. The use of traditional Chinese medicine is prevalent in first-generation immigrants and those with greater gaps in acculturation.9 One study in 2007 reported that approximately 65% of older Chinese immigrants reported using these traditional therapies in addition to their prescribed therapy.10

Chinese medicine utilizes plants, minerals, seeds, and animal products that are often used in combination and may interfere with drugs utilized in Western medicine. This can result in adverse reactions and may be unsafe, depending on the underlying medical condition.8

Traditional Chinese practices are believed to support health through the balancing of yin and yang, boosting the immune system, relieving inflammation and pain, and promoting the flow of qi to maintain balance and well-being.8 Procedures that interfere with this life force may not be accepted for fear of causing harm or death.6

Nurses should consider whether an older patient's agitation or refusal to participate in the treatment plan reflects his or her healthcare beliefs rather than dementia or confusion. Patients may also harbor doubts about a treatment plan but choose not to verbalize it and eventually fail to follow through. This can be misinterpreted as noncompliance, but it may just be a lack of confidence or belief that the treatment will be effective.

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Identifying barriers

Many hospitals have a culturally diverse staff, but this does not guarantee that patients can be consistently matched to a nurse based on their culture. Language barriers can make obtaining an accurate health history time-consuming or even impossible, resulting in missed diagnoses and suboptimal treatment. Although telephone interpreter services are available, they may not be mandatory and there is often an associated cost. In addition, for patients who are physically or cognitively impaired, the use of interpreter lines will not overcome communication barriers.

The presence of family members, although reassuring for the patient, often does not facilitate care as language barriers may persist. Many hospitals do have a list of staff members or volunteers who speak additional languages to assist the non-English-speaking patient. Decreased visual and auditory acuity, which are common in many older patients, may further complicate matters. Older adults may also be inaccurately labeled with dementia due to slowed responses or inappropriate answers related to the language barrier.

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Improvement strategies

Hospitals looking to improve cultural competency should consider the following strategies.

  • Collect patient ethnicity data. Hospital administrators can use data categorizing their patients' ethnicities and preferred languages to more effectively evaluate the interdependencies between cultural barriers, health outcomes, and system costs.
  • Provide translation services. Interpretation services should be encouraged despite the costs. Hospitals should also consider translating hospital signage, patient information, and patient education brochures for non-English-speaking patients. Although computer-based translation services are available, providers must ensure the service is legitimate. Experience has shown that even the slightest variation or error in translation can entirely change the intent of the information being conveyed. If the patient or family does not understand the information provided to them, how can they be expected to know how to access services, connect with their care providers and services, provide informed consent, or feel protected by the healthcare system?
  • Identify major cultures in your area. It is not realistic to think that allowances and adjustments to care can be made for every culture and ethnicity, but identifying the top three to five cultures within a hospital's area and proactively offering culturally sensitive education to staff would be a meaningful start.
  • Educate your staff. Consider compiling an easily accessed computer-based overview of specific cultures' healthcare beliefs and practices. Hospitals could also distribute language-specific surveys to patients to evaluate how to best provide culturally sensitive care.
  • Employ support services. Upon discharge, connect patients with culturally sensitive community support services. These may include personal support workers, geriatric assessment networks, or long-term-care facilities that can provide care in the patient's language and have an awareness of specific cultural beliefs.
  • Establish community focus groups. These groups identify culturally specific issues in hospital-based care. Groups can be chaired by culturally matched staff to facilitate participation, enhance credibility, and support the commitment for change. Establishing culturally specific volunteer services is another viable option.
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Implications for nursing

Assessing and responding appropriately to a patient's cultural needs is the nurse's responsibility. Nurses can adopt an open and inquisitive mindset toward their patients and enrich their knowledge of the most prevalent cultures in their hospital community. In more diverse areas, general in-service education may help teach best practice approaches and strategies.

Realistically, driving change can be time-consuming and frustrating. Long-term strategies may be more attainable if short-term interventions are accepted and implemented with minimal barriers. Choosing the most easily attainable short-term goal as a starting point can lay the groundwork for lasting, sustainable change.

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Traditional Chinese beliefs and practices

  • Feng shui. This is a philosophy that involves harmonizing a person's energy with that of the surrounding environment. For example, the way furniture is arranged in a room is thought to influence a person's health, prosperity, and happiness. When the foot of a bed is positioned directly facing a doorway, this is considered a position of death, similar to how a coffin may be carried out. This could potentially affect a person's mood and sense of well-being.
  • Lucky and unlucky numbers. Many Chinese believe the number 8 is lucky because its pronunciation is phonetically similar to the Chinese word for prosperity. The number 6 suggests smoothness or continuity, while the number 4 is considered unlucky because its pronunciation is similar to the Chinese word for death.11 This could influence a patient's reaction to an assigned area, room number, or hospital floor, and may cause additional stress.
  • Acupuncture and massage. These are thought to support illness resistance and stimulate qi—a circulating, nurturing force in the body believed to be concentrated in the chest and midabdomen. Acupuncture is a common pain relief therapy. It involves the insertion of needles into the skin and muscles at various locations, depending on the illness or complaint, in order to enhance the flow of qi and restore health. Although rooted in Chinese culture, acupuncture has become widely accepted in Western culture as an effective method of pain relief.
  • Tuina, a form of Chinese massage, is often used in conjuncture with acupuncture as both therapies are focused on circulating qi. Applying pressure to the same acupuncture points reinforces the therapy. Tuina may also involve the use of herbal compresses or heat to achieve results.12
  • Traditional healers may use a method called qi gong to set broken or dislocated bones and joints, including neck and spinal cord injuries.13
  • Coining and cupping. These are established methods of treating illness in Chinese culture and are typically administered by traditional healers.
  • Cupping involves the placement of small cups made of glass or bamboo on the body that results in suction and is thought to remove toxins. The cups are heated prior to application and upon removal leave round, reddened, or purple areas on the skin.
  • Coining involves scraping oil-lubricated skin with a coin or spoon that results in the appearance of abrasions or bruising. It is believed that these marks are a sign of toxins leaving the body to allow for self-healing. Coining and cupping may be done as individual or combination treatments.14
  • Healthcare providers should be familiar with these customs. Those who are not could misinterpret the markings as signs of abuse.
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A brief guide to Chinese ideology

To serve diverse populations, healthcare practitioners must take their clients' cultural backgrounds into account. In Chinese culture, for example, the main ideology is based on Confucianism, Buddhism, and Taoism.

  • Confucianism teaches harmony, respect for parents, and family loyalty. Achieving happiness and good health depends on respecting older members of the community.
  • Buddhism teaches that enlightenment and good health are achieved by helping others and by being merciful and humble.
  • Taoism emphasizes the virtues of a simple, honest life and maintaining harmony with nature.7
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Chinese beliefs; community assessment; cultural barriers; cultural competency; health disparities; traditional healing practices

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