Margaret M. Andrews_ Joyceen S. Boyle - Transcultural Concepts in Nursing Care-LWW (2015)

Transcultural Concepts in Nursing Care ● Seventh

Edition

Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan

Joyceen S. Boyle, PhD, RN, MPH, FAAN Adjunct Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Adjunct Professor of Nursing College of Nursing Georgia Regents University Augusta, Georgia

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Acquisitions Editor: Christina C. Burns Product Development Editor: Christine Abshire Development Editor: Elizabeth Connolly Editorial Assistant: Cassie Berube Marketing Manager: Dean Karampelas Production Project Manager: Joan Sinclair Design Coordinator: Joan Wendt Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Production Service: SPi Global 7th edition Copyright © 2016 by Wolters Kluwer Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the abovementioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Transcultural concepts in nursing care / editors, Margaret M. Andrews, Joyceen S. Boyle. — Seventh edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-9397-8 I. Andrews, Margaret M., editor. II. Boyle, Joyceen S., editor. [DNLM: 1. Transcultural Nursing. 2. Culturally Competent Care. WY 107] RT86.54 362.17'3—dc23 2015015790 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1

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Contributors

Margaret M. Andrews, PhD, RN, CTN-A, FAAN

Patti Ludwig-Beymer, PhD, RN, CTN-A, NEA-BC, FAAN

Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan

Vice President and Chief Nursing Officer Edward Hospital and Health Services Naperville, Illinois

Margaret A. McKenna, PhD, MPH, MN Martha B. Baird, PhD, APRN/CNS-BC, CTN-A Assistant Professor School of Nursing University of Kansas Medical Center Kansas City, Kansas

Joanne T. Ehrmin, PhD, RN, CNS Professor Department of Health Promotion College of Nursing University of Toledo Toledo, Ohio

Patricia A. Hanson, PhD, RN, APRN-BC, GNP Professor College of Nursing and Health Madonna University Livonia, Michigan

Jana Lauderdale, PhD, RN, FAAN Assistant Dean for Cultural Diversity School of Nursing Vanderbilt University Nashville, Tennessee

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Clinical Associate Professor Department of Health Services University of Washington Seattle, Washington

Margaret Murray-Wright, MSN, RN Associate Director, Undergraduate Programs and Clinical Assistant Professor of Nursing University of Michigan-Flint Flint, Michigan

Dula F. Pacquiao, EdD, RN, CTN-A, TNS Cultural Diversity Consultant Education, Research and Practice Lecturer, University of Hawaii Hilo School of Nursing Hilo, Hawaii

Maureen J. Reinsel, MA, MSN, APRN, AGPCNP-C Technical Writer for Patient and Program Monitoring Improving Data for Decision-Making in Global Cervical Cancer Programs (IDCCP) Jhpiego Corporation Baltimore, Maryland

Barbara C. Woodring, EdD, CPN, RN Professor Emerita Byrdine F. Lewis School of Nursing and Health Professions Georgia State University Atlanta, Georgia

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Foreword

I am pleased for the opportunity to write the Foreword to Drs. Margaret Andrews and Joyceen Boyle’s seventh edition of their book, which illuminates the historical and theoretical foundations and evolution of transcultural nursing emerging from the disciplines of nursing and anthropology. I have been asked to “fill the shoes” of our mentor and colleague, the late Dr. Madeleine Leininger, who wrote the previous Forewords to their book. Dr. Leininger, the first nurse anthropologist and the “mother” of transcultural nursing, passed away in 2012 leaving us a legacy of transcultural nursing scholarship and a body of knowledge that has accelerated exponentially from its earliest beginnings in Cincinnati, Ohio, in the 1950s to its adoption in most nations of the world. Leininger addressed the human condition through knowledge of what it means to be human, caring, understanding, and open to all cultural traditions by creating the discipline of transcultural nursing. At the outset of the programmatic development of the discipline of Transcultural Nursing, Joyceen Boyle and I were asked by Dr. Leininger to become her first two doctoral students in 1977 at the University of Utah, College of Nursing, Salt Lake City, Utah. Both of us had backgrounds in public health or anthropology and a great interest in the study of diverse cultures. As friends and students, Joyceen and I felt privileged to be pioneers as Dr. Leininger put into motion her beliefs, and values of transcultural nursing, focusing on nursing and human science, caring science, theory development, anthropology, culture, and transcultural nursing. Leininger advanced her theoretical understanding developing The Worldwide Nursing Theory of Culture Care Diversity and Universality and her Ethnonursing methodology. Her transcultural beliefs and values have been infused into nursing program o bjectives for iv

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e ducation, research, administration, and practice and were the foundation for the development of standards of practice for culturally competent care for individuals, groups, local and global communities, and organizations. Dr. Andrews teamed up early in her scholarly career with her mentor, Dr. Joyceen Boyle and they, with other major contributors, wrote one of the earliest textbooks, Transcultural Concepts in Nursing Care published first in 1989 who also was influenced by Dr. Leininger. Because of their long history of knowledge generation in transcultural nursing, this work of Andrews and Boyle is very comprehensive and shows the depth of their scholarship in terms of culture, theory development and application, research, and their commitment to the delivery of culturally competent care in practice. Rapid changes in science, technology, genetics, health care, economics, geopolitics, transportation, demographics, migration and immigration, religious ideologies, unrelenting wars, and global issues including human rights and social justice have challenged nurses to understand new ways of engaging with clients and families, and also professional colleagues in terms of transcultural nursing. By means of the new sciences of complexity and the generation of enormous quantities of research of every affiliation, and diverse philosophical, political, and religious perceptions, we can see the interconnectedness of everything in the universe and the necessity for discernment and evaluation of what is really happening in the world. Theoretical and experiential knowledge about our responsibilities to one another thus is growing and impacts the need for intense communication to examine and solve problems both locally and globally. Continuing to identify relevant issues to promote health, human safety, and

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Foreword

improve the quality of life of all people is a major goal of thoughtful national and international health care professionals. For example, we can explore, within the United Nations Millennium Development Goals for 2015 and beyond, the framework for the world community. These developments are now shaping Andrews’ and Boyle’s paradigmatic thinking in the seventh edition and their interest in addressing the challenges of the interconnectedness of all by their Transcultural Interprofessional Practice (TIP) Model with a theoretical foundation. Their model illuminates the necessity for increased collaboration and communication with clients and multiple health care and folk participants to address complex approaches to transcultural issues in the provision of culturally congruent, safe, and competent care. The beginning chapters in their book highlight foundational and evolutionary knowledge of the concepts of culture, subculture, race, ethnicity, context, communication including digital communication—the Internet and social media— evidence-based practice and problem solving, culture-specific nursing care, interprofessional collaboration and best practices, transcultural nursing, genetics, and theory development. The chapters focus on culturally competent nursing care by highlighting transcultural nursing across the life span, multicultural health care settings including the culture of organizations, the delivery of mental health care, a focus on family and community, a spotlight on the cultural diversity of the workforce, and the challenges in transcultural nursing (religion, ethics, and international nursing). Each chapter follows with a set of review questions and learning activities that illuminate what students, faculty, and clinical practitioners will have integrated into their plan of care to meet mutual goals presented in the chapter case studies. The seventh edition reflects many of the changes in the concept of the culture-at-large, especially genetics. While giving attention to Leininger’s theory in Chapter 1, what is significant in this seventh edition, as stated, is the development of their own theory, the Andrews and Boyle Transcultural Interprofessional Practice (TIP)

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Model. The key concepts identified in the TIP model are context, interprofessional health care team, communication, and problem-solving process. The cultural context (health-related beliefs and practices that weave together environmental, economic, social, religious, moral, legal, political, educational, biophysical, genetic, and technological factors), the interprofessional health care team (nurses, physicians, social workers, therapists, pharmacists, and others), cross-cultural communication among client, family, and significant others, and members of the interprofessional health care team including folk and traditional healers, and religious and spiritual healers facilitate the foundation of the problem-solving process that has five steps. These five steps include comprehensive holistic client assessment, mutual goal setting, planning, implementation of the plan of action and interventions, and evaluation of the plan for effectiveness to achieve the stated goals, and desired outcomes; provide culturally congruent and competent care; deliver quality care that is safe and affordable; and ensure that the care is evidence based with best practices. As I reflect on the work of my colleagues, Andrews and Boyle, not only within the pages of this book but also what each of them has accomplished over many years as leaders, teachers, researchers, online educators, and as Presidents of the Transcultural Nursing Society, what comes to mind is their deep dedication and devotion to the discipline and profession of Transcultural Nursing. Through their intellectual astuteness and creative actions, they have been and are role models and mentors to students and other leaders who have spread and broadened transcultural care knowledge worldwide. They are committed to the primary goal of transcultural nursing to facilitate culturally congruent knowledge and care so that people of the world are understood and their health care needs can be met within the dynamics of their cultures and cultural understanding. A seventh edition of a book attests to the fact that students, faculty, and other practitioners find within its pages relevant and challenging information to learn about cultures and

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Foreword

ethnic groups, know how to relate and serve them, conduct research, facilitate the solving of problems, and “making things work.” Today collaboration and communication are the key. Margaret Andrews and Joyceen Boyle have captured that essence in their Transcultural Interprofessional Practice (TIP) theory and model, which is presented in this work. I wholeheartedly endorse this new edition. I am most proud to call these authors not only my colleagues but also my friends as they move forward in the evolution of what can be termed authentic transcultural nursing by means of collaboration and interprofessionalism. Nursing students, faculty, other health care professionals, and practitioners

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of every health care and anthropological discipline will be stimulated by the theory and the content expressed by the authors and the many contributors in this new edition to improve the health of and help people of diverse cultures worldwide. Marilyn A. Ray, RN, PhD, CTN-A, FSfAA, FAAN Colonel (Retired), United States Air Force, Nurse Corps Professor Emeritus The Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

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Preface

Given the large number of cultures and subcultures in the world, it’s impossible for nurses to know everything about them all; however, it is possible for nurses to develop excellent cultural assessment and cross-cultural communication skills and to follow a systematic, orderly process for the delivery of culturally competent care. The Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model, which we are introducing in this seventh edition of Transcultural Concepts in Nursing Care and describe in more detail in Chapters 1 and 2, emphasizes the need for effective communication, efficient, client- and patient-centered teamwork, and collaboration among members of the interprofessional health care team. The TIP Model has a theoretical foundation in transcultural nursing that fosters communication and collaboration between and among all members of the team and enables multiple team members to manage complex, frequently multifaceted transcultural care issues, moral and ethical dilemmas, challenges, and care-related problems in a collegial, respectful, synergistic manner. The process used in the TIP Model is an adaptation and application of the classic scientific problem-solving method used to deliver nursing and health care to people from different national origins, ethnicities, races, socioeconomic backgrounds, religions, genders, marital statuses, sexual orientations, ages, abilities/disabilities, sizes, veteran status, and other characteristics used to compare one group of people to another. The Commission on Collegiate Nursing Education, the American Association of Colleges of Nursing’s Essentials of Baccalaureate Education for Professional Nursing Practice, the National League for Nursing, most state boards of nursing, and

other accrediting and certification bodies require or strongly encourage the inclusion of cultural aspects of care in nursing curricula. This, of course, underscores the importance of the purpose, goal, and objectives for Transcultural Concepts in Nursing Care, Seventh Edition. Purpose: To contribute to the development of theoretically based transcultural nursing knowledge and the advancement of transcultural nursing practice. Goal: To increase the delivery of culturally competent care to individuals, families, groups, communities, and institutions. Objectives: 1. To apply a transcultural nursing framework to

guide nursing practice in diverse health care settings across the lifespan. 2. To analyze major concerns and issues encountered by nurses in providing transcultural nursing care to individuals, families, groups, communities, and institutions. 3. To expand the theoretical bases for using concepts from the natural and behavioral sciences and from the humanities to provide culturally competent nursing care. 4. Provide a contemporary approach to transcultural nursing that includes effective crosscultural communication, team work, and interprofessional collaborative practice. We believe that cultural assessment skills, combined with the nurses’ critical thinking abilities, will provide the necessary knowledge on which to base transcultural nursing care. Using this approach, nurses have the ability to provide culturally competent and contextually meaningful care for clients—individuals, groups, families, communities, and institutions. vii

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The editors and chapter authors share a commitment to: ●●

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Foster the development and maintenance of a disciplinary knowledge base and expertise in culturally competent care. Synthesize existing theoretical and research knowledge regarding nursing care of different ethnic/minority/marginalized and other disenfranchised populations. Identify and describe evidence-based practice and best practices in the care of diverse individuals, families, groups, communities, and institutions. Create an interdisciplinary and interprofessional knowledge base that reflects heterogeneous health care practices within various cultural groups. Identify, describe, and examine methods, theories, and frameworks appropriate for developing knowledge that will improve health and nursing care to minority, underserved, underrepresented, disenfranchised, and marginalized populations.

Recognizing Individual Differences and Acculturation We believe that it is tremendously important to recognize the myriad of health-related beliefs and practices that exist within the population categories. For example, the differences are rarely recognized among people who identify themselves as Hispanic/Latino: this group includes people from along the U.S.–Mexico border, Puerto Rico, Mexico, Spain, Guatemala, or “little Havana” in Miami, as well as other Central and South American countries, who may share some similarities (speaking Spanish, for example) but who may also have distinct cultural differences. We would like to comment briefly on the terms minority and ethnic minorities. These terms are perceived by some to be offensive because they connote inferiority and marginalization. Although we have used these terms occasionally, we prefer to make reference to a specific subculture or culture whenever possible. We refer to categorizations

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according to race, ethnicity, religion, or a combination, such as ethnoreligion, but we make every effort to avoid using any label in a pejorative manner. We do believe, however, that the concepts or terms minority or ethnicity are limiting, not only for those to whom the label perhaps applies but also for nursing theory and practice. We believe that concept of culture is richer and has more theoretical usefulness. In addition, we all have cultural attributes while not all are from a minority group or claim a particular ethnicity.

Critical Thinking Linked to Delivering Culturally Competent Care We believe that cultural assessment skills, combined with the nurse’s critical thinking ability, will provide the necessary knowledge on which to base transcultural nursing care. Using this approach, we are convinced that nurses will be able to provide culturally competent and contextually meaningful care for clients from a wide variety of cultural backgrounds, rather than simply memorizing the esoteric health beliefs and practices of any specific cultural group. We believe that nurses must acquire the skills needed to assess clients from virtually any and all groups that they encounter throughout their professional life. Many educational programs in nursing are now teaching transcultural nursing content across the curriculum. We suggest that Transcultural Concepts in Nursing Care can be used by faculty members to integrate transcultural content across the curriculum in the following manner: Chapters 1 to 4 in the first clinical courses when students are learning how to conduct health histories, health assessments, and physical examinations; Chapters 10 and 11, mental health nursing and family and community nursing, in the appropriate specialty nursing courses; Chapters 5 to 8, which include nursing care across the lifespan, in courses that focus on the nursing care of the childbearing family, children, adults, and older adults; Chapters 9, 12, and 14, which concern culturally competent organizations, diversity in the

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multicultural health care workforce, and competence in ethical decision making, in courses that focus on nursing leadership and management; Chapter 13, which examines religion, culture, and nursing, an excellent resource throughout the curriculum; and Chapter 15 in courses that focus on global health/community health nursing.

New to the Seventh Edition All content in this edition was reviewed and updated to capture the nature of the changing health care delivery system, new research studies, and theoretical advances, emphasis on effective communication, team work, and collaboration, and to explain how nurses and other health care providers can use culturally competent skills to improve the care of clients, families, groups, and communities. In writing the seventh edition, we have been impressed with the developments in the field of transcultural nursing. The Transcultural Nursing Society and the American Academy of Nursing (AAN) have moved ahead with developing Standards of Practice for Culturally Competent Care that nurses around the world are using as a guide in clinical practice, research, education, and administration. In addition, a special task force from the Transcultural Nursing Society has developed a Core Curriculum for Transcultural Nursing that is being used as a basis for certification in transcultural nursing and for instructional purposes by faculty and students in educational programs. The recognition of the Standards of Practice and Core Curriculum for transcultural nursing enhances the development of cultural competence in nursing, thus improving the care of clients. Lastly, the Andrews/Boyle Transcultural Interprofessional Practice Model is introduced in recognition of the need to put the client or patient first and of the changing complexion of the health care workforce.

New Chapter Contributors We welcome two new colleagues in the seventh edition, both from the University of

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ichigan-Flint School of Health Professions M and Studies. Margaret (Margie) Murray-Wright, Associate Director of Undergraduate Programs and Clinical Assistant Professor of Nursing, infused state-of-the art content on genetics and genomics and coauthored Chapter 3, Cultural Competence in the Health History and Physical Examination. An Adult-Gerontology Nurse Practitioner, Maureen J. Reinsel has extensive experience in global public health and international development in Asia, Africa, and Europe. In addition to her nursing background, Maureen earned her MA degree in International Affairs from the Johns Hopkins University School of Advanced International Studies. She wrote Chapter 15, Nursing and Global Health, which is available online.

Chapter Pedagogy Learning Activities All of the chapters include review questions as well as learning activities to promote critical thinking. When relevant web-based information is available to supplement the chapter content, references are provided on . In addition, each chapter includes chapter objectives and key terms to help readers understand the purpose and intent of the content. Evidence-Based Practice Current research studies related to the content of the chapter are presented as Evidence-Based Practice boxes. We have included a section in each box describing clinical implications of the research. Case Studies Case Studies based on the authors’ actual clinical experiences and research findings are presented to make conceptual linkages and to illustrate how concepts are applied in health care settings. Case studies are oriented to assist the reader to begin to develop cultural competence with selected cultures.

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Text Organization Part One: Foundations of Transcultural Nursing This first section focuses on the foundational aspects of transcultural nursing. The development of transcultural nursing frameworks that include concepts from the natural and behavioral sciences are described as they apply to nursing practice. Because nursing perspectives are used to organize the content in Transcultural Concepts in Nursing Care, the reader will not find a chapter purporting to describe the nursing care of a specific cultural group. Instead, the nursing needs of culturally diverse groups are used to illustrate cultural concepts used in nursing practice. Chapter 1 provides an overview of the theoretical foundations of transcultural nursing, and Chapter 2 introduces key concepts associated with cultural competence using the Andrews/ Boyle Transcultural Interprofessional Practice Model as the organizing framework. In Chapter 3, we discuss the domains of cultural knowledge that are important in cultural assessment and describe how this cultural information can be incorporated into all aspects of care. Chapter 4 provides a summary of the major cultural belief systems embraced by people of the world with special emphasis on their health-related and culturally based values, attitudes, beliefs, and practices. Part Two: Transcultural Nursing: Across the Lifespan Chapters 5 through 8 use a developmental framework to discuss transcultural concepts across the lifespan. The care of childbearing women and their families, children, adolescents, middle-aged adults, and the elderly is examined, and information about cultural groups is used to illustrate common transcultural nursing issues, trends, and concerns.

c ultural competence in mental health and in family and community health care settings. We also examine cultural competence in health care organizations and cultural diversity in the health care workforce, two very critical and current topics of concern. The clinical application of concepts throughout this section uses situations c ommonly encountered by nurses and describes how transcultural nursing principles can be applied in diverse settings. The chapters in this section are intended to illustrate the application of transcultural nursing knowledge to nursing practice. Part Four: Contemporary Challenges in Transcultural Nursing In the fourth section of the text, Chapters 13 to15, we examine selected contemporary issues and challenges that face nursing and health care. In Chapter 13, we review major religious traditions of the United States and the interrelationships among religion, culture, and nursing. Recognizing the numerous moral and ethical challenges in contemporary health care as well as within the transcultural nursing, Chapter 14, available on , discusses cultural competence in ethical and moral dilemmas from a transcultural perspective. Chapter 15, available on , provides a global perspective of what is occurring in the international areas to promote human and health. This chapter is slightly different from the rest of the chapters as it highlights the field of international nursing and the ways in which nurses can contribute to the global efforts to improve the health status of people across the world.

Instructor Resources The following tools to assist you with teaching your course are available upon adoption of this text on : ●●

Part Three: Nursing in Multicultural Health Care Settings In the third section of the text (Chapters 9 through 12), we explore the components of

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The Test Generator lets you generate new tests from a bank of NCLEX-style questions to help you assess your students’ understanding of the course material. PowerPoint Presentations provide an easy way for you to integrate the textbook with your

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students’ classroom experience, either via slide shows or handouts. Instructor’s Guide for Teaching Transcultural Concepts includes activities and discussion topics to help you engage students in the material.

Student Resources Students who have purchased Transcultural Concepts in Nursing Care, Seventh Edition have access to the following additional resources: ●●

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Chapter 14, Cultural Competence in Ethical Decision Making, discusses cultural competence in ethical and moral dilemmas from a transcultural perspective. Chapter 15, Nursing and Global Health, discusses the field of international nursing and the opportunities available for nurses who would like to practice internationally. Journal Articles corresponding to book chapters offer access to current research available in Wolters Kluwer journals.

Lippincott RN to BSN Online Lippincott RN to BSN Online, a full curriculum online course solution aligned with The Essentials of Baccalaureate Education for Professional N ursing Practice and Quality and Safety Education for Nurses Competencies, uniquely features self-paced multimedia modules that foster experiential, active learning. Lippincott RN to BSN Online capitalizes on the “flipped classroom” pedagogy trend by integrating quality textbook content, assessments, and remediation with interactive modules. At its core is its exceptional instructional design strategies— storytelling, modeling, case-based, social, and collaborative learning. These innovative student and instructor resources take RN to BSN courses to the next level by featuring a guiding framework derived from the Cognitive Learning

Theory and the best practices for e-learning from the Next Generation Learning Initiative. For more information, go to http://thepoint. lww.com/rntobsn.

Acknowledgments We are pleased to acknowledge the assistance and support of our families, friends, and colleagues in once again making this book possible. We also appreciate the help of the many nursing faculty members, practitioners, and students who have offered helpful comments and suggestions. We have found it very gratifying to be able to call upon many of our colleagues for help and advice in this new edition. We would like to gratefully acknowledge and thank Elizabeth Connolly, Development Editor, Wolters Kluwer Health, for her helpful recommendations on ways to strengthen the seventh edition, her careful attention to detail, her flexibility, her invaluable input on the Andrews/Boyle Transcultural Interprofessional Practice Model, her assistance in locating suitable digital images, and the long hours that she spent reviewing and rereviewing the chapters and appendices. We gratefully acknowledge the support of our friends, too numerous to list by name, who wrote encouraging e-mails or phoned to express their interest and encouragement. We thank all of our colleagues who have purchased our book in the past and the many who have expressed interest in the seventh edition. We are always appreciative of their support. Last of all, we would once again like to thank each other for what has been a lifetime of friendship that has withstood the test of time and now seven editions of this book! Through it all, we have found our professional endeavors in transcultural nursing and the friends that we have made along the way to be both satisfying and rewarding. Margaret M. Andrews, PhD, RN, CTN-A, FAAN Joyceen S. Boyle, PhD, RN, MPH, FAAN

For a list of the reviewers of this book and the accompanying Test Generator questions, please visit thepoint.lww.com/Andrews7e.

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at http://

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Contents

Part One: Foundations of Transcultural Nursing Chapter 1

Theoretical Foundations of Transcultural Nursing 2 Margaret M. Andrews and Joyceen S. Boyle

Chapter 2

Culturally Competent Nursing Care 30 Margaret M. Andrews

Chapter 3

Cultural Competence in the Health History and Physical Examination 55 Margaret M. Andrews and Margaret Murray-Wright

Chapter 4

The Influence of Cultural and Health Belief Systems on Health Care Practices 102 Margaret M. Andrews

Part Two: Transcultural Nursing: Across the Lifespan Chapter 5

Transcultural Perspectives in Childbearing 120 Jana Lauderdale

Chapter 6

Transcultural Perspectives in the Nursing Care of Children 153 Margaret M. Andrews and Barbara C. Woodring

Chapter 7

Transcultural Perspectives in the Nursing Care of Adults 186 Joyceen S. Boyle

Chapter 8

Transcultural Perspectives in the Nursing Care of Older Adults 213 Margaret A. McKenna

Part Three: Nursing in Multicultural Health Care Settings Chapter 9

Creating Culturally Competent Health Care Organizations 242 Patti Ludwig-Beymer

Chapter 10 Transcultural Perspectives in Mental Health Nursing 272 Joanne T. Ehrmin

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Chapter 11 Culture, Family, and Community 317 Joyceen S. Boyle and Martha B. Baird

Chapter 12 Cultural Diversity in the Health Care Workforce 359 Margaret M. Andrews

Part Four: Contemporary Challenges in Transcultural Nursing Chapter 13 Religion, Culture, and Nursing 394 Patricia A. Hanson and Margaret M. Andrews

Chapter 14 Cultural Competence in Ethical Decision Making 447 Dula F. Pacquiao

Chapter 15 Nursing and Global Health 465 Maureen J. Reinsel and Margaret M. Andrews Chapters 14 and 15 available on

Appendix A Andrews/Boyle Transcultural Nursing Assessment Guide for Individuals and Families A-1 Joyceen S. Boyle and Margaret M. Andrews

Appendix B Andrews/Boyle Transcultural Nursing Assessment Guide for Families, Groups, andCommunities B-1 Joyceen S. Boyle and Margaret M. Andrews

Appendix C Andrews/Boyle Transcultural Nursing Assessment Guide for Health Care Organizations and Facilities C-1 Joyceen S. Boyle, Margaret M. Andrews, and Patti Ludwig-Beymer

Appendix D Components of a Cultural Assessment: Traditional Native American Healing D-1 Joyceen S. Boyle

Appendix E Boyle/Baird Transcultural Nursing Assessment Guide for Refugees E-1 Joyceen S. Boyle and Martha B. Baird

Index I-1

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Part One

Foundations of Transcultural Nursing

Theoretical Foundations of Transcultural Nursing ●●Margaret M. Andrews and Joyceen S. Boyle

Key Terms Anthropology Assessment Assumptions Chronemics Communication Core Curriculum Cross-cultural communication Cultural competence Cultural context Culturally competent care Culturally congruent nursing care Cultural-specific Cultural universals

Culture Culture-specific nursing care Culture-universal nursing care Ethnicity Ethnonursing research Evaluation Evidence-based practice Hijab Implementation Interprofessional collaboration Interprofessional health care team Language Modesty Monochronic culture Mutual goal setting

Nonverbal communication Paralanguage Personal space Polychronic culture Problem-solving process Proxemics Race Subculture Transcultural Interprofessional Practice (TIP) Model Transcultural nursing Transcultural nursing certification Verbal Communication

Learning Objectives 1. Explore the historical and theoretical foundations of transcultural nursing. 2. Critically examine the relevance of transcultural nursing in addressing contemporary issues and trends in nursing. 3. Analyze Leininger’s contributions to the creation and development of transcultural nursing as a theory and evidence-based formal area of study and practice within the nursing profession. 4. Critically examine the contributions of selected transcultural scholars to the advancement of transcultural nursing theory and practice. 5. Discuss key components of the Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model.

Chapter 1 Theoretical Foundations of Transcultural Nursing

Introduction to Transcultural Nursing In her classic, groundbreaking book titled “Nursing and Anthropology: Two Worlds to Blend,” Leininger (1970) analyzed the ways in which the fields of anthropology and nursing are interwoven and interconnected (c.f., Brink, 1976; McKenna, 1985; Osborne, 1969). Leininger used the term transcultural nursing (TCN) to describe the blending of nursing and anthropology into an area of specialization within the discipline of nursing. Using the concepts of culture and care, Leininger established TCN as a theory and evidence-based formal area of study and practice within nursing that focuses on people’s culturally based beliefs, attitudes, values, behaviors, and practices related to health, illness, healing, and human caring (Leininger, 1991, 1995; Leininger & McFarland, 2002, 2006). TCN is sometimes used interchangeably with cross-cultural, intercultural, and multicultural nursing. The goal of TCN is to develop a scientific and humanistic body of knowledge in order to provide culture-specific and culture-universal nursing care practices for individuals, families, groups, communities, and institutions of similar and diverse cultures. Culture-specific refers to particular values, beliefs, and patterns of behavior that tend to be special or unique to a group and that do not tend to be shared with members of other cultures. Culture-universal refers to the commonly shared values, norms of behavior, and life patterns that are similarly held among cultures about human behavior and lifestyles (Leininger, 1978, 1991, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a). For example, although the need for food is a cultureuniversal, there are culture-specifics that determine what items are considered to be edible; acceptable methods used to prepare and eat meals; rules concerning who eats with whom, the frequency of meals, and gender- and age-related rules governing who eats first and last at meal time; and the amount of food that individuals are expected to consume.

Given that culture is the central focus of anthropology and TCN, we begin this chapter by introducing, defining, and describing the concept of culture. We’ll then discus the historical and theoretical foundations of TCN, including its relevance in contemporary nursing practice and the significant contributions of Leininger and other TCN scholars, leaders, and clinicians to the global advancement of TCN research, theory, education, and clinical practice. In the remainder of the chapter, we examine the Transcultural Interprofessional Practice (TIP) Model as a framework for delivering client-centered, high-quality nursing and health care that are culturally congruent and competent, safe, affordable, and accessible to people from diverse backgrounds across the lifespan. The term client is used throughout the book because nursing concerns not only the care of people who are ill but also those who strive for optimum health and wellness in their lives.

Anthropology and Culture To understand the history and foundations of TCN, we begin by providing a brief overview of anthropology, an academic discipline that is concerned with the scientific study of humans, past and present. Anthropology builds on knowledge from the physical, biological, and social sciences as well as the humanities. A central concern of anthropologists is the application of knowledge to the solution of human problems. Historically, anthropologists have focused their education on one of four areas: sociocultural anthropology, biological/physical anthropology, archaeology, and linguistics. Anthropologists often integrate the perspectives of several of these areas into their research, teaching, and professional lives (American Anthropological Association, n.d.; Council on Nursing and Anthropology, n.d.). One of the central concepts that anthropologists study is culture. A complicated, multifaceted concept, culture has numerous definitions. The earliest recorded definition comes from a 19th c entury British pioneer in the field of anthropology named Edward Tylor, who defines

Part One Foundations of Transcultural Nursing

culture as the complex whole that includes knowledge, beliefs, art, morals, law, customs, and any other capabilities and habits acquired by members of a society (Tylor, 1871). Influenced by her formal academic preparation in anthropology (Meade, 1937), Leininger defines culture as the “learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group of people that guide thinking, decisions, and actions in a patterned way…. Culture is the blueprint that provides the broadest and most comprehensive means to know, explain, and predict people’s lifeways over time and in different geographic locations” (McFarland & Wehbe-Alamah, 2015a, p. 10). Culture influences a person’s definition of health and illness, including when it is appropriate to self-treat and when the illness is sufficiently serious to seek assistance from one or more healers outside of the immediate family. The choice of healer and length of time a person is allowed to recover, after the birth of a baby or following the onset of an illness, are culturally determined. How a person behaves during an illness and the help

rendered by others in facilitating healing also are culturally determined. Culture determines who is permitted, or expected, to care for someone who is ill. Similarly, culture determines when a person is declared well and when they are healthy enough to resume activities of daily living and/or return to work. When someone is dying, culture often determines where, how, and with whom the person will spend his or her final hours, days, or weeks. Although the term culture sometimes connotes a person’s racial or ethnic background, there are also many other examples of nonethnic cultures, such as those based on socioeconomic status, for example, the culture of poverty or affluence and the culture of the homeless; ability or disability, such as the culture of the deaf or hearing impaired and the culture of the blind or visually impaired; sexual orientation, such as the lesbian, gay, bisexual, and transgender (LGBT) cultures; age, such as the culture of adolescence and the culture of the elderly; and occupational or professional cultures, such as nursing (American Nurses Association, 2013; International Council of Nurses, 2013) (see Figure 1-1), medicine,

Figure 1-1. The profession of nursing is an example of a nonethnic occupational culture. The faculty member on the left is transmitting the requisite knowledge and skills from one generation to the next by mentoring the nursing student on the right.

Chapter 1 Theoretical Foundations of Transcultural Nursing

and other professions in health care, business, education, and related fields. In a classic study of culture by the anthropologist Edward Hall (1984), three levels of culture are identified: primary, secondary, and tertiary. The primary level of culture refers to the implicit rules known and followed by members of the group, but seldom stated or made explicit, to outsiders. The secondary level refers to underlying rules and assumptions that are known to members of the group but rarely shared with outsiders. The primary and secondary levels are the most deeply rooted and most difficult to change. The tertiary level refers to the explicit or public face that is visible to outsiders, including dress, rituals, cuisine, and festivals. The term subculture refers to groups that have values and norms that are distinct from those held by the majority within a wider society. Members of subcultures have their own unique shared set of customs, attitudes, and values, often accompanied by group-specific language, jargon, and/or slang that sets them apart from others. A subculture can be organized around a common activity, occupation, age, ethnic background, race, religion, or any other unifying social condition. In the United States, subcultures might include the various racial and ethnic groups. For example, Hispanic is a panethnic designation that includes many subcultures consisting of people who self-identify with Mexican, Cuban, Puerto Rican, and/or other groups that often share Spanish language and culture (Morris, 2015). Ethnicity is defined as the perception of oneself and a sense of belonging to a particular ethnic group or groups. It can also mean feeling that one does not belong to any group because of multiethnicity. Ethnicity is not equivalent to race, which is a biological identification. Rather, ethnicity includes commitment to and involvement in cultural customs and rituals (Douglas & Pacquiao, 2010). In the United States, ethnicity and race are defined by the federal Office of Management and Budget (OMB) and the U.S. Census Bureau; they provide standardized categories, which are used in the collection of census information on racial and ethnic populations and are also often used by biomedical researchers. There are six officially recognized eth-

nic and racial categories: White American, Native American, and Alaska Native; Asian American, Black, or African American; Native Hawaiian and other Pacific Islander; and people of two or more races; a race called “some other race” is also used in the census and other surveys but is not official. The Census Bureau also classifies Americans as “Hispanic or Latino” and “Not Hispanic or Latino,” which identifies Hispanic and Latino Americans as a racially diverse ethnicity. In the traditional anthropological and biological systems of classification, race refers to a group of people who share such genetically transmitted traits as skin color, hair texture, and eye shape or color. Races are arbitrary classifications that lack definitional clarity because all cultures have their own ways of categorizing or classifying their members (Hesmondhalgh & Sala, 2013; Hunt, Truesdel, & Kreiner, 2013). Some define race as a geographically and genetically distinct population, whereas others suggest that racial categories are socially constructed (Zimitri, 2013). The most current scientific data indicate that all humans share the same 99.1% of genes; the remaining 0.1% accounts for the differences in humans (National Human Genome Institute, 2014).

Historical and Theoretical Foundations of Transcultural Nursing More than 60 years ago, Madeleine Leininger (1925 to 2012; see Figure 1-2) noted cultural differences between patients and nurses while working with emotionally disturbed children. This clinical nursing experience piqued her interest in cultural anthropology. As a doctoral student in anthropology, she conducted field research on the care practices of people in Papua New Guinea and subsequently studied cultural similarities and differences in the culture care perceptions and expressions of people around the world. At the same time that Leininger (Leininger, 1978, 1991, 1995, 1997, 1998, 1999; Leininger & McFarland, 2002, 2006) was establishing TCN,

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Figure 1-2. Author, Dr. Margaret Andrews (left), and Transcultural Nursing Foundress, Dr. Madeleine Leininger (right), at a meeting of the American Academy of Nursing.

other anthropologists, nurse–anthropologists, and nurses who were studying, teaching, and writing about ethnicity, race, diversity, and/or culture in nursing used terms such as cross-cultural nursing, ethnic nursing care (Orque, Bloch & Monrroy, 1983), or referred to caring for people of color (Branch & Paxton, 1976). The term transcultural nursing is used in this book, in recognition of the historical, research, and theoretical contributions of Leininger (1978), who used this term in her research and other scholarly works. Leininger cites eight factors that influenced her to establish TCN as a framework for addressing 20th-century societal and health care challenges and issues, all of which remain relevant today:

3. An increase in health care providers’ and

1. A marked increase in the migration of people

within and between countries worldwide

2. A rise in multicultural identities, with people

expecting their cultural beliefs, values, and ways of life to be understood and respected by nurses and other health care providers

patients’ use of technologies that connect people globally and simultaneously may become the source of conflict with the cultural values, beliefs, and practices of some of the people receiving care Global cultural conflicts, clashes, and violence that impact health care as more cultures interact with one another An increase in the number of people traveling and working in different parts of the world An increase in legal actions resulting from cultural conflict, negligence, ignorance, and the imposition of health care practices A rise in awareness of gender issues, with growing demands on health care systems to meet the gender- and age-specific needs of men, women, and children An increased demand for community- and culturally based health care services in diverse environmental contexts (Leininger, 1995)

Chapter 1 Theoretical Foundations of Transcultural Nursing

TCN exists today as an evidence-based, dynamic area of specialization within the nursing profession because of the visionary leadership of its founder, Madeleine Leininger, and many other nurses committed to the provision of care that is consistent with and “fits” the cultural beliefs and practices of those receiving it. This section explores the contributions of Leininger and then examines the ways in which other nursing scholars contributed to the development and advancement of TCN theory, research, practice, education, and administration globally.

Leininger’s Contributions to Transcultural Nursing Leininger’s Theory of Culture Care Diversity and Universality describes, explains, and predicts nursing similarities and differences in care and caring in human cultures (Leininger, 1991). Leininger uses concepts such as worldview, social and cultural structure, language, ethnohistory, environmental context, and folk and professional healing systems to provide a comprehensive and holistic view of factors that influence culture care. Culturally based care factors are recognized as major influences on human experiences related to well-being, health, illness, disability, and death. After conducting a comprehensive cultural assessment based on the preceding factors, the three modes of nursing decisions and actions— culture care preservation and/or maintenance, culture care accommodation and/or negotiation, and culture care repatterning and/or restructuring—are used to provide culturally congruent nursing care (Leininger, 1991, 1995; Leininger & McFarland, 2002, 2006). Culturally congruent nursing care “refers to those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are mostly tailor-made to fit with an individual’s, group’s or institution’s cultural values, beliefs, and lifeways in order to provide meaningful, beneficial, satisfying care that leads to health and well-being” (Leininger, 1991, p. 47). Cultural congruence is central to Leininger’s Theory of Culture Care Diversity and Universality.

Among the strengths of Leininger’s theory is its flexibility for use with individuals, families, groups, communities, and institutions in diverse health systems. To help develop, test, and organize the emerging body of knowledge in TCN, Leininger recognized that it would be necessary to have a specific conceptual framework from which various theoretical statements are developed. Leininger’s Sunrise Enabler (Figure 1-3) depicts components of the Theory of Cultural Care Diversity and Universality, provides a visual representation of these components, and illustrates the interrelationships among the components. As the world of nursing and health care has become increasingly multicultural, the theory’s relevance has increased as well. While creating TCN as a respected and recognized nursing specialty and developing her theory, Leininger also had the foresight to establish the Transcultural Nursing Society (TCNS), generate the TCNS Newsletter, and create the Journal of Transcultural Nursing (JTN), for which she served as the founding editor. The TCNS holds regional and annual conferences, disseminates the newsletter, and collaborates with a publishing company to produce a quarterly journal, all of which provide forums for the exchange of TCN knowledge, research, and evidence-based, best practices relative to the provision of culturally congruent and culturally competent nursing and health care. To integrate TCN into the curricula of schools of nursing, Leininger established the first master’s and doctoral programs in nursing with a theoretical and research focus in TCN and provided exemplars for TCN courses and curricula suitable for all levels of nursing education (undergraduate and graduate) through her lectures, publications, and consultations. Leininger also created a new qualitative research method called ethnonursing research to investigate phenomena of interest in TCN (Leininger, 1995; Leininger & McFarland, 2002, 2006; McFarland, Mixer, Webhe-Alamah, & Burk, 2012; McFarland & Wehbe-Alamah, 2015). Hundreds of studies have been conducted using ethnonursing research, which is the first research methodology developed by a nurse for

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Leininger’s Sunrise Enabler to Discover Culture Care CULTURE CARE Worldview Cultural & Social Structure Dimensions

Kinship & Social Factors

Cultural Values, Beliefs & Lifeways

Political & Legal Factors

Environmental Context, Language & Ethnohistory

Religious & Philosophical Factors

Influences

Economic Factors

Care Expressions Patterns & Practices

Technological Factors

Educational Factors

Holistic Health/Illness/Death Focus: Individuals, Families, Groups, Communities, or Institutions in Diverse Health Contexts of

Generic (Folk) Care

Nursing Care Practices

Professional Care–Cure Practices

Culture Care Decisions & Actions Culture Care Preservation and/or Maintenance Culture Care Accommodation and/or Negotiation Culture Care Repatterning and/or Restructuring

Culturally Congruent Care for Health, Wellbeing, or Dying Code:

(Influencers)

Figure 1-3. Leininger’s Sunrise Enabler to discover culture care. (Reprinted by permission of McFarland, M. R., & Wehbe-Alamah, H. B. (2015). Leininger’s sunrise enabler. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Culture care diversity and universality: A worldwide nursing theory (3rd ed., p. 25). Burlington, MA: Jones and Bartlett Learning.)

Chapter 1 Theoretical Foundations of Transcultural Nursing

use in studying topics relevant to nursing. Ray and colleagues studied caring, complexity science, and transcultural caring dynamics in nursing and healthcare (Davidson & Ray, 2011; Ray, 2010; Ray, Turkel, & Cohn, 2011). Lastly, Leininger’s contributions to TCN rapidly gained global and interprofessional recognition as many health care professionals from medicine, physical therapy, occupational therapy, social work, and related disciplines learned about the Theory of Cultural Care Diversity and Universality and either adopted or adapted it to fit their respective disciplines. As nursing and health care have become increasingly multicultural and diverse, TCN’s relevance has increased as well. There also is heightened societal awareness that people of all cultures deserve to receive nursing and health care that are culturally congruent and culturally competent. Cultural competence refers to the complex integration of knowledge, attitudes, values, beliefs, behaviors, skills, practices, and cross-cultural encounters that include effective communication and the provision of safe, affordable, quality, accessible, evidencebased, and efficacious nursing care for individuals, families, groups, and communities of diverse and similar cultural backgrounds. Cultural competence is discussed in detail in Chapter 2.

Advancements in Transcultural Nursing In addition to Leininger, many other TCN scholars and leaders around the world have made, and continue to make, significant contributions to the body of transcultural knowledge, research, theory, and evidence-based practices that guide nurses in the delivery of culturally congruent and culturally competent care for people from similar and diverse cultures (Clark, 2013; Courtney & Wolgamott, 2015; deRuyter, 2015; Eipperle, 2015; Larson, 2015; McFarland & Wehbe-Alamah, 2015a & b;McFarland, et al., 2015; Mixer, 2015; Raymond & Omeri, 2015). While the authors of this textbook have chosen to emphasize the research and theory generated by Leininger, there are many different ways to conceptualize TCN and deliver culturally congruent and culturally competent nursing care.

The following TCN scholars and leaders have enhanced, expanded, and advanced the specialty through their research, teaching, publications, conceptual models, frameworks, and/or theories: Josepha Campinha-Bacote (Campinha-Bacote, 2011), Geri-Ann Galanti (Gilanti, 2014), Joyce Newman Giger (Giger, 2013), Marianne Jeffreys (Jeffreys & Dogan, 2014), Larry Purnell (Purnell, 2014), Marilyn Ray (Davidson & Ray, 2011; Ray, 2010; Ray, Turkel, & Cohn, 2011), Priscilla Sagar (Sagar, 2012, 2014, 2015), Rachel Spector (Spector, 2013), and the late Ruth Davidhizar.

The Core Curriculum In collaboration with a group of other TCN scholars and experts globally, the editor and associate editor of the JTN published the Core Curriculum in Transcultural Nursing and Health Care to “establish a core base of knowledge that supports TCN practice” (Douglas & Pacquiao, 2010, p. S5). The Core Curriculum marks the culmination of many years of research and theory development in TCN and draws on knowledge and research from the natural, social, and behavioral sciences; philosophy, theology, and religious studies; history; the fine arts; and applied or professional disciplines such as medicine, social work, education, and other fields. The Core Curriculum clearly identifies, delineates, and authoritatively establishes the core of knowledge that supports TCN practice. The Core Curriculum includes the following: ●●

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Contributions by many of the foremost experts in TCN from around the world who provide concrete and specific curricular outline for TCN. A comprehensive compendium that contains an overview of the key knowledge, research, evidence, and general content areas that collectively form the foundation for TCN practice. Content on subjects such as global health; comparative systems of health care delivery; cross‐cultural communication; culturally based health and illness beliefs and practices across the lifespan; culturally based healing and care modalities; cultural health assessment; educational issues for students, organizational staff,

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patients, and communities; organizational cultural competency; research methodologies for investigating cultural phenomena and evaluating interventions; and professional roles and attributes of the transcultural nurse. Content that will prepare nurses to take one or both of the examinations leading to transcultural nursing certification. Basic certification in transcultural nursing (CTNB) and advanced certification in transcultural nursing (CTN-A). Both exams are offered by the TCNS’s Certification Commission (Transcultural Nursing Certification Commission, 2007) and appear on the list of Magnet national certifications for inclusion on the Demographic Data Collection Tool. See Sagar (2015) for further information about certification in TCN.

The Core Curriculum also is used in schools of nursing, hospitals, health departments, and other health care organizations to determine the key content to be included in seminars, workshops, conferences, and credit-bearing and continuing professional development courses on TCN and cultural competency. Those interested in cultural competence, multiculturalism, diversity, and related topics from multiple disciplines will also find valuable information in the Core Curriculum. As scientific, technological, and discipline-specific advances are made in TCN, the Core Curriculum will be updated and refined. The coauthors of this book contributed to the Core Curriculum, as did many of the chapter contributors; therefore, the key concepts contained in the Core Curriculum also are found in this book.

Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model Conceptual frameworks, theoretical models, and theories in nursing are structured ideas about human beings and their health. Models enable nurses and other health care team members to organize and understand what happens in

ractice, critically analyze situations for clinical p decision making, develop a plan of care, propose appropriate nursing interventions, predict the outcomes from the care, and evaluate the effectiveness of the care provided (Alligood, 2014).

Goals, Assumptions, and Components of the Model The goals of the Andrews/Boyle TIP Model are to: ●●

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Provide a systematic, logical, orderly, scientific process for delivering culturally congruent, culturally competent, safe, affordable, accessible, and quality care to people from diverse backgrounds across the lifespan Facilitate the delivery of nursing and health care that is beneficial, meaningful, relevant, culturally congruent, culturally competent, and consistent with the cultural beliefs and practices of clients from diverse backgrounds Provide a conceptual framework to guide nurses in the delivery of culturally congruent and competent care that is theoretically sound, evidence based, and utilizes best professional practices

Fundamental assumptions underlying the TIP Model include those related to TCN (Box 1-1), humans (Box 1-2), and cross-cultural communication between and among team members (Box 1-3). These assumptions are ideas that are formed or taken for granted as having veracity without proof or evidence. Assumptions are useful in providing a basis for action and in creating “what if…” scenarios to simulate possible situations until such time as there is proof or evidence available to corroborate or refute the assumption. The TIP Model consists of the following interconnected and interrelated components: the context from which people’s health-related values, attitudes, beliefs, and practices emerge; the interprofessional health care team; communication; and the problem-solving process.

Cultural Context Derived from the Latin contexere (con- meaning together and texere meaning to weave or

Chapter 1 Theoretical Foundations of Transcultural Nursing

Box 1-1 Assumptions about Transcultural Nursing ●●

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Transcultural nursing is a theoretical and evidence-based formal area of study and practice within professional nursing that focuses on people’s culturally based beliefs, attitudes, values, behaviors, and practices related to wellness, health, birth, illness, healing, dying, and death. Transcultural nursing requires that nurses engage in an ongoing process of constructively critical, reflective self-assessment that enables them to identify their own culturally based values, attitudes, beliefs, behaviors, biases, stereotypes, prejudices, and practices. Transcultural nursing knowledge is interconnected with the knowledge, research, and scholarship of other disciplines in the natural sciences (e.g., biology, chemistry, physics), social and behavioral sciences (e.g., anthropology, sociology, psychology, economics, political science), professional disciplines (e.g., medicine, pharmacy, social work, education), and the humanities (e.g., music, art, history, languages, philosophy, theater). Transcultural nursing practice encompasses autonomous and collaborative care of individuals of all ages across the lifespan whether they are sick or well, able or disabled. Transcultural nursing engages nurses the care of families, groups, populations, and communities globally. Transcultural nursing includes the promotion of health, prevention of disease, and the care of sick, ill, disabled, and dying people from diverse cultures across the lifespan from birth to old age. Transcultural nursing roles include advocacy, research, health policy development, health systems leadership, management, education, clinical practice, and consultation. Transcultural nursing practice requires that nurses establish and maintain a caring, empa-

braid), the term context refers to the conditions, circumstances, and/or situations that exist when and where something happens, thereby providing meaning to what transpired. In the TIP Model, the following factors contribute to

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thetic, therapeutic relationship with clients and a collaborative, collegial relationship with other members of the interprofessional health care team. Transcultural nursing assessment is facilitated when the nurse’s communications are client-centered and focused on establishing and maintaining a therapeutic nurse–client relationship. Transcultural nursing practice requires that nurses be aware of changes in the world that influence and challenge their knowledge of the unfolding meaning of diversity and the need for the delivery of nursing and health care that is respectful and responsive to individual needs and differences of the people and communities served. Transcultural nursing practice encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well and in all settings. Transcultural nursing practice requires that nurses establish and maintain a caring, empathetic, therapeutic relationship with clients; formally educated and/ or licensed credentialed healers, such as registered nurses, licensed physicians, and other health professionals; and folk, traditional, religious, spiritual, and other healers identified by clients as significant to their health and well-being. In transcultural nursing practice, the nurse’s communications are other oriented and focused on what is best for the client’s health well-being, recovery, or peaceful death. Transcultural nursing practice requires that nurses be respectful and responsive to individual needs and differences of the people and communities served.

the cultural context of human experiences and need to be assessed, interpreted, examined, and evaluated when clients interact with nurses and other members of the interprofessional health care team: environmental, social, economic,

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Box 1-2 Assumptions about Humans ●●

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Humans are complex biological, cultural, psychosocial, spiritual beings who experience health and illness along a continuum throughout the span of their lives from birth to death. All humans have the right to safe, accessible, and affordable nursing and health care, regardless of national origin, race, ethnicity, gender, age, socioeconomic background, religion, sexual orientation, size, and related characteristics. Whether rich or poor; educated or illiterate; religious or nonbelieving; male or female; black, white, yellow, red, or brown, each person deserves to be respected by nurses and other health members of the health care team. As people from different racial, ethnic, and cultural backgrounds travel and comingle with those having backgrounds that differ from their own, the likelihood of intermarriage and offspring of mixed racial and ethnic heritage increases. Regardless of their national origin or current citizenship, humans around the world share culture-universal needs for food, shelter, safety, and love; seek well-being and health; and endeavor to avoid, alleviate, or eliminate the

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pain and suffering associated with disease, illness, dying, and death. Although humans have common cultureuniversal needs, they also have culture-specific needs that are interconnected with their health-related values, attitudes, beliefs, and practices. In times of health and illness, humans seek the therapeutic (beneficial) assistance of various types of healers to promote health and well-being, prevent disease, and recover from illness or injury. Humans seek therapeutic interventions from family and significant others; credentialed or licensed health care providers; folk, traditional, indigenous, religious, and/or spiritual healers; and companion or therapy animals and pets as they perceive appropriate for their condition, situation, or problem. Interventions are judged to have a therapeutic effect when they result in a desirable and beneficial outcome, whether the outcome was expected, unexpected, or even an unintended consequence of the intervention.

Box 1-3 Assumptions about Effective Communication ●●

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Effective communication begins with an assessment of the client’s ability to read, write, speak, and comprehend messages. Effective communication in contemporary society sometimes requires literacy in the use of computers, smartphones, and numerous technology-assisted medical or health devices. Effective communication includes the ability to convey sincere interest in others, patience, and willingness to intervene or begin again when misunderstandings occur. To provide safe, quality, affordable, accessible, efficacious, culturally congruent, and culturally competent nursing and health care, members of the interprofessional health care team must communicate effectively.

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Communication occurs verbally, nonverbally, in writing, and in combination with technology. Communication should be appropriate for the client’s age, gender, health status, health literacy, and related factors. When nurses communicate with others from cultural and linguistic backgrounds different from their own, the probability of miscommunication increases significantly. In promoting effective cross-cultural communication with clients from diverse backgrounds, nurses should avoid technical jargon, slang, colloquial expressions, abbreviations, and excessive use of medical terminology.

Chapter 1 Theoretical Foundations of Transcultural Nursing

religious, philosophical, moral, legal, political, educational, biological (genetic/inherited factors), and technological. In TCN, culture is the lens through which nurses see the world, their clients, and other members of the team. When culture is interwoven with the other factors (see Figure 1-4), it forms the health-related cultural values, attitudes, beliefs, and practices of humans worldwide, including clients and other members of the team.

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Interprofessional Health Care Team The transcultural interprofessional health care team has at its core the client, who is the team’s raison d’etre (reason for being). In addition to the client, the team may have one or more of the following members:

The client’s family, and others significant in his or her life, including a legally appointed guardian who might not be genetically related Credentialed health professionals such as nurses; physicians; physical, occupational, respiratory, music, art, dance, recreational, and other therapists; social workers; health navigators; public and community health workers; and related professionals with formal academic preparation, licensure, and/or certification Folk, indigenous, or traditional healers— unlicensed individuals who learn healing arts and practices through study, observation, apprenticeship, imitation, and sometimes by inheriting healing powers, for example, herbalists, curanderos, medicine men/women, Amish brauchers, bonesetters, lay midwives, sabadors, and healers with related names

Cultural Context Environmental

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Social

Moral

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Biological

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Legal

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Economic

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Genetic

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Political

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Religious

•

Philosophical

Educational

Technological Factors

Health-related values, attitudes, beliefs, and practices

Humans Worldwide Interprofessional Health Care Team

Figure 1-4. Influence of cultural context on health values, beliefs, and practices of the interprofessional health care team. (© Margaret M. Andrews.)

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Religious or spiritual healers—clergy or lay members of religious groups who heal through prayer, religious or spiritual rituals, faith healing practices, and related actions or interventions, for example, priests, priestesses, elders, rabbis, imams, monks, Christian Science practitioners, and others believed to have healing powers derived from faith, spiritual powers, or religion. Others identified by the client as significant to his or her health, well-being, or healing such as companion animals or pets as culturally appropriate.

professionals must recognize their own individual scope of practice and skill set and have an awareness of and appreciation for other health professionals’ capacity to contribute to the delivery of care to clients in order to achieve optimal health outcomes. Working as a member of an interprofessional team requires communication, cooperation, and collaboration (Fulmer & Gaines, 2014; Institute of Medicine, 2011; Interprofessional Education Collaborative Expert Panel, 2011).

The World Health Organization defines interprofessional collaboration as multiple health

Derived from the Latin verb communicare, meaning to share, communication refers to the meaningful exchange of information between one or more participants. The information exchanged may be conveyed through ideas, feelings, intentions, attitudes, expectations, perceptions, instructions, or commands. Communication is an organized, patterned system of behavior that makes all nurse–client interactions possible. It is the exchange of messages and the creation of meaning (Munoz & Luckman, 2008). Because communication and culture are acquired simultaneously, they are integrally linked. Figure 1-5 illustrates the ways in which communication, cultural context, and health-related values, attitudes, beliefs, and practices of members of the interprofessional health care team are interconnected and interrelated. In effective communication, there is mutual understanding of the meaning attached to the messages. Being respectful and polite, using language that is understood by the other(s), and speaking clearly will facilitate verbal (or spoken) communication. Barriers to effective verbal communication occur when participants are using different languages; when technical terms, abbreviations, idioms, colloquialisms, or regional expressions are used; or when the tone of voice conveys a message that is inconsistent with the words spoken, for example, a client in the postanesthesia care unit following major surgery verbally denies having pain, but

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workers from different professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality of care (World Health Organization, 2013). In collaboration with leaders in nursing, dentistry, and other health care fields, the Institute of Medicine (2011) advocates that interprofessional collaboration be integrated into the curricula of health professions programs, building on recommendations from its earlier report, To Err is Human, which focuses on the threat to patient safety caused by human error and ineffective interprofessional communication (Institute of Medicine, 1999). To be successful in interprofessional collaboration, the following core competencies are required: values and ethics related to interprofessional practice, knowledge of the roles of team members, and a team approach to health care (Fulmer & Gaines, 2014; Institute of Medicine, 1999, 2011; Interprofessional Education Collaborative Expert Panel, 2011; O’Brien, 2013). Interprofessional collaboration is a partnership that starts with the client and includes all involved health care providers working together to deliver client and family-centered care. Trust must be established and an appreciation of each other’s roles must be gained in order for effective collaboration to take place (Interprofessional Education Collaborative Expert Panel). Health

Communication

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Context Environmental Philosophical

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Biological

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Moral

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Social

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Legal

Genetic

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Economic

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Political

Religious

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Educational

Technological Factors

Health-related values, attitudes, beliefs, and practices

CLIENT Family Significant Other Communication Folk & Traditional Healers

Religious & Spiritual Healers

Credentialed Health Care Providers Nurses, Physicians, Therapists, Pharmacists, Social Workers, et al. = Influencers = Communication

Verbal and Nonverbal Languages Greetings Silence Eye contact and facial expressions Gestures Posture Time (Chronemics) Distance (Proxemics) Modesty Touch Technology-assisted Literature, art, music, and dance

Figure 1-5. Cross-cultural communication among members of the interprofessional health care team—clients, family, significant others, credentialed health professionals, and folk, traditional, religious, and spiritual healers. (©Margaret M. Andrews.)

the nurse observes that the client has clenched teeth, taught muscles, pursed lips, and a wrinkled brow, all of which are nonverbal indicators of pain. Whereas language refers to what is said, paralanguage refers to how it is said and relates to all aspects of the voice that are not part of the verbal message. Paralanguage may modify or nuance meaning or convey emotion through rhythm, pitch, stress, volume, speed, hesitations, or intonation. For example, consider the sentence, “I would like to help you.” By placing

the emphasis on the words I, like, help, and you in four different sentences, the meaning of the sentence changes significantly. Nonverbal communication refers to how people convey meaning without words, for example, through the use of facial expressions, gestures, posture (body language), and the physical distance between the communicators (proxemics). The many nuances of verbal and nonverbal communication are interconnected, interwoven, interrelated, and often embedded in one another.

Part One Foundations of Transcultural Nursing

Aspects of communication that are of particular importance for the transcultural nurse include language, the use of interpreters, greetings, silence, eye contact and facial expressions, gestures, posture, chronemics (time), proxemics, modesty, touch, technology-assisted communication, and literature, art, music, and dance. Language More than 6,000 languages are spoken throughout the world; 382 individual languages and language groups are spoken in the United States alone, where nearly 60 million people, ages 5 years or older, speak a language other than English at home (U.S. Census Bureau, 2013a). Fifty-six percent of the people who speak a language other than English at home report they speak English “very well” (U.S. Census Bureau, 2013b, p. 9). Spanish is the second most commonly spoken language in the United States, spoken by 37 million people age 5 and older; 9%

of those individuals indicated that they did not speak English at all (U.S. Census Bureau, 2013b, p. 3). After English (230.9 million speakers) and Spanish (37.5 million), Chinese (2.8 million) was the language most commonly spoken at home (U.S. Census Bureau, 2013b, pp. 5–6). Language is one of the primary ways that culture is transmitted from one generation to the next. Interpreters One of the greatest challenges in cross-cultural communication for nurses occurs when the nurse and client speak different languages. After assessing the language skills of the client who speaks a different language from the nurse, the nurse may be in one of two situations: either struggling to communicate effectively through an interpreter or communicating effectively when there is no interpreter. Box 1-4 provides recommendations for overcoming language barriers.

Box 1-4 Overcoming Language Barriers Using an Interpreter ●●

●●

Before locating an interpreter, determine the language the client speaks at home; it may be different from the language spoken publicly (e.g., French is sometimes spoken by welleducated and upper-class members of certain Asian or Middle Eastern cultures). After assessing client’s health literacy, use electronic devices such as cell phones, tablets, and laptop computers to connect client with Web-based translation programs. Avoid interpreters from a rival tribe, state, region, or nation (e.g., a Palestinian who knows Hebrew may not be the best interpreter for a Jewish client). Be aware of gender differences between interpreter and client. In general, the same gender is preferred. Be aware of age differences between interpreter and client. In general, an older, more

●● ●● ●●

mature interpreter is preferred to a younger, less experienced one. Be aware of socioeconomic differences between interpreter and client. Ask the interpreter to translate as closely to verbatim as possible. Expect an interpreter who is not a relative to seek compensation for services rendered.

Recommendations for Institutions ●●

●●

Keep pace with assistive equipment and technology for people who are deaf, hard of hearing, blind, visually impaired, and/or disabled. Maintain a computerized list of interpreters, including those certified in sign language, who may be contacted as needed. Network with area hospitals, colleges, universities, and other organizations that may serve as resources.

Chapter 1 Theoretical Foundations of Transcultural Nursing

What To Do When There Is No Interpreter ●● ●●

●●

Be polite and formal. Greet the person using the last or complete name. Gesture to yourself and say your name. Offer a handshake or nod. Smile. Proceed in an unhurried manner. Pay attention to any effort by the patient or family to communicate. Speak in a low, moderate voice. Avoid talking loudly. There is often a tendency to raise the volume and pitch of your voice when the listener appears not to understand, but this may lead the listener to perceive that the nurse is shouting and/or angry. Use any words known in the patient’s language. This indicates that the nurse is aware of and respects the client’s culture. Use simple words, such as pain instead of discomfort. Avoid medical jargon, idioms, and slang. Avoid using contractions. Use nouns repeatedly instead of pronouns. For example, do not say, “He has been taking his medicine, hasn’t he?” Do say, “Does Juan take medicine?”

●● ●●

●●

●● ●●

Pantomime words and simple actions while verbalizing them. Give instructions in the proper sequence. For example, do not say, “Before you rinse the bottle, sterilize it.” Do say, “First, wash the bottle. Second, rinse the bottle.” Discuss one topic at a time. Avoid using conjunctions. For example, do not say, “Are you cold and in pain?” Do say, “Are you cold [while pantomiming]?” “Are you in pain?” Validate whether the client understands by having him or her repeat instructions, demonstrate the procedure, or act out the meaning. Write out several short sentences in English, and determine the person’s ability to read them. Try a third language. Many Southeast Asians speak French. Europeans often know three or four languages. Or, try Latin words or phrases. Ask if any of the client’s family and friends could serve as an interpreter. Obtain phrase books from a library or bookstore, make or purchase flash cards, contact hospitals for a list of interpreters, and use both formal and informal networking to locate a suitable interpreter.

Adapted from Andrews, M. (2000). Transcultural considerations in health assessment. In C. Jarvis (Ed.), Physical examination and health assessment (p. 69). Philadelphia, PA: W.B. Saunders.

Even a person from another culture or country who has a basic command of the language spoken by the majority of nurses and other health professionals may need an interpreter when faced with the anxiety-provoking situation of entering a hospital, encountering an unfamiliar symptom, or discussing a sensitive topic such as birth control or gynecologic or urologic concerns. A trained medical interpreter knows interpreting techniques, has knowledge of medical terminology, and understands patients’ rights. The trained interpreter is also knowledgeable about cultural beliefs and health practices. This person can help bridge the cultural gap and can give advice concerning the cultural appropriateness of nursing and medical recommendations. Although the nurse is in charge of the focus and flow of the interview, the interpreter should be viewed as an important member of the health

care team. It can be tempting to ask a relative, a friend, or even another client to interpret because this person is readily available and likely is willing to help. However, this violates confidentiality for the client, who may not want personal information shared. Furthermore, the friend or relative, though fluent in ordinary language usage, is likely to be unfamiliar with medical terminology, hospital or clinic procedures, and health care ethics. In ideal circumstances, ask the interpreter to meet the client beforehand to establish rapport and obtain basic descriptive information about the client such as age, occupation, educational level, and attitude toward health care. This eases the interpreter and client into the relationship and allows the client to talk about aspects of his or her life that are relatively nonthreatening.

Part One Foundations of Transcultural Nursing

When using an interpreter, expect that the interaction with the client will require more time than is needed if the nurse and client speak the same language. It will be necessary to organize nursing care so that the most important interactions or procedures are accomplished first, before the client becomes fatigued. In the absence of an interpreter, try using electronic devices with translation software and other applications that may be helpful in effectively communicating and delivering care for people who speak a language different from the nurse. Greetings Some cultures value formal greetings at the start of the day or whenever the first encounter of the day occurs—a practice found even among close family members. When communicating with people from cultures that tend to be more formal, it is important to call a person by his or her title, such as Mr., Mrs., Ms., Dr., Reverend, and related greeting as a sign of respect, and until such time as the individual gives permission to address them less formally. The recommended best practice at the time the nurse initially meets a client or new member of the health care team is to state his or her name and then ask the client or team member by what name he or she prefers to be called. Silence Wide cultural variations exist in the interpretation of silence. Some individuals find silence extremely uncomfortable and make every effort to fill conversational lags with words. By contrast, many Native Americans consider silence essential to understanding and respecting the other person. A pause following a question signifies that what has been asked is important enough to be given thoughtful consideration. In traditional Chinese and Japanese cultures, silence may mean that the speaker wishes the listener to consider the content of what has been said before continuing. Other cultural meanings of silence may be found. Arabs may use silence out of respect for another’s privacy, whereas people of French, Spanish,

and Russian descent may interpret it as a sign of agreement. Asian cultures often use silence to demonstrate respect for elders. Among some African Americans, silence is used in response to a question perceived as inappropriate. Eye Contact and Facial Expressions Eye contact and facial expressions are the most prominent forms of nonverbal communication. Eye contact is a key factor in setting the tone of the communication between two people and differs greatly between cultures and countries. In the United States, Canada, Western Europe, and most parts of Australia, eye contact is interpreted similarly: conveying interest, active engagement with the other person, forthrightness, and honesty. People who avoid eye contact when speaking are viewed negatively and may be perceived as withholding information and/or lacking in confidence. In some parts of Asia, Africa, and the Middle East, and certain Native American nations, however, direct eye contact may be seen as disrespectful, a sign of aggression, or a sign that the other person’s authority is being challenged. In some cultures, staring at someone for a prolonged period of time communicates that the person doing the staring has a sexual interest in the other person. People who make eye contact, but only briefly, are viewed as respectful and courteous. In some Native American cultures, the person might look at the floor while someone in a position of authority is speaking as a sign of respect and interest. Among some African American and White cultures, occulistics (eye rolling) takes place when someone speaks or behaves in a manner that is regarded as inappropriate. Strongly influenced by a person’s cultural background, facial expressions include affective displays that reveal emotions, such as happiness through a smile or sadness through crying, and various other nonverbal gestures that may be perceived as appropriate or inappropriate according to the person’s age and gender. These nonverbal expressions are often unintentional and can conflict with what is being said verbally.

Chapter 1 Theoretical Foundations of Transcultural Nursing

Gestures Gestures that serve the same function as words are referred to as emblems. Examples of emblems include signals that mean okay, the “thumbs up” gesture, the “come here” hand movement, or the hand gesture used when hitchhiking. Gestures that accompany words to illustrate a verbal message are known as illustrators. Illustrators mimic the spoken word, such as pointing to the right or left while verbally saying the words right or left. Regulators convey meaning through gestures such as raising one’s hand before verbally asking a question. Regulators also include head nodding and short sounds such as “uh huh” or “Hmmmm” and other expressions of interest or boredom. Without feedback, some people find it difficult to carry on a conversation. Adaptors are nonverbal behavior that either satisfy some physical need such as scratching or adjusting eyeglasses or represent a psychological need such as biting fingernails when nervous, yawning when bored, or clenching a fist when angry. Although normally subconscious, adaptors are more likely to be restrained in public places than in private gatherings of people. Adaptive behaviors often accompany feelings of anxiety or hostility (Galvin, Prescott & Huseman, 1988). All of the nonverbal communication previously described varies widely cross-culturally and cross-nationally. Posture Posture reflects people’s emotions, attitudes, and intentions. Posture may be open or closed and is believed to convey an individual’s degree of confidence, status, or receptivity to another person. An open posture is characterized by hands apart or comfortably placed on the arms of a chair while directly facing the person speaking. The person often leans forward, toward the speaker. Open posture communicates interest in someone and a readiness to listen. Someone seated in a closed posture might have his or her arms folded, legs crossed, or be positioned at a slight angle from the person with whom they are interacting. The person may also allow his or her

eyes to dart quickly from one spot to another in an unfocused, distracted manner. Closed posture usually conveys disinterest or discomfort. Chronemics There are cultural variations in how people understand and use time. Chronemics is the study of the use of time in nonverbal communication. The manner in which a person perceives and values time, structures time, and reacts to time contributes to the context of communication. Social scientists have discovered that individuals are divided in two major groups in the ways they approach time: monochronic or polychronic. In monochronic cultures, such as many groups in the United States, Northern Europe, Israel, and much of Australia, time is seen as a commodity, and people tend to use expressions such as “waste time” or “lose time” or “time is money.” Given that time is so highly valued, showing up late, especially for a meeting or a dinner, is usually perceived as very disrespectful to the individuals who are made to “waste their time” waiting (Lombardo, n.d.). A monochronic culture functions on clock time. People tend to focus on one thing at a time and usually prefer to complete objectives in a systematic way. In a meeting, for example, it’s considered culturally appropriate to follow the predetermined agenda and avoid straying from the agenda by talking about unrelated topics (Rutledge, 2013). People in polychronic cultures, such as some groups in Southern Europe, Latin America, Africa, and the Middle East, take a very different view of time. People from these cultures often believe that time cannot be controlled, and it is flexible. Days are planned based on events rather than the clock. For many people in these cultures, when one event is finished, it is time to start the next, regardless of what time it is. In a polychronic culture, following an agenda might not be very important. Instead, many tasks, such as building relationships, negotiating, and/or problem solving, can be accomplished at the same time. In many Asian cultures, such as Japanese,

Part One Foundations of Transcultural Nursing

Chinese, and Taiwanese groups, people tend to arrive a little early. In many parts of Europe, the United States, Canada, Israel, and Australia, people tend to arrive precisely on time and may perceive it as an inconvenience to others if they arrive too early. In many parts of Latin America, Arab areas in the Middle East, and Africa, people tend to be more flexible in their notion of arrival times and may show up significantly later than the mutually agreed-upon time. Among certain Native American groups, an appointment or event begins “when everyone arrives,” and there is considerable tolerance for those who show up after the appointed time. These examples are stereotypes, and not all of members of a culture or subculture will perceive time in the same manner. Proxemics Another form of nonverbal communication is manifested in closeness and personal space. The study of space and how differences in that space can make people feel more relaxed or more anxious is referred to as proxemics, a term that was coined in the 1950s by the anthropologist and cross-cultural researcher Edward T. Hall. Distances have been identified based on the relationship between or among the people involved: (1) Intimate space (touching to 1 foot) is typically reserved for whispering and embracing; nurses and other health care providers, however, sometimes need to enter this intimate space when providing care for clients. (2) Personal space (ranges from 2 to 4 feet) is used among family and friends or to separate people waiting in line at the drug store or ATM machine. (3) Social space (4 to 10 feet) is used for communication among business or work associates and to separate strangers, such as those taking a course on natural child birth. (4) Public space (12 to 25 feet) is the distance maintained between a speaker and the audience (Hall, 1984, 1990). Cultural and ethnic variations occur in proxemics. For example, when having a conversation, people from Arab parts of the Middle East, France, and Latin America generally prefer to

stand closer to one another than those from Canadian, American, and British cultures, who also tend to feel more uncomfortable when they have to sit close to one another (Munoz & Luckmann, 2008). There are also important gender and age factors to consider in cross-cultural communication. In general, clients are likely to prefer a nurse or other health care provider of the same gender, particularly when care requires entering his or her personal space and/or touching the client. Similarly, the same gender may be preferred when the health history and/or physical examination includes the reproductive organs. In some ethnic and religious groups, it may be inappropriate or forbidden for health care providers of the opposite gender to shake hands, provide care, or otherwise touch the client. For example, observant Muslim women are not permitted to shake hands with male physicians, nurses, or other health professionals. As a sign of respect to the man, some Muslim women will place one or both arms over their chest and slightly bow their head. Whenever an observant Muslim is having a conversation with a person of the opposite gender, a third person needs to be present to avoid the appearance of impropriety. Among some people from Chinese, Japanese, or other Asian cultures, there may be both gender and age factors to be considered in cross-cultural communication. Modesty Modesty is a form of mixed nonverbal and verbal communication that refers to reserve or propriety in speech, dress, or behavior. It conveys a message that is intended to avoid encouraging sexual attention or attraction in others (aside from a person’s spouse). In cultures that have been studied by anthropologists or transcultural nurses, men and women have cultural beliefs about modesty and rules concerning which behavior and dress are appropriate in various situations and circumstances. The following are examples of groups that have required rules or optional guidelines pertaining to modesty.

Chapter 1 Theoretical Foundations of Transcultural Nursing

Traditional Muslim women beyond the age of puberty wear a headscarf to cover their head and hair as a sign of modesty and religious faith. The word hijab describes the act of covering up generally but is sometimes used to describe the headscarves worn by Muslim women (Figure1-6). These scarves come in many styles and colors and have different names around the world, such as niqab, al mira, Shayla, khimar, chador, and burka. The type of hijab most commonly worn in the United States, Canada, Australia, and Western Europe covers the head and neck but leaves the face clear. In various parts of the Arab world, cultural expectations for women may include covering the head, face, neck, or the entire body in order to conform to certain standards of modesty established by various Islamic denominations and groups. The burka is the most concealing of all Islamic coverings. It is a one-piece veil that conceals the face and body, often leaving just a mesh screen to see through. There are differences between modesty at home and modesty in public. At home, Muslim women typically do not wear

veils, scarves, or other coverings in the presence of male family members such as their fathers, husbands, sons, and other male or female relatives. Women from observant Orthodox and Hasidic Judaism, Amish, Mennonite, and some conservative Catholics cover their heads, arms, and/or legs as a cultural and/or religious expression of modesty and often as a sign of their affiliation with a particular religious order within Catholicism. The Hebrew word tznius or tzniut means modesty. It is generally used in reference to women and also relates to humility and general conduct, especially between men and women. Hasidic, Sikh, and Amish men often cover their heads and/or wear clothing that conveys modesty. For Buddhists, modesty is the quality of being unpretentious about one’s virtues or achievements. The most important thing is not what type of clothes an individual wears or their color, but the quality of his or her heart. Buddhist monks have modesty guidelines pertaining to the manner in which they wear their robes, never allowing skin to show on both sides of the body.

Figure 1-6. When in public places, some Muslim women wear a headscarf (hijab) to cover their hair, head, and neck, as a sign of modesty and religious faith.

Part One Foundations of Transcultural Nursing

The Church of Jesus Christ of Latter-day Saints (LDS), also known as the Mormon Church, has issued official statements on modesty and dress for its members. Modesty is an attitude of propriety and decency in dress, grooming, language, and behavior. Clothing such as “short shorts” and short skirts, shirts that do not cover the stomach, and clothing that does not cover the shoulders or is low cut in the front or the back are discouraged. Men and women are also encouraged to avoid extremes in clothing or hairstyles. Most LDS members do not wear sleeveless shirts or blouses or shorts that fail to reach the knee. Women do not wear pants or slacks to religious services, and members of both genders attend services well-groomed and well-dressed (Church of Jesus Christ of Latter Day Saints, 2014). All cultures have rules, often unwritten, concerning who may touch whom, where, when, how, for what reason, and for how long. In general, it is best for nurses to refrain from touching clients or coworkers of either gender unless necessary for the accomplishment of a job-related task, such as the provision of safe client care. Typically, people from Asian cultures are not as overtly demonstrative of affection or as tactile as Whites, Hispanics, or African Americans. Generally, they refrain from public embraces, kissing, loud talking, laughter, and boisterous behavior in public. Affection is expressed in a more reserved manner, usually in private rather than public places. In some instances, nurses and other members of the health care team from cultures that differ from the client’s may send unintended messages through their use of touch. Special attention to male–female relationships and to the age of the client is warranted in nurse–client interactions and especially when it is necessary to touch members of the opposite gender. Technology-Assisted Communication Communication sometimes uses a combination of verbal, nonverbal, and written signals. With innovations in health care devices and software, technological advances are changing how care

is delivered and the nature of the nursing profession. One of the major challenges of technology from a transcultural perspective is the gap between the regions and nations that have greater resources than others. While some strides are being made, it will still be many years before technological capabilities are mobilized in ways that benefit people globally by enhancing safe, quality, accessible, affordable, evidence-based, culturally congruent, and culturally competent nursing and health care. This is a matter of social justice that needs to be addressed as an integral component of TCN. Although linguists have known that language changes over time, the digital language is changing faster than any other language in recorded history. For example, the first chat room was invented at the University of Illinois in 1973. In 1992, the first mobile text message was sent. By 2012, people in the world were sending 200,000 texts per second (Eisinger, 2012). Ninety percent of Whites, 90% of African Americans, and 92% of Hispanics own cell phones (Pew Internet Research Center, 2014). Seventy-two percent of all English-speaking adults send text messages (68% of Whites, 79% of Blacks, and 83% of Hispanics). As text messaging increases, the number of minutes spent on the phone decreases. The average person in the United States looks at his or her phone 150 times per day (My Cloud Media Company, 2014). In many health care agencies, nurses are given smartphones, pagers, tablets, and other technology-assisted devices for job-related activities to improve patient outcomes. While the Internet, social media, and texting enable people to communicate more often, use of technology is primarily about saving time or taking digital shortcuts. It has become easy for nurses to use technology instead of interacting more directly with clients or other members of the health care team. While the digital shortcuts may be expedient and time-saving, the quality of the communication for this generation and the next is currently being studied to determine the ways in which technology is rewriting the

Chapter 1 Theoretical Foundations of Transcultural Nursing

europathways in children’s brains (Brackett n et al., 2013). Between television, tablets, video games, and smartphones, the average child in the United States spends nearly 8 hours each day staring at a screen (Blue Cross/Blue Shield, 2014). When children—or adults—spend so much time communicating through technology, they’re not developing their verbal or emotional skills; screen time needs to be balanced with face time. An emoji cannot truly convey emotion—☺ is not the same as a human smile—nor can a text message replace a warm embrace or hug when a client needs emotional support from family and friends during times of injury or illness. Nurses and other members of the health care team need to communicate in multiple ways, balancing face to face and digital interactions. It is important for the nurse to identify the client’s preferred mode for communication as an integral component of the overall assessment of communication used by the client, his or her family, and significant others. Literature, Art, Music, and Dance The literature, art, music, and dance of various cultural groups communicate to the world the cherished values, beliefs, history, traditions, and contributions of people from nations, tribes, and population groups. The creative products, in the form of books, poems, artwork, music, and dance, describe the social climate of the day; portray religious, racial, gender, political, class, and other perspectives; and serve as unique historical documents and artifacts to help people better see, hear, know, understand, and appreciate the richness of the world’s diverse cultures as they are communicated through the literary works, artistic and musical creations, and dance of people from cultures around the world. Problem-Solving Process The TIP Model is intended to guide members of the interprofessional health care team in determining what decisions, actions, and interventions the client needs to achieve an optimal state of

well-being and health. As indicated in Figure 1-7, the model helps nurses to conceptualize the care of people from diverse backgrounds in a logical, orderly, systematic, scientific five-step process: 1. A comprehensive cultural assessment. The

4. 5.

cultural assessment includes a self-assessment and a holistic assessment of the client that includes a health history and physical examination (Chapter 3 provides an in-depth discussion of these topics). Mutual goal setting that takes into account the perspectives of each member of the health care team—the client, the client’s family and significant others, and all those who are coparticipants with the client in the decisionmaking and goal-setting processes including credentialed health professionals and folk, traditional, indigenous, religious, and/or spiritual healers. Planning care that includes input from and dialogue with members of the interprofessional health care team. Implementation of the care plan through a wide range of actions and interventions. Evaluation of the care plan from multiple, diverse perspectives to determine the degree to which the plan (a) is effective in achieving the intended goal(s); (b) provides care that is culturally congruent with and fits the client’s culturally based beliefs and practices related to wellness, health, illness, disease, healing, dying, and death; (c) reflects the delivery of culturally competent care by nurses and other members of the interprofessional team; (d) provides quality care that is safe, affordable, and accessible; and (e) integrates research, evidence-based, and best practices (Melnyk, 2015) into the care.

Data from the formal evaluation of the plan guide the nurses and other team members in determining if modifications or changes to the plan are necessary to accomplish the mutual goal(s) in step two or if new goals need to be discussed, proposed, planned, and established. If changes are needed, return to assessment, the first step

Part One Foundations of Transcultural Nursing

Context Environmental Philosophical

•

Social

•

Moral

•

Biological

•

Legal

Genetic

•

Economic

•

Political

Religious

•

Educational Problem-Solving Process

Technological Factors

Health-related values, attitudes, beliefs, and practices 1. Assessment

Folk & Traditional Healers

CLIENT Family Significant Other

2. Mutual Goal Setting

Religious & Spiritual Healers

3. Planning Return to Step 1, if necessary 4. Implementation

Credentialed Health Care Providers Safe?

Nurses, Physicians, Therapists, Pharmacists, Social Workers, et al.

Culturally Congruent?

5. Evaluation

Culturally Competent?

Quality? Accessible?

Affordable?

Evidence-based?

Best Practices?

Figure 1-7. The five-step problem-solving process is a key part of the Transcultural Interprofessional Practice (TIP) Model. This client-centered model also includes the context from which people’s health-related values, attitudes, beliefs, and practices emerge; the interprofessional health care team; and communication. (© Margaret M. Andrews.)

in the problem-solving process, and repeat the other steps as appropriate until each of the mutual goals is met. As indicated in Benner’s classic work titled, From Novice to Expert, in the acquisition and development of problem-solving skills, a nurse passes through levels of proficiency: novice, advanced beginner, competent, proficient, and expert (Benner, 1984). The development of proficiency in using the previously described problem-solving process requires time and repeated

simulated and/or in situ clinical experiences. As Benner aptly observes, the process leading to proficiency as an expert takes place gradually and seldom follows a direct pathway from novice to expert, rather a nurse passes through the intermediate stages, sometimes regressing to an earlier stage of competence, other times catapulting to a more advanced stage (Benner, 1984; Benner, Sutphen, Leonard, & Day, 2010). The process of developing competence in clinical problem solving is uneven and nonlinear, as is the process of

Chapter 1 Theoretical Foundations of Transcultural Nursing

developing cultural competence, a topic that is discussed in the next chapter.

Summary In this chapter, we examined the historical and theoretical foundations of TCN and its close ties with anthropology. In the mid-20th century, Madeleine Leininger, a visionary nurse–anthropologist, created the infrastructure to support, develop, and expand TCN by establishing the TCNS, the JTN, graduate programs in TCN at schools of nursing, and by creating the ethnonursing research method. We also explored the contributions of selected TCN leaders and scholars to the advancement of TCN practice, research, and theory. Lastly, we described the TIP Model that serves as a framework for nurses seeking to collaborate with clients and other members of the health care team in the delivery of quality nursing care that is beneficial, meaningful, relevant, culturally congruent, culturally competent, and consistent with the cultural beliefs and practices of clients from diverse backgrounds.

Review Questions 1. When Dr. Madeleine Leininger established

transcultural nursing in the middle of the 20th century, she identified eight reasons why this specialty was needed. Review the reasons and discuss the relevance of these reasons in contemporary nursing and health care. 2. In your own words, describe the meaning of culture and its relationship to nursing. 3. Identify at least five nonethnic cultures and describe the characteristics of each. 4. Describe the composition of the interprofessional health care team in the Transcultural Interprofessional Practice (TIP) Model and identify factors that facilitate effective communication between and among team members. 5. Identify six examples of nonverbal communication and briefly describe each one.

6. In the Transcultural Interprofessional Practice

Model, what criteria are used to determine the effectiveness of the plan of care in meeting mutual goals established by the patient and other members of the interprofessional health care team?

Critical Thinking Activities 1. Visit the TCNS’s official website (http://www.

tcns.org).

a. Briefly summarize the information you find at the website. b. Critically evaluate the strengths and limitations of this information source and the data available. What else would you like to know about transcultural nursing that isn’t available on this website? c. Critically reflect on the information about transcultural nursing that you’ve learned and indicate how it will help you to provide nursing care for people from cultures that differ from your own. d. Search for other websites on transcultural nursing. What are the similarities and differences in the perspectives on transcultural nursing presented by the TCNS and other websites? How is it helpful or unhelpful to review different viewpoints on the same subject? 2. Read the following article: Andrews, M., &

Friesen, L. (2011). Finding electronically available information on cultural competence in health care. Online Journal of Cultural Competence in Nursing and Healthcare, 1(4), 27–47. (available on the OJCCNH website). Using the key word transcultural nursing, search for online resources that were posted during the past year. How many references did you find? If you want information about a specific cultural, ethnic, or minority group, what key words will help you to narrow the search? Consult a reference librarian for assistance if you need help.

Part One Foundations of Transcultural Nursing

3. Conduct an electronic search for websites

about modesty among observant Muslims and Orthodox and Hasidic Jews.

a. Evaluate the credibility, accuracy, veracity, and currency of each website and the information available on the topic. b. Compare and contrast the beliefs and practices of each group for men and women. c. What are the clinical implications of this information? 4. Maria Rodriguez is a 61-year-old female who

self-identifies as being Mexican American. She reads, writes, and speaks Spanish; it is her primary language. Although she speaks English well enough to manage activities of daily living, she has difficulty reading and comprehending medical documents in

English. Maria is scheduled to be discharged from the hospital on her 3rd day postoperatively following a below-the-knee amputation of her right leg. She is diagnosed with peripheral vascular disease, diabetes mellitus, obesity, and hypertension. Maria lives alone in a two-story single dwelling. Her son, age 30, is on active duty in Iraq. Her 21-year-old daughter is 8months pregnant and lives outof-state. Unable to manage her care at home, Maria is unhappy that she will need to be discharged to a rehabilitation center for the next several weeks. She tells the nurse manager that she is severely depressed and threatens to commit suicide. Using the Transcultural Interprofessional Practice (TIP) Model as a guiding framework, analyze the case and develop a plan of care for Maria.

References Alligood, M. R. (2014). Nursing theory: Utilization and application. Maryland Heights, MO: Mosby-Elsevier. American Anthropological Association. (n.d.). What is anthropology? Retrieved from http://aaanet.org/whatisanthropology.cfm American Nurses Association. (2013). What is nursing? Retrieved from http://www.nursingworld.org/especially foryou/what-is-nursing Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: AddisonWesley. Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Educating nurses: A call for a radical transformation. San Francisco, CA: Jossey-Bass. Blue Cross/Blue Shield. (2014). Limit screen time for a happier family. Living Healthy, Fall, 2014, 16. Brackett, M. A., Bertoli, M., Elbertson, N., Bausseron, E., Castillo, R., & Salovey, P. (2013). Emotional intelligence: Reconceptualizing the cognition-emotion link. In M. D. Robinson, E. Watkins, & E. Harmon-Jones (Eds.), Handbook of cognition and emotion (pp. 365–379). New York: Guilford Press. Branch, M. F., & Paxton, P. P. (Eds.) (1976). Providing safe nursing care for ethnic people of color. New York: Appleton-Century-Crofts. Brink, P. J. (1976). Transcultural nursing care. Englewood Cliffs, NJ: Prentice-Hall, Inc. Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of cultural conflict: The role of cultural

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for all disciplines. International Journal of Qualitative Methods, 11(3), 259–279. University of Alberta, Canada. McFarland, M. R., Wehbe-Alamah, H. B., Vossos, H., & Wilson, M. (2015). Synopsis of findings discovered within a descriptive metasynthesis of doctoral dissertations guided by the culture care theory with use of the ethnonursing research method. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 287–315). Burlington, MA: Jones and Bartlett Learning. McKenna, M. (1985). Anthropology and nursing: The interaction between two fields of inquiry. Western Journal of Nursing Research, 6(4), 423–431. Mead, M. (1937). Cooperation and collaboration among primitive peoples. New York: McGraw-Hill. Melnyk, B. (2014). Evidence-based practice in nursing and healthcare, 3rd edition. Philadelphia: Wolters Kluwer Health. Mixer, S. J. (2015). Application of culture care theory in teaching cultural competence and culturally congruent care. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 369–388). Burlington, MA: Jones and Bartlett Learning. Morris, E. (2015). An examination of subculture as a theoretical social construct through an ethnonursing study of urban African American adolescent gang members. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 255–286). Burlington, MA: Jones and Bartlett Learning. Munoz, C., & Luckman, J. (2008). Transcultural communication in nursing (2nd ed.). Clifton Park, NJ: Delmar Learning. My Cloud Media Company. (2014). Why SMS text messaging marketing is worth the effort. Retrieved at http://www.mycloudmedia.co.uk/blog/sms-text-message-marketing-worth-effort/ National Human Genome Institute (2014). Fact sheet on science, research, ethics, and the institute. National Institutes of Health, last updated August 7, 2014. Retrieved from http://www.genome.gov/10000202 O’Brien, J. (2013). Interprofessional Collaboration. RN.com. Retrieved at http://www.rn.com/getpdf.php/1892. pdf?Main_Session=0c7d338fb741e35dc663010a8e86bc8b Omeri, A. (2015). Culture care diversity and universality: A pathway to culturally congruent practices in transcultural nursing education, research, and practice in Australia. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 443–474). Burlington, MA: Jones and Bartlett Learning. Orque, M. S., Bloch, B., & Monrroy, L. S. (1983). Ethnic nursing care. St. Louis, MO: C.V. Mosby. Osborne, O. (1969). Anthropology and nursing: Some common traditions and interests. Nursing Research, 18(3), 251–255.

Pew Internet Research Center. (2014). Mobile technology fact sheet. Retrieved from http://pewinternet.org/fact-sheets/ mobile/technology-fact-sheet Purnell, L. (2014). Guide to culturally competent health care. Philadelphia, PA: F.A. Davis Company. Ray, M. (2010). Transcultural caring dynamics in nursing and health care. San Francisco, CA: Jossey Boss Wiley. Ray, M., Turkel, M., & Cohn, J. (2011). Relational caring complexity: The study of caring and complexity in health care hospital organizations. In A. Davidson, M. Ray & M. Turkel (Eds.), Nursing, caring and complexity science: For human-environment well-being (pp. 95–117). New York: Springer Publishing Company. Ray, M. & Turkel, M. (2014). Caring as emancipatory nursing praxis: The theory of Relational Caring Complexity. Advances in Nursing science, 37(2), 132–146. Raymond, L. M., & Omeri, A. (2015). Transcultural midwifery: Culture care for Mauritian immigrant childbearing families living in New South Wales, Australia. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 183–254). Burlington, MA: Jones and Bartlett Learning. Rutledge, B. (2013). Cultural differences—Monochronic vs polychronic. The Articulate CEO, February, 2013. Retrieved at http://hearticulateceo.typepad.com/my-blog/ 2011/08/cultural-differences-monochronic-versuspolychronic.html Sagar, P. L. (2012). Transcultural nursing theory and models: Application in nursing education, practice, and administration. New York: Springer Publishing Company. Sagar, P. L. (2014). Transcultural nursing education strategies. New York: Springer Publishing Company. Sagar, P. L. (2015). Transcultural nursing certification: Its role in nursing education, practice, and administration. In M. R. McFarland & H. B. Wehbe-Alamah. Leininger’s Culture Care Diversity and Universality: A worldwide theory of nursing (3rd ed., pp. 579–592). Burlington, MA: Jones & Bartlett Learning. Schacter, D. L., Wegner, D., & Gilbert, D. (2007). Psychology. Worth Publishers, 26–27. Spector, R. E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson. Stanford Center on Poverty and Inequality. (2014). State of the union: Poverty and inequality report 2014. Palo Alto, CA: Author. Transcultural Nursing Certification Commission. (2007). Transcultural Nursing Certification revision. Conducted at Transcultural Nursing Certification Committee Meeting, Fenton, MI, March 23–25, 2007. Transcultural Nursing Society. (2007). Transcultural Nursing Society: Historical moments. Transcultural Nursing Society Newsletter, 16(1), 9. Tylor, E. B. (1871). Primitive culture. Volumes 1 and 2. London, UK: Murray.

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U.S. Census Bureau. (2013a). Language use in the United States: 2011. Retrieved from http://www.census.gov/ prod/2013pubs/acs-22.pdf U.S. Census Bureau. (2013b). Language use. U.S. Department of Commerce. Retrieved September 12, 2014, from U.S. Census Bureau: https://www.census.gov/hhes/socdemo/ language/about/faqs.html#Q3 Wehbe-Alamah, H. B. (2015). Folk care beliefs and practices of traditional Lebanese and Syrian Muslims in the Midwestern United States. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 137– 181). Burlington, MA: Jones and Bartlett Learning. Wehbe-Alamah, H. B., & McFarland, M. R. (2015a). The ethnonursing research method. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity

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Culturally Competent Nursing Care ●●Margaret M. Andrews

Key Terms Cross-cultural communication Cultural assessment Cultural competence (individual and organizational) Cultural self-assessment Cultural stereotype Cultural baggage Culture of the deaf

Diversity Disabling hearing loss Discrimination Emigrate Folk healer Hard of hearing Health Disparity Health Tourism Healthy People 2020 Immigrate Immigrant

Interprofessional collaborative practice Language access services Prejudice Racism Refugee Self-location Social determinants of health Traditional healer Vulnerable populations

Learning Objectives 1. Critically analyze the complex integration of knowledge, attitudes, and skills needed for the delivery of culturally competent nursing care. 2. Compare and contrast individual cultural competence and organizational cultural competence. 3. Evaluate guidelines for the practice of culturally competent nursing care. 4. Use a transcultural interprofessional framework for the delivery of culturally congruent and culturally competent nursing care for clients with special needs.

In this chapter, we provide an overview of the rationale for cultural competence in the delivery of nursing care and describe individual and organizational cultural competence, topics that will be discussed throughout the remainder of the book. We analyze cultural self-assessment, a valuable exercise that enables nurses to gain insights into their own unconscious cultural attitudes (biases, cultural stereotypes, prejudice, and tendencies

to discriminate against people who are different from themselves). We discuss the need for cultural knowledge about other ethnic and nonethnic groups and psychomotor skills that are required for the delivery of culturally congruent and competent nursing care. We examine the use of the problemsolving process—assessment, mutual goal setting, planning, implementation, and evaluation—in the delivery of culturally congruent and competent

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care for clients from diverse backgrounds. We explore the roles and responsibilities of nurses and other members of the interprofessional health care team in the delivery of culturally competent care and the need for effective cross-cultural communication. We analyze the importance of assessing the cultural context and social determinants of health (World Health Organization, n.d.) that influence the delivery of culturally competent care for clients from diverse cultures, for example, environmental, social, economic, religious, philosophical, moral, legal, political, educational, biological, and technological factors. By introducing national and global guidelines for the delivery of culturally competent nursing care and identifying cultural assessment instruments, we provide nurses with tools to guide them in the delivery of care that is culturally acceptable and congruent with the client’s beliefs and practices, culturally competent, affordable, accessible, and rooted in state of the science research, evidence-based, and best practices. Lastly, we examine clients with special needs including those at high risk for health disparities, those who are deaf, and those with communication and language needs.

one country or region to another for economic, political, religious, social, and personal reasons. The verb emigrate means to leave one country or region to settle in another; immigrate means to enter another country or region for the purpose of living there. People emigrate from one country or region and immigrate to a different nation or region. In the United States, for example, 41 million people (13% of the population) are foreign-born, a term used by the Census Bureau in reference to anyone who is not a US citizen at birth, including those who eventually become citizens through naturalization (U.S. Census Bureau, 2012). Additionally, an estimated 8 to 10 million people from other countries are living in the United States without documentation. In many countries, national borders have become increasingly porous and fluid, enabling people to move more freely from one country or region to another. Nurses respond to global health care needs such as infectious disease epidemics and the growing trends in health tourism, in which patients travel to other countries for medical and surgical health care needs. By traveling to another nation, clients often obtain more affordable care services or receive specialized care that is unavailable in their own country. Nurses also respond to natural and human-made disasters around the world and provide care for refugees (people who flee their country of origin for fear of persecution based on ethnicity, race, religion, political opinion, or related reasons) and other casualties of civil unrest or war in politically unstable parts of the world. In all of these situations, nurses are expected to demonstrate effective cross-cultural communication and deliver culturally congruent and culturally competent nursing care to people from diverse countries and cultures. Technological advances in science, engineering, transportation, communication, information and computer sciences, health care, and health professions education result in increased electronic and face-to-face communications

Rationale for Culturally Competent Care Multiple factors are converging at this time in history to heighten societal awareness of cultural similarities and differences among people. In many parts of the world, there is growing awareness of social injustice for people from diverse backgrounds and the moral imperative to safeguard the civil and health care rights of vulnerable populations. Vulnerable populations are groups that are poorly integrated into the health care system because of ethnic, cultural, economic, geographic (rural and urban settings), or health characteristics, such as disabilities or multiple chronic conditions (Office of Minority Health & Equity, 2013). Immigration and migration result in growing numbers of immigrants, people who move from

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between nurses and people from diverse backgrounds. Population demographics, health care standards, laws, and regulations make cultural competence integral to nursing practice, education, research, administration, and interprofessional collaborations. Interprofessional collaborative practice

refers to multiple health providers from different professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality care (World Health Organization [WHO], 2010). Interprofessional teams have a collective identity and shared responsibility for a client or group of clients. Culturally competent care is an extension of interprofessional collaborative practice (Institute of Medicine, 2011; Interprofessional Education Collaborative Expert Panel, 2011; Oelke, Thurston, & Arthur, 2013), involving clients and their families; credentialed or licensed health professionals; folk or traditional healers from various philosophical perspectives, such as herbalists, medicine men or women, and others; and religious and spiritual leaders, such as rabbis, imams, priests, elders, monks, and other religious representatives or clergy, all of whom are integral members of the interprofessional team. The religious and spiritual healers are especially helpful when the client is discerning which decision or action in health-related matters is best, especially when there are moral, ethical, or spiritual considerations involved (see Chapter 13, Religion, Culture, and Nursing and Chapter 14, Cultural Competence in Ethical Decision Making).

Guidelines for the Practice of Culturally Competent Nursing Care A set of guidelines for implementing culturally competent nursing care was recently developed by a task force consisting of members

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of the American Academy of Nursing (AAN) Expert Panel on Global Nursing and Health and the Transcultural Nursing Society (TCNS). In addition to endorsement by the membership of the AAN and TCNS, these guidelines have been endorsed by the International Council of Nurses. Intended to present universally accepted guidelines that can be embraced by nurses around the world, the ten items listed in Table 2-1 provide a useful framework for implementing c ulturally competent care. The guidelines include knowledge of culture; education and training in culturally competent care; critical reflection; cross-cultural communication; culturally competent practice; cultural competence in systems and organizations; patient advocacy and empowerment; multicultural workforce (see Chapter 12, Cultural Diversity in the Health Care Workforce); cross-cultural leadership; and evidence-based practice and research. The guidelines have their foundation in principles of social justice, such as the belief that everyone is entitled to fair and equal opportunities for health care and to have their dignity protected. The guidelines and accompanying descriptions are intended to serve as a resource for nurses in clinical practice, administration, research, and education (Douglas et al., 2014).

Definitions and Categories of Cultural Competence There is no universally accepted definition of cultural competence. Rather, there are hundreds of definitions that have “evolved from diverse perspectives, interests, and needs and are incorporated in state legislation, Federal statutes and programs, private sector organizations, and academic settings” (National Center for Cultural Competence, n.d.a). Although definitions vary, there is general consensus that cultural competence conceptually can be divided into two major

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Table 2-1: Guidelines for the Practice of Culturally Competent Nursing Care Guideline

Description

1. Knowledge of Cultures

Nurses shall gain an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations they care for, as well as knowledge of the complex variables that affect the achievement of health and well-being.

2. Education and Training in Culturally Nurses shall be educationally prepared to provide culturally Competent Care congruent health care. Knowledge and skills necessary for assuring that nursing care is culturally congruent shall be included in global health care agendas that mandate formal education and clinical training as well as required ongoing, continuing education for all practicing nurses. 3. Critical Reflection

Nurses shall engage in critical reflection of their own values, beliefs, and cultural heritage in order to have an awareness of how these qualities and issues can impact culturally congruent nursing care.

4. Cross-Cultural Communication

Nurses shall use culturally competent verbal and nonverbal communication skills to identify client’s values, beliefs, practices, perceptions, and unique health care needs.

5. Culturally Competent Practice

Nurses shall utilize cross-cultural knowledge and culturally sensitive skills in implementing culturally congruent nursing care.

6. Cultural Competence in Health Health care organizations should provide the structure and resources Care Systems and Organizations necessary to evaluate and meet the cultural and language needs of their diverse clients. 7. Patient Advocacy and Empow - Nurses shall recognize the effect of health care policies, delivery erment systems, and resources on their patient populations and shall empower and advocate for their patients as indicated. Nurses shall advocate for the inclusion of their patient's cultural beliefs and practices in all dimensions of their health care. 8. Multicultural Workforce

Nurses shall actively engage in the effort to ensure a multicultural workforce in health care settings. One measure to achieve a multicultural workforce is through strengthening of recruitment and retention efforts in the hospitals, clinics, and academic settings.

9. Cross-Cultural Leadership

Nurses shall have the ability to influence individuals, groups, and systems to achieve outcomes of culturally competent care for diverse populations. Nurses shall have the knowledge and skills to work with public and private organizations, professional associations, and communities to establish policies and guidelines for comprehensive implementation and evaluation of culturally competent care.

10. Evidence-Based Research

Practice

and Nurses shall base their practice on interventions that have been systematically tested and shown to be the most effective for the culturally diverse populations that they serve. In areas where there is a lack of evidence of efficacy, nurse researchers shall investigate and test interventions that may be the most effective in reducing the disparities in health outcomes.

Reprinted by permission of the Journal of Transcultural Nursing.

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categories: (1) individual cultural competence, which refers to the care provided for an individual client by one or more nurses, physicians, social workers, and/or other health care, education, or social services professionals, and (2) organizational cultural competence, which focuses on the collective competencies of the members of an organization and their effectiveness in meeting the diverse needs of their clients, patients, staff, and community. Before nurses can provide culturally competent care for individual clients or contribute to organizational cultural competence, they need to engage in a cultural self-assessment to identify their cultural baggage. Cultural baggage refers to the tendency for a person’s own culture to be foremost in his/her assumptions, thoughts, words, and behavior. People are seldom consciously aware that culture influences their world view and interactions with others.

Cultural Self-Assessment The purpose of the cultural self-assessment is for nurses to critically reflect on their own culturally based attitudes, values, beliefs, and practices and gain insight into, and awareness of, the ways in which their background and lived experiences have shaped and informed the person the nurse has become today. The nurse’s cultural self- assessment is a personal and professional journey that emphasizes strengths as well as areas for continued growth, thereby enabling nurses to set goals for overcoming barriers to the delivery of culturally congruent and competent nursing care (Chettih, 2012; Douglas et al., 2014; McClimens, Brewster, & Lewis, 2014; National Center for Cultural Competence, n.d.a, National Center for Cultural Competence [NCCC], n.d.b; Timmins, 2006). Part of the cultural self-assessment process includes nurses’ awareness of their human tendencies toward bias, ethnocentrism, cultural imposition, cultural stereotyping, prejudice, and discrimination. Bias refers to the tendency, outlook, or inclination that results in an unreasoned

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judgment, positive or negative, about a person, place, or object. “If anyone, no matter who, were given the opportunity of choosing from amongst all the nations in the world the set of beliefs which he thought best, he would inevitably—after careful considerations of their relative merits—choose that of his own country.” Herodotus, ancient Greek historian, Histories, circum. 450 to 420 B.C.

The term ethnocentrism refers to the human tendency to view one’s own group as the center of and superior to all other groups. People born into a particular culture grow up absorbing and learning the values and behaviors of the culture, and they develop a worldview that considers their culture to be the norm. Other cultures that differ from that norm are viewed as inferior. Ethnocentrism may lead to pride, vanity, belief in the superiority of one’s own group over all others, contempt for outsiders, and cultural imposition. Box 2-1 identifies other examples of —“-isms,” preconceived, unfavorable, judgments about people based on personal characteristics of another. “-Isms” are derived from cultural baggage, biases, stereotypes, prejudice, and/or discrimination related to someone with a background that differs from one’s own. As indicated in Evidence-Based Practice 2-1, racism, the belief that one’s own race is superior and has the right to dominate others, has a profound impact on the body’s stress management system. Exposure to racism over prolonged periods of time may result in severe cardiovascular disease. Cultural imposition is the tendency of a person or group to impose their values, beliefs, and practices onto others. Cultural stereotype refers to a preconceived, fixed perception or impression of someone from a particular cultural group without meeting the person. The perception generally has little or no basis in fact, but nonetheless is perpetuated by individuals who are unwilling to re-examine or change their perceptions even when faced with new evidence that disproves the incorrect perception. Cultural stereotypes fail to recognize individual differences, group changes that occur over

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Box 2-1 Selected Examples of “-isms” Based on Preconceptions about Others Characteristic

Type of -ism

Race

Racism

Ethnicity

Ethnocentrism

National origin

Nationalism

Socioeconomic class

Classism

Gender

Sexism, feminism

Sexual orientation

Homophobism*

Disability

Ableism*

Religion

Islamism* (political ideology associated with some denominations of Islam) Anti-Semitism (anti-Jewish) Anti- (name of religion), e.g., anti-Mormonism

Political opinion

Anti- (name of ideology), e.g., anti-capitalism, anti-communism

Size

Sizeism*

*Neologism—a newly coined term or phrase that is in the process of entering common or mainstream use, but isn’t yet found in dictionaries.

time, and personal preferences. Ethnocentrism, cultural imposition, and cultural stereotypes are barriers to effective cross-cultural communication and the provision of culturally competent care, as are prejudice and discrimination. Prejudice refers to inaccurate perceptions of others or preconceived judgments about people based on ethnicity, race, national origin, gender, sexual orientation, social class, size, disability, religion, language, political opinion, or related personal characteristics (Dunagan, Kimble, Gunby, & Andrews, 2014). Whereas prejudice concerns perceptions and attitudes, discrimination refers to the act or behavior of setting one individual or group apart from another, thereby treating one person or group differently from other people or groups. In the context of civil rights law, unlawful discrimination refers to unfair or unequal treatment of an individual or group based on age, disability, ethnicity, gender, marital status, national origin, race religion, and sexual orientation (Goico, 2014; Titles I and V of the Americans with Disabilities Act of 1990; Title VII of the Civil Rights Act of 1964, Public Law 88–352).

0002491985.INDD 35

By engaging in cultural self-assessments and demonstrating genuine interest in and curiosity about the client’s cultural beliefs and practices, nurses learn to develop their cultural competency and learn to put aside their own ethnocentric tendencies. Box 2-2 contains a cultural self-assessment tool that enables nurses to gain insights into how they relate to people from five different categories: racial/ethnic groups, social issues/problems, religious differences, physical and emotional handicaps, and different political perspectives. After completing and scoring the cultural self-assessment contained in Box 2-2, continue to the next section, which focuses on the cultural assessment of clients.

Cultural Assessment of Clients The foundation for culturally competent and culturally congruent nursing care is the cultural assessment, a term that refers to the collection of data about the client’s health state. There are two major categories of data: subjective data (i.e., what clients say about themselves during the

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Box 2-2 How Do You Relate to Various Groups of People in the Society? Described below are different levels of response you might have toward a person. Levels of Response 1. Greet: I feel I can greet this person warmly and welcome him or her sincerely. 2. Accept: I feel I can honestly accept this person as he or she is and be comfortable enough to listen to his or her problems. 3. Help: I feel I would genuinely try to help this person with his or her problems as they might relate to or arise from the label–stereotype given to him or her. 4. Background: I feel I have the background of knowledge and/or experience to be able to help this person. 5. Advocate: I feel I could honestly be an advocate for this person. The following is a list of individuals. Read down the list and place a checkmark next to anyone you would not “greet” or would hesitate to “greet.” Then, move to response level 2, “accept,” and follow the same procedure. Try to respond honestly, not as you think might be socially or professionally desirable. Your answers are only for your personal use in clarifying your initial reactions to different people. Level of Response 1

Individual

Greet

Help

Background

Advocate

1. Haitian

□

2. Child abuser

□

3. Jew

□

4. Person with hemophilia

□

5. Neo-Nazi

□

6. Mexican American

□

7. IV drug user

□

8. Catholic

□

9. Senile, elderly person

□

10. Teamster Union member

□

11. Native American

□

12. Prostitute

□

13. Jehovah’s Witnesses

□

14. Cerebral palsied person

□

15. Equal Rights Amendment (ERA) proponent

□

16. Vietnamese American

□

17. Gay/lesbian

□

18. Atheist

□

19. Person with AIDS

□

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Chapter 2 Culturally Competent Nursing Care

How Do You Relate to Various Groups of People in the Society? Level of Response 1

Individual

Greet

Help

Background

Advocate

20. Communist

□

21. Black American

□

22. Unmarried pregnant teenager

□

23. Protestant

□

24. Amputee

□

25. Ku Klux Klansman

□

26. White Anglo-Saxon

□

27. Alcoholic

□

28. Amish person

□

29. Person with cancer

□

30. Nuclear armament proponent

□

Scoring Guide: The previous activity may help you anticipate difficulty in working with some clients at various levels. The 30 types of individuals can be grouped into five categories: ethnic/racial, social issues/ problems, religious, physically/mentally handicapped, and political. Transfer your checkmarks to the following form. If you have a concentration of checks within a specific category of individuals or at specific levels, this may indicate a conflict that could hinder you from rendering effective professional help. Level of Response 1

Greet

Help

Background

Advocate

1. Haitian American

□

6. Mexican American

□

11. Native American

□

16. Vietnamese American

□

21. Black American

□

26. White Anglo-Saxon

□

2. Child abuser

□

7. IV drug user

□

12. Prostitute

□

17. Gay/lesbian

□

22. Unmarried pregnant teenager

□

27. Alcoholic

□

Individual Ethnic/racial

Social issues/problems

(continued )

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Part One Foundations of Transcultural Nursing

Religious 3. Jew

□

8. Catholic

□

13. Jehovah’s Witnesses

□

18. Atheist

□

23. Protestant

□

28. Amish person

□

How Do You Relate to Various Groups of People in the Society? Level of Response 1

Greet

Help

Background

Advocate

4. Person with hemophilia

□

9. Senile elderly person

□

14. Cerebral palsied person

□

19. Person with AIDS

□

24. Amputee

□

29. Person with cancer

□

5. Neo-Nazi

□

10. Teamster Union member

□

15. ERA proponent

□

20. Communist

□

25. Ku Klux Klansman

□

30. Nuclear armament proponent

□

Individual Physically/mentally handicapped

Political

Reproduced with permission of the author Randall-David, E. (1989). Strategies for working with culturally diverse communities and clients (pp. 7–9). U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, National Hemophilia Program.

admission or intake interview) and objective data (i.e., what health professionals observe about clients during the physical examination through observation, percussion, palpation, and auscultation). See Chapter 3, Cultural Competence in the Health History and Physical Examination, for an in-depth discussion of cultural competence in the health history and physical examination (cf., Jarvis, 2014). When conducting a comprehensive cultural assessment of clients, nurses need to be able to successfully form, foster, and sustain relationships with people who may frequently come from

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a cultural background that is different from the nurse’s, thus making it necessary to quickly establish rapport with the client. The ability to see the situation from the client’s point of view is known as an emic or insider’s perspective; looking at the situation from an outsider’s vantage point is known as an etic perspective. The ability to successfully form, foster, and sustain relationships with members of a culture that differs from one’s own requires effective cross-cultural communication. Cross-cultural communication is based on knowledge of many factors, such as the other person’s values, perceptions, attitudes, manners,

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Evidence-Based Practice 2-1

Racism and Cardiovascular Disease Risk factors for premature death and increased susceptibility to cardiovascular disease include social determinants of health (SDH), which are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels (World Health Organization, n.d.). The SDH also include socioeconomic factors such as employment, income, working conditions, education, and health literacy; environmental factors such as housing and food security; and biological factors such as age, gender, health, and race. Racism is an influential SDH because it shapes a person’s health and well-being and is interwoven with life opportunities across the lifespan, even when there is no socioeconomic hardship (Etowa & McGibbon, 2012; Galabuzi, 2006). These opportunities may include equitable access to jobs, housing, education, and health. Racism stems from discrimination, bias, and cultural stereotyping. The experience of discrimination is a key factor in producing health disparities and poor health outcomes. Discrimination frequently produces the stressors that lead to health problems and is a barrier to accessing and using health services. Discrimination also limits the person’s right to a wide array of opportunities and resources due to characteristics such as race, gender, and culture. Although a person’s race may predetermine genetic differences in health outcomes, such as sickle cell anemia in African Americans and/or Tay–Sachs disease in Jews, racism is a key SDH. When discriminatory practices become embedded in societal systems, such as the health and education systems, they are referred to as “systemic” and become interwoven with racist health policies and practices within the health care delivery system. Racism impacts the ability of individuals, families, and communities to access health care. The results of research indicate that, when seeking health care, the experience of discrimination can range from 50% (Thomas, 2008) to 68% (Peters, 2006). The results of one study, in which the investigators shadowed black patients as they navigated the health care

system, reveal that 20% to 30% did not receive any follow-up or referral appointments for community services after discharge (Woodger & Cowan, 2010). Female immigrants in Canada identified language and culture as barriers to accessing care. Black patients with cardiovascular disease in the United States were likely to receive lower quality care, for example, fewer cardiac catheterizations, and receive fewer diagnostic and treatment options than white counterparts, even when controlling for insurance and socioeconomic background (Redburg, 2005). Black men with cardiovascular disease were more likely to die from the illness than white men, after controlling for age and income (Thomas, Eberly, Smith, Neaton, & Stamler, 2005). Racism has a profound impact on the body’s stress management system, the sympathetic adrenal medulla (SAM) and the hypothalamus–pituitary– adrenal cortex (HYPAC) (McGibbon, 2012). In the presence of chronic racism-related stresses, the SAM-HYPAC system becomes overwhelmed, leading to a release of catecholamines such as epinephrine. Due to the presence of epinephrine, both blood pressure and heart rate are raised significantly; therefore, racism influences the prevalence of hypertension through stress exposure and reactivity. The prolonged elevation of blood pressure, in turn, causes strain on the myocardium and left ventricular hypertrophy as a compensatory mechanism to offset the increased vascular resistance produced by hypertension. The process of sustained sympathetic activation eventually causes heart failure. Other body systems also react with the kidneys responding to hypertension through activation of the renin–angiotensin system (Swann, 2011). When a person experiences racism on a daily basis, the stress response becomes overwhelmed, and the adrenal system is no longer able to maintain homeostasis. Chronic adrenal fatigue can cause depression, obesity, hypertension, diabetes, cancer, ulcers, allergies, eczema, autoimmune diseases, headaches, and liver disease (Varcorolis & Halter, 2010). (continued )

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Racism and Cardiovascular Disease (continued) In summary, chronic, persistent racism can lead to hypertension, heart failure, myocardial infarction, and stroke. Black clients may also respond differently to some cardiac medications. People experiencing racism appear to be more likely to develop cardiovascular disease due to the physiological impact of racism because no significant genetic variants are linked to cardiovascular disease among African Americans or African Canadians (Peters, 2006).

Clinical Implications Nurses need to position themselves strategically to bring about change in the Canadian and US health care systems by acting as patient advocates, addressing racism for individual clients, and acting collectively as members of the nursing profession to rid the system of racism through systemic changes. Strategies for action include the following: ●●

●●

Engaging in self-reflexive practice through which nurses examine the ways that their own social and cultural backgrounds, experiences, beliefs, and attitudes affect practice Acknowledging the nurse’s own self-location (e.g., race, culture, class, gender, socioeconomic status, disability, and other social identities) influences one’s own beliefs, attitudes, and the therapeutic nurse–client relationship Revitalizing the undergraduate and graduate nursing curricula through transformative education about racism and antiracist practices, thereby openly addressing how inequities in the SDH can intersect and overlap to deepen disadvantage and how advocacy by nurses can bring about change Providing leadership in analyzing organizational approaches to racial diversity and workplace policies to foster inclusiveness, equity, and justice in the Canadian and US health systems, for example, establish an Aboriginal Health Worker role on an inpatient cardiac unit Conducting research on Canadian and US populations experiencing racism in their daily lives and

within the health system with goal of strengthening cardiovascular care for African Canadian and African American clients and ensuring that people from a variety of racial backgrounds are represented in investigations and on research councils that review proposals and allocate funds for cardiovascular research

Reference: Jackson, J., McGibbon, E., & Waldron, I. (2013). Racism and cardiovascular disease: Implications for nursing. Canadian Journal of Cardiovascular Nursing, 23(4), 12–18.

Additional References Etowa, J., & McGibbon, E. (2012). Racism as a determinant of health. In E. McGibbon (Ed.). Oppression: A social determinant of health (pp. 120–138). Toronto, ON: Brunswick Books. Galabuzi, G.-E. (2006). Canada’s economic apartheid. Toronto, ON: Canadian Scholar’s Press. Peters, R. (2006). The relationship of racism, chronic stress emotions, and blood pressure. Journal of the National Medical Association, 98, 1532–1540. Redburg, R. F. (2005). Gender, race and cardiac care: Why the differences? Journal of the American College of Cardiology, 46, 1852–1854. Swann, J. I. (2011). Understanding the common triggers and effects of stress. British Journal of Healthcare Assistants, 5, 483–486. Thomas, K. L. (2008). Discrimination: A new cardiovascular risk factor? American Heart Journal, 156, 1023–1025. Thomas, A. J., Eberly, L. E., Smith, G. D., Neaton, J. D., Stamler, J. (2005). Race/ethnicity, income, major risk factors, and cardiovascular disease mortality. American Journal of Public Health, 95, 1417–1423. Varcarolis, E. M., & Halter, M. (2010). Foundations of psychiatric mental health nursing. St. Louis, MO: Saunders Woodger, D., & Cowan, J. (2010). Institutional racism in healthcare services: Using mainstream methods to develop a practical approach. Ethnicity and Inequalities in Health and Social Care, 3, 36–44. World Health Organization (n.d.). What are the social determinants of health? Retrieved at http://www.int/ social_determinants/en/

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Chapter 2 Culturally Competent Nursing Care

social structure, decision-making practices, and an understanding of how members of groups communicate both verbally and nonverbally. Knowledge about a client’s family and kinship structure helps nurses to ascertain the values, decision-making patterns, and overall communication within the household. It is necessary to identify the significant others whom clients perceive to be important in their care and who may be responsible for decision making that affects their health care. For example, for many clients, familism—which emphasizes interdependence over independence, affiliation over confrontation, and cooperation over competition—may dictate that important decisions affecting the client be made by the family, not the individual alone. When working with clients from cultural groups that value cohesion, interdependence, and collectivism, nurses may perceive the family as being overly involved and usurping the autonomy of both the client and the nurse. At the same time, clients are likely to perceive the involvement with family as a source of mutual support, security, comfort, and fulfillment. The family is the basic social unit in which children are raised and where they learn culturally based values, beliefs, and practices about health and illnesses. The essence of family consists of living together as a unit. Relationships that may seem obvious sometimes warrant further e xploration when the nurse interacts with clients from culturally diverse backgrounds. For example, most European Americans define siblings as two persons with the same mother, the same father, the same mother and father, or the same adoptive parents. In some Asian cultures, a sibling relationship is defined as any infant breast-fed by the same woman. In other cultures, certain kinship patterns, such as maternal first cousins, are defined as sibling relationships. In some African cultures, anyone from the same village or town may be called brother or sister. Among some Hispanic groups, for example, female members of the nuclear or extended family such as sisters and aunts are primary providers of care for infants and children. In some African

American families, the grandmother may be the decision maker and primary caretaker of children. To provide culturally congruent and competent care, nurses must effectively communicate with the appropriate decision maker(s). When making health-related decisions, some clients may seek assistance from other members of the family. It is sometimes culturally expected that a relative (e.g., parent, grandparent, eldest son, or eldest brother) will make decisions about important health-related matters. For example, in Japan, it is the obligation and duty of the eldest son and his spouse to assume primary responsibility for aging parents and to make health care decisions for them. Among the Amish, the entire community is affected by the illness of a member and pays for health care from a common fund. The Amish join together to meet the needs of both the sick person and his or her family throughout the illness, and the roles of dozens of people in the community are likely to be affected by the illness of a single member. The individual value orientation concerning relationships is predominant among the dominant cultural majority in North America. Although members of the nuclear family may participate to varying degrees, decision making about health and illness is often an individual matter. Nurses should ascertain the identity of all key participants in the decision-making process; sometimes, decisions are made after consultation with family members, but the individual is the primary decision maker.

0002491985.INDD 41

Individual Cultural Competence Individual cultural competence is a complex integration of knowledge, attitudes, values, beliefs, behaviors, skills, practices, and cross-cultural nurse–client interactions that include effective communication and the provision of safe, affordable, accessible, research, evidence-based, and best practices, acceptable, quality, and efficacious nursing care for clients from diverse backgrounds. The term diverse or diversity refers to the client’s uniqueness in the dimensions of race; ethnicity; national origin; socioeconomic background; age;

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Part One Foundations of Transcultural Nursing

gender; sexual orientation; philosophical and religious ideology; lifestyle; level of education; literacy; marital status; physical, emotional, and psychological ability; political ideology; size; and other characteristics used to compare or categorize people. Although the connotation of diversity is generally positive, Talabere (1996) argues that it is itself an ethnocentric term because it focuses on “how different the other person is from me” rather than “how different I am from the other.” In using the term cultural diversity, the white panethnic group is frequently viewed as the norm against which the differences in everyone else (ethnocentrically referred to as nonwhites) are measured or compared. Cultural competence is not an end point, but a dynamic, ongoing, lifelong, developmental process that requires self-reflection, intrinsic motivation, and commitment by the nurse to value, respect, and refrain from judging the beliefs, language, interpersonal styles, behaviors, and culturally based, health-related practices of individuals and families receiving services as well as the professional and auxiliary staff who are providing such services. Culturally competent nursing care requires effective cross-cultural communication, a diverse workforce, and is provided in a variety of social, cultural, economic, environmental, and other contexts across the life span (Roberts, Warda, Garbutt, & Curry, 2014). Scholars from nursing, medicine, psychology, and many disciplines have written about cultural competence (American Medical Association, 2013; Andrews, 2013; Andrews & Collins, 2015; Andrews et al., 2011; Basuray, 2014; Betancourt, Green, & Carrillo, 2002; Campinha-Bacote, 2003, 2011; Cross, Bazron, Dennis, & Isaacs, 1989; Douglas & Pacquiao, 2010; Douglas et al., 2014; Institute of Medicine, 2011; Leininger, 1970, 1978, 1991, 1995, 1999; Leininger & McFarland, 2002, 2006; McFarland & WehbeAlamah, 2015; Purnell, 2014; Purnell & Paulanka, 2013; Spector, 2013). Given the large number of cultures and subcultures in the world, it’s impossible for nurses

0002491985.INDD 42

to know everything about them all; however, it is possible for nurses to develop excellent cultural assessment and cross-cultural communication skills and to follow a systematic, orderly process for the delivery of culturally competent care. Nurses are encouraged to study in-depth the top two or three cultural groups that they encounter most frequently in their clinical practice and develop the affective (feelings or emotions), cognitive (conscious mental activities such as thinking), and psychomotor (combined thinking and motor) skills necessary to deliver culturally competent nursing care. As new groups move into a geographic area, nurses need to update their knowledge and skills in order to be responsive to the changing demographics. For nurses in large multicultural urban centers, the challenge of keeping pace with client diversity is complex and needs to become an integral component of the nurse’s continuing professional development. Professional organizations, employer-sponsored in-service programs, and Web-based resources provide nurses with valuable sources of information on culturally based health beliefs and practices of clients from diverse backgrounds. Figure 2-1 provides a more detailed view of the five-step problem-solving process for delivering culturally congruent and competent nursing care for individual clients introduced in Chapter 1. Clients (the individual, their family, and significant others) are at the center and are the focus of the interprofessional health care team (which includes credentialed and/or licensed health professionals, folk, traditional, religious, and spiritual healers). Step one of the process is assessment—of both the nurse and the client. This begins with nurses’ self-assessment of their attitudes, values, and beliefs about people from backgrounds that differ from their own; their knowledge of their own self-location (cultural, gender, class, and other social self-identities) compared to those of clients and other team members; and the psychomotor skills needed for the delivery of culturally

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Chapter 2 Culturally Competent Nursing Care 1. Assessment

2. Mutual Goal Setting

Cultural Self-Assessment

3. Care Planning

• Self-reflection (biases, cultural stereotypes, prejudice, discrimination) • Self-location (cultural, gender, class, & other self-identities) • Psychomotor skills

4. Implementation

5. Evaluation of care plan and objectives by client and team: Safe?

(In collaboration with client and team of credentialed, folk, traditional, religious, and spiritual healers)

Acceptable? Culturally congruent? Culturally competent? Affordable?

Client Cultural Assessment

Accessible?

• Health History (subjective data)

Quality?

• Physical Examination (objective data)

Evidence-based? Best practices?

Return to previous steps as needed

Figure 2-1. The five-step problem-solving process for delivering culturally congruent and competent nursing care for individual clients (Copyright Margaret M. Andrews).

congruent and competent care (see Box 2-3). The self-assessment includes self-reflection and reflexivity (analysis of cause–effect relationships) for the purpose of uncovering the nurse’s unconscious biases, cultural stereotypes, prejudices, and discriminatory behaviors. Nurses then have the opportunity to change, or rectify, affective, cognitive, or psychomotor deficits by reframing their attitude toward certain individuals and groups from diverse backgrounds, learning more about the cultures and subcultures most frequently encountered in their clinical practice, and developing psychomotor skills that enhance their ability to use and their clinical skills to deliver culturally congruent and competent nursing care. The comprehensive cultural assessment of the client and his/her family and significant others (people, companion animals, and pets) requires nurses to gather subjective and objective data through the health history and the physical examination (see Chapter 3). The nurse should consider the influence of the following factors: environmental, social, economic, religious, philosophical, moral, legal, political, educational, biological (genetic and acquired diseases, conditions,

0002491985.INDD 43

disorders, injuries, and illnesses), and technological. In addition, the nurse may have professional and organizational cultures that influence the nurse–patient interaction, such as hospital or agency policies that determine visiting hours, or laws governing the nurse’s scope of practice and professional responsibilities within a particular jurisdiction or setting. The influence of cultural and health belief systems (on the nurse and the client) must also be considered in relation to disease causation, healing modalities, and choice of healer(s). See Chapter 4, The Influence of Cultural Belief Systems on Health Care Practices, for detailed information. In steps two through four, the nurse collaborates with the client, the client’s family and significant others, and members of the health care team (credentialed, folk, traditional, religious, and spiritual healers). The terms folk healer and traditional healer sometimes are used interchangeably. Folk healers typically learn healing practices through an apprenticeship with someone experienced in folk healing. Folk healers primarily use herbal remedies, foods, and inanimate objects in a therapeutic manner. Traditional

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Part One Foundations of Transcultural Nursing

Box 2-3 Selected Examples of Psychomotor Skills Useful in Transcultural Nursing Assessment ●●

●●

●● ●●

Techniques for assessing biocultural variations in health and illness, for example, assessing cyanosis, jaundice, anemia, and related clinical manifestations of disease in darkly pigmented clients; differentiating between mongolian spots and ecchymoses (bruises) Measurement of head circumference and fontanelles in infants using techniques not in violation of taboos for selected cultural groups Growth and development monitoring for children of Asian heritage using culturally appropriate growth grids Cultural modification of the Denver II and other developmental tests used for children Conducting culturally appropriate obstetric and gynecologic examinations of women from various cultural backgrounds

Communication ●● ●●

Speaking and writing the language(s) used by clients Using alternative methods of communicating with non–English-speaking clients and families when no interpreter is available (e.g., pantomime)

or indigenous healers often are divinely chosen and/or learn the art of healing by applying knowledge, skills, and practices based on experiences indigenous to their culture, for example, Native American medicine men/women and shamans. The focus of most traditional and indigenous healers is on establishing and restoring balance and harmony in the body–mind–spirit through the use of spiritual healing interventions, such as praying, chanting, drumming, dancing, participating in sweat lodge rituals, and storytelling. The definition and scope of practice of religious and spiritual healers varies widely, but these healers often help clients analyze complex health-related decisions involving moral and/or ethical issues

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Hygiene ●● ●●

Skin care for clients of various racial/ethnic backgrounds Hair care for clients of various ethnic/racial backgrounds, for example, care of African American clients’ hair

Activities of Daily Living ●●

●● ●●

Assisting Chinese American clients to regain the use of chopsticks as part of rehabilitation regimen after a stroke Assisting paralyzed Amish client with dressing when buttons and pins are used Assisting West African client who uses “chewing stick” with oral hygiene

Religion ●● ●●

Emergency baptism and anointing of the sick for Roman Catholics Care before and after ritual circumcision by mohel (performed 8 days after the birth of a male Jewish infant)

(see Chapter 13, Religion, Culture and Nursing, and Chapter 14, Cultural Competence in Ethical Decision Making). All healers whom the client wants to be involved in care should be included in steps two to five to the extent this is feasible. In step two, mutual goals are set, and objectives are established to meet the goals and desired health outcomes. In step three, the plan of care is developed using approaches that are client centered and culturally congruent with the client’s socioeconomic, philosophical, and religious beliefs, resources, and practices. Members of the health care team assume roles and responsibilities according to their educational background, clinical knowledge,

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Chapter 2 Culturally Competent Nursing Care

and skills. For credentialed or licensed members of the team such as nurses, physicians, physical, occupational and respiratory therapists, social workers, and similar health professions, roles, responsibilities, and scope of practice are delineated by ministries of health, provincial or state health professions licensing, and/or registration boards. In most instances, the credentialed or licensed healer has formal academic preparation and has passed an examination that tested knowledge and skills deemed necessary for clinical practice. In step four, decisions, actions, treatments, and interventions that are congruent with the patient’s health-related cultural beliefs and practices are implemented by those team members who are best prepared to assist the client. In some instances, there is overlapping of scope of practice, roles, and responsibilities between and among team members (Figure 2-2). Clientcentered interprofessional team conferences are usually helpful in sorting out roles and responsibilities of team members when there is lack of clarity about who will deliver a particular service.

Lastly, in step five, the client and members of the health care team collaboratively evaluate the care plan and its objectives to determine if the care is safe; culturally acceptable, congruent, and competent; affordable; accessible; of high quality; and based on research, scientific evidence, and/ or best practices. If modifications or changes are needed, the nurse should return to previous steps and repeat the process. Throughout the five steps of the process for the delivery of culturally congruent and competent nursing care, the nurse behaves in an empathetic, compassionate, caring manner that matches, “fits,” and is consistent with the client’s cultural beliefs and practices.

Organizational Cultural Competence According to the National Center for Cultural Competence (National Center for Cultural Com petence, n.d.), cultural competence requires that organizations have the following characteristics: ●●

A defined set of values and principles and demonstration of behaviors, attitudes, policies, and

Figure 2-2. Effective cross-cultural communication is vital to the establishment of a strong nurse–client relationship. It is important to understand both verbal and nonverbal cues when communicating with people from different cultural backgrounds (Margaret M. Andrews).

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●●

Part One Foundations of Transcultural Nursing

structures that enable them to work effectively cross-culturally The capacity to (1) value diversity, (2) conduct self-assessments, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity and the cultural contexts of the communities they serve Incorporation of the previously mentioned items in all aspects of policy making, administration, practice, and service delivery and systematic involvement of consumers, key stakeholders, and communities (National Center for Cultural Competence, n.d.c; Marrone, 2014; Ray, 2010a, 2010b)

Organizational cultural competence is discussed in detail in Chapter 9, Creating Culturally Competent Organizations. Appendix C contains the Andrews/Boyle Transcultural Nursing Assessment Guide for Health Care Organizations and Facilities.

Clients with Special Needs In the remainder of this chapter, we discuss the delivery of culturally competent nursing care for three groups of clients with special needs: those at high risk for health inequities and health disparities, those who are deaf, and those with communication and special language needs.

Health Disparities The Health Resources and Services Admini stration defines health disparities as populationspecific differences in the presence of disease, health outcomes, or access to health care. These differences can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death (U.S. Department of Health and Human Services, 2012). Many different populations are affected by disparities. These include the following: ●● ●● ●●

Racial and ethnic minorities Residents of rural areas Women, children, and the elderly

0002491985.INDD 46

●● ●●

Persons with disabilities Other special populations such as the deaf

In the United States, health disparities are a well-known problem among panethnic minority groups, particularly African Americans, Asian Americans, Native Americans, and Latinos. When examining health disparities globally, the World Health Organization uses the term health inequities (American Medical Association, n.d.). Recent studies indicate that despite the steady improvements in the overall health of the United States, clients from racial and ethnic minority backgrounds experience a lower quality of health services, are less likely to receive routine medical procedures, and have higher rates of morbidity and mortality than nonminorities. Disparities in health care exist even when controlling for gender, condition, age, and socioeconomic status (American Medical Association, 2013; Clark, 2014; Frieden, 2013; Mandal, 2014; Purnell et al., 2011). The U.S. Department of Health, Health Resources and Services Administration, identifies culturally competent nursing care as an effective approach in reducing and eliminating health disparities and inequities in high-risk populations such as Blacks, Latinos, and American Indians. Studies demonstrate that these groups have a higher prevalence of chronic conditions, along with higher rates of mortality and poorer health outcomes, when compared with counterparts in the general population. For example, the incidence of cancer among African Americans is 10% higher than it is for Whites. African Americans and Latinos are also approximately twice as likely to develop diabetes as counterparts in the general population. Throughout the remaining chapters of the book, there will be discussion of the delivery of culturally congruent and culturally competent nursing care for clients from diverse backgrounds across the lifespan (Frieden, 2013).

Culture of the Deaf Although nurses tend to think about clients from racially and ethnically diverse backgrounds, when discussing culturally competent nursing

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Chapter 2 Culturally Competent Nursing Care

care, there are many people who self-identify with nonethnic cultures and/or with more than one culture or subculture. For example, more than 5% of the world’s population (360 million adults and 32 million children) experience disabling hearing loss (World Health Organization, 2014). Additionally, nurses will encounter clients who are both Black and deaf, gay and deaf, Native American and deaf, and many other combinations of two or more cultures (Holcomb, 2013). Disabling hearing loss is defined as the loss of greater than 40 decibels in the better ear in adults and the loss of greater than 30 decibels in the better ear in children. Disabling hearing loss means that a client has very little or no hearing, which has consequences for interpersonal communication, psychosocial well-being, quality of life, and economic independence. Hearing loss may affect one or both ears, can be congenital or acquired, and occurs on a continuum from mild to severe. Hearing loss leads to difficulty in hearing conversational speech or loud sounds. Clients who are hard of hearing usually communicate through spoken language and can benefit from hearing aids, captioning, and assistive listening devices (National Institute on Deafness and Other Communication Disorders, 2014; World Health Organization, 2014). If hearing loss develops in childhood, it impedes speech and language development and, in severe cases, requires special education. In adulthood, disabling hearing loss can lead to embarrassment, loneliness, social isolation, stigmatization, prejudice, abuse, mental health problems such as depression, difficulties in interpersonal relationships with partners and children, restricted career choices, occupational stress, and lower earnings when compared with counterparts who do not have disabling hearing loss. Approximately one-third of people over 65years of age are affected by disabling hearing loss. The prevalence in this age group is greatest in South Asia, Asia Pacific, and sub-Saharan Africa (World Health Organization, 2014). Some clients with congenital deafness or others with significant hearing losses may benefit

from cochlear implants, but the decision to have a cochlear implant is interconnected with an animated debate within and between members of the deaf culture and members of the culture of medicine concerning the appropriateness of cochlear implants. The fundamental issues underlying the debate concern the philosophical belief about deafness and the concept of deaf culture. From an emic perspective, many deaf people see their bodies as well, whole, and nonimpaired, and they self-identify as members of a linguistic minority, not with the culture of disability (Harris, 2014; Holcomb, 2013; Humphries, 2014). As members of a cultural minority, some deaf people perceive themselves as being on a journey of cultural awareness, one of several stages on the way to achieving a positive sense of self and deaf identity. On the other hand, others who are deaf advocate reframing the concept of a deaf culture and conceptualizing it as the deaf experience based on values stemming from a visual orientation. Recognizing that literature and the arts provide forums for cultural awareness, appreciation, and expression of ideas and feelings, there are a growing number of deaf people using these media to communicate their experiences with one another and with hearing members of society (Harris, 2014; Holcomb, 2013). From an etic (outsider’s) perspective, some physicians and other members of the hearing society embrace concepts about deaf peoples’ bodies that emphasize their differences from the bodies of people in the hearing society, thereby placing unwanted, unwarranted, and unnecessary limitations on deaf people’s lives and capabilities. In the biological sciences, for example, the bodies of hearing people historically have been constructed with a normative bias. In other words, the body that hears is the normative prototype (Humphries, 2014). Some physicians engage in the cultural imposition of medical and surgical interventions on members of the deaf culture through eugenics (a science that tries to improve the human race by controlling which people become parents), genetic engineering, and insistence that deaf people should use hearing aids,

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agree to cochlear implant surgery, and embrace other technologies that profoundly change their lives and their culture (Harris, 2014; Holcomb, 2013; Humphries, 2014). Box 2-4 uses the framework of the five-step process for delivering culturally congruent and competent nursing care for people who self- identify as members of the deaf culture, beginning with a cultural assessment of self and the client, mutual goal setting, planning, implementation, and evaluation. Box 2-5 identifies measures that nurses can take to prevent deafness. There are hundreds of sign language dialects in use around the world. Each culture has d eveloped

its own form of sign language to be compatible with the language spoken in that country. In the United States, an estimated 500,000 people communicate by using American Sign Language (ASL), including many who are deaf and hearing impaired, and family members, friends, or teachers of people with hearing impairments (Harrington, 2010). An ASL interpreter is often helpful in avoiding communication difficulty when caring for someone who is deaf or hearing impaired. Signaling and assistive listening devices, alerting devices, telecommunication devices for the deaf (TDD), and telephone amplifiers might also help promote effective communication and

Box 2-4 Culturally Congruent and Competent Care for Deaf Clients 1. Cultural Assessment

Self-Assessment: What is your attitude toward people who are deaf? Do you think of people who are deaf as able-bodied or disabled? How do you feel about those who use hearing aids and other assistive devices for hearing? How do you assess your self-location with regard to culture, gender, class, age, and other selfidentities compared to the client’s background? What do you know about deafness, for example, causes, categories or types, and assistive devices? Do you know anyone who is deaf? If so, how do you feel about the interactions you had with this person(s)? Client Assessment: Health History (Subjective Data) See Appendix A, Transcultural Nursing Assessment Guide for Individuals and Families, for questions you might want to pose in the following categories: Cultural affiliations or self-identities associated with deafness? Client’s preferred method for communication? Sign language? Written communication? Verbal communication? Are any assistive devices needed for effective communication? Has exclusion from communication significantly impacted everyday life? Is there any evidence of feelings

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of loneliness, isolation, and frustration, particularly for older adults with hearing loss? Cultural sanctions and restrictions? Economic or financial concerns? Adults with hearing loss have a much higher unemployment rate and earn less than counterparts who have hearing. Is the client employed? Education and health literacy levels? In developing countries, children with hearing loss and deafness rarely receive any schooling. What is the educational and health literacy level of the client? Improving access to education and vocational rehabilitation services, and raising awareness, especially among employers, would decrease unemployment rates among adults with hearing loss. Health-related beliefs and practices? Kinship and social support network? Nutrition and diet? Religion and spirituality? Values orientation of the client, including his/her perspective on culturally acceptable interventions to improve hearing? Physical Examination (Objective Data) See Chapter 3, Cultural Competence in the Health History and Physical Examination.

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Chapter 2 Culturally Competent Nursing Care

2. Mutual Goal Setting 3. Care Planning 4. Implementation of Care Plan 5. Evaluation of Care

Culturally acceptable, congruent, and competent? Affordable? Accessible? Quality? Evidence based? Best practices?

In collaboration with client’s family, significant others, credentialed, licensed members of the health care team (e.g., audiologist, speech– language pathologist), folk, traditional, religious, and/or spiritual healers

facilitate the provision of culturally competent care in home, community, hospital, and other settings.

Communication and Language Assistance With growing concerns about racial, ethnic, and language disparities in health and health care and the need for health care systems to accommodate increasingly diverse patient populations, language access services (LAS) have become

a matter of increasing national importance. Currently, about 20% of the US population speaks a language other than English at home, and 9% has limited English proficiency. By 2050, more than half the population will come from racial or ethnic minority backgrounds. Diversity is even greater when dimensions such as geography, socioeconomic status, disability status, sexual orientation, and gender identity are considered. Attention to these trends is critical for ensuring that health disparities narrow, rather than widen, in the future. In 2013, the Office of Minority Health released an

Box 2-5 Prevention of Deafness 50% of all cases of hearing loss can be prevented through primary prevention. Strategies for prevention include: ●●

●● ●● ●● ●●

Immunizing children against childhood diseases, including measles, meningitis, rubella, and mumps Immunizing adolescent girls and women of rep roductive age against rubella before pregnancy Screening for and treating syphilis and other infections in pregnant women Improving antenatal and perinatal care, including promotion of safe childbirth Avoiding the use of ototoxic drugs, unless prescribed and monitored by a qualified physician,

●●

nurse practitioner, or other health care provider Referring infants with high risk factors (such as those with a family history of deafness, those born with low birth weight, birth asphyxia, jaundice, or meningitis) for early assessment of hearing, prompt diagnosis, and appropriate management, as required Reducing exposure (both occupational and recreational) to loud noises by creating awareness, using personal protective devices, and developing and implementing suitable legislation

Data from World Health Organization (2014).

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update of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards, see Box 2-6). Standards under the theme “Communication and Language Assistance” include the recommendation that language assistance should be provided as needed, in a manner appropriate to the organization’s size, scope, and mission (U.S. Census Bureau, 2013a, 2013b). Clients are informed about the availability of assistance in their preferred language after being asked to

indicate their language needs (Jones & Boyle, 2011; Office of Minority Health, 2013, n.d.; Siaki, 2011). Health care organizations and providers that receive federal financial assistance without providing free language assistance services could be in violation of Title VI of the Civil Rights Act of 1964 and its implementing regulations. The director of the U.S. Department of Health and Human Services Office for Civil Rights encourages requests for information and technical assistance concerning the law (Hoh, Garcia, & Alvarez, 2014).

Box 2-6 National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards) aim to improve health care quality and advance health equity by establishing a framework for organizations to serve the nation’s increasingly diverse communities.

Principal Standard 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership, and Workforce 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

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Communication and Language Assistance 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

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Chapter 2 Culturally Competent Nursing Care

10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality impro vement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic

diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Source: Office of Minority Health (2014).

Summary In this chapter, the reader was introduced to individual and organizational cultural competence and provided with the knowledge and skills needed to deliver culturally congruent and competent nursing care to individual clients from diverse cultures. Nurses are encouraged to think about out the delivery of care as a five-step process consisting of (1) a constructively critical self-assessment of the nurse’s own attitudes, knowledge, and skills and a cultural assessment of clients from diverse backgrounds by gathering subjective and objective data using the health history and physical examination; (2) mutual goal setting in collaboration with the client and other members of the interprofessional health care team (family, significant others, credentialed, licensed, folk, traditional, religious, and/or spiritual healers); (3) development of the plan of care; (4) implementation of the care plan; and (5) evaluation of the plan for client acceptance, cultural congruence, cultural competence, affordability, accessibility, and use of research, evidence, and best practices. If necessary, the steps in the process may be repeated. Interprofessional collaboration with the client and members of the health care team is integral to the provision of culturally congruent and competent nursing care. Lastly, we examined clients

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with special needs including those at high risk for health disparities, those who are deaf, and those with communication and language needs.

REVIEW QUESTIONS 1. Compare and contrast individual and organi-

zational cultural competence.

2. Describe the five steps in the process for deliv-

ering culturally congruent and competent care for clients from diverse backgrounds. 3. In your own words, define the following terms: cultural baggage, ethnocentrism, cultural imposition, prejudice, and discrimination. 4. Identify key strategies to assist clients with communication and language needs.

CRITICAL THINKING ACTIVITIES 1. After critically analyzing the definitions of

cultural competence presented in the chapter, craft a definition of the term in your own words.

2. In discussions of culturally competent nurs-

ing care, the culture of the deaf and hearing impaired is sometimes overlooked because it is categorized as a nonethnic culture. Search the Internet for information on the culture

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Part One Foundations of Transcultural Nursing

of the deaf. What cultural characteristics do deaf people have in common with members of other cultural groups? If a client is both deaf and self-identifies as a member of another ethnic or nonethnic culture, how does this influence your ability to deliver culturally congruent and culturally competent nursing care? 3. To provide culturally competent nursing care,

you should engage in a cultural self-assessment. Answer the questions in Box 2-2, How Do You Relate to Various Groups of People in the Society? Score your answers using the guide provided. What did you learn about yourself? How would you approach learning more about the health-related beliefs and practices of groups for which you need more background knowledge? What resources might you use in your search for information?

4. At the request of the Bureau of Primary

Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, staff at the National Center

for Cultural Competence (NCCC) developed the Cultural Competence Health Practitioner Assessment, which is available online. Visit the NCCC website and complete this assessment. 5. Mary Johnson is an African American nurse

working in the Post-Anesthesia Care Unit (PACU). When Mrs. Li, a recent immigrant from China, arrives in the PACU following a major bowel resection for cancer, Mary assesses Mrs. Li for pain. Mary notes that Mrs. Li is not complaining about pain, is lying quietly in her bed, and has a stoic facial expression. Mary comments to another nurse that “all Chinese patients seem to do just fine without post-operative pain medications. I’m not going to administer any analgesics unless she asks me for something.” Do you agree with Nurse Johnson’s assessment of Mrs. Li’s pain? What nonverbal manifestations of pain would you assess? How would you reply to Nurse Johnson’s statement that she doesn’t intend to administer any pain medication?

REFERENCES American Medical Association. (2013). Health literacy and patient safety: Helping patients understand. Chicago, MA: Author. American Medical Association. (n.d.). Eliminating health disparities. Retrieved from http://www.ama-assn.org/ ama/pub/physician-resources/public-health/eliminatinghealth-disparities.page Andrews, J. D. (2013). Cultural, ethnic, and religious reference manual for healthcare providers (4th ed.). Kernersville, NC: JAMARDA Resources. Andrews, M. M., & Collins, J. W. (2015). Using Leininger’s theory as the organizing framework for a federal project on cultural competence. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 537– 582). Burlington, MA: Jones and Bartlett Learning. Andrews, M., Thompson, T., Wehbe-Alamah, H., McFarland, M. R., Hasenau, S., Horn, B., …, Vint, P. (2011). Developing a culturally competent workforce through collaborative partnerships. Journal of Transcultural Nursing, 22(3), 300–306. Basuray, J. (2014). Culture & health: Concept and practice (2nd ed.). Ronkonkoma, NY: Linus Publications, Inc. Betancourt, J., Green, A., & Carrillo, E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund. Retrieved from

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http://www.commonwealthfund.org/usr_doc/betancourt_ culturalcompetence_576.pdf Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services (4th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates. Campinha-Bacote, J. (May 31, 2011). Delivering patient- centered care in the midst of a cultural conflict: The role of cultural competence. Online Journal of Issues in Nursing, 16(2), Manuscript 5. Chettih, M. (2012). Turning the lens inward: Cultural competence and providers’ values in health care decision making. Gerontologist, 52(6), 739–747. Clark, L. (2014). A humanizing gaze for transcultural nursing research will tell the story of health disparities. Journal of Transcultural Nursing, 25(2), 122–128. Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care, Vol. I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center. Douglas, M. K., & Pacquiao, D. F. (2010). Core curriculum for transcultural nursing and health care. Journal of Transcultural Nursing, 21(4 Suppl), 5S–417S. Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., … Purnell, L.

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(2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(20), 109–121. Dunagan, P. B., Kimble, L. P., Gunby, S.S., & Andrews, M. M. (2014). Attitudes of prejudice as a predictor of cultural competence among baccalaureate nursing students. Journal of Nursing Education, 53, 320–328. doi: 10.3928/01484834-20140521-13 Frieden, T. R. (2013). CDC Health disparities and inequalities report—United States, 2013. Forward. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C.: 2002), 62(Suppl 3), 1–2. Goico, A. L. (2014). EEOC expands pregnancy discrimination definitions and offers new guidance that increases employer obligations to pregnant employees. Employee Relations Law Journal, Winter 2014, 39–43. Harrington, T. (2010). Sign language: Ranking and number of users. Retrieved from http://libguides.gallaudet.edu/content.php?pid=114804&sid=991835 Harris, R. (2014). Introduction to American deaf culture. Sign Language Studies, 14(3), 406–410. Hoh, H. K., Garcia, J. N., Alvarez, M. H. (2014). Culturally and linguistically appropriate services—Advancing health with CLAS. New England Journal of Medicine, 371, 198–201. Holcomb, T. K. (2013). Introduction to American deaf culture. New York: Oxford University Press. Humphries, T. (2014). Our time: The legacy of the twentieth century. Sign Language Studies, 15(1), 57–73. Institute of Medicine. (2011). Future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Jarvis, C. (2014). Physical examination and assessment, Saint Louis, MO: Elsevier. Jones, E. G. & Boyle, J. S. (2011). Working with translators and interpreters in research: Lessons learned. Journal of Transcultural Nursing, 22(2), 109–115. Leininger, M. M. (1970). Nursing and anthropology: Two worlds to blend. New York: John Wiley & Sons. Leininger, M. M. (1978). Transcultural nursing: Concepts, theories and practices. New York: John Wiley & Sons. Leininger, M. M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing. Leininger, M. M. (1995). Transcultural nursing: Concepts, theories, research and practices. New York: McGraw-Hill. Leininger, M. M. (1999). What is transcultural nursing and culturally competent care? Journal of Transcultural Nursing, 10(1), 9. Leininger, M. M., & McFarland, M. R. (2002). Transcultural nursing: Concepts, theories, research and practices. New York: McGraw-Hill.

Leininger, M. M., & McFarland, M. R. (2006). Culture care diversity and universality: A worldwide theory for nursing (2nd ed.). Sudbury, MA: Jones & Bartlett, Publishers. Mandal, A. (2014). What are health disparities? Retrieved from http://www.news-medical.net/health/HealthDisparities-What-are-Health-Disparities.aspx Marrone, S. (2014). Organizational cultural competence. Transcultural Nursing Society Annual Conference, October, 2014, Charleston, SC. McClimens, A., Brewster, J., & Lewis, R. (2014). Recognising and respecting patients’ cultural diversity. Nursing Standard, 12(28), 45–52. McFarland, M. R., & Wehbe-Alamah, H. B. (2015). The theory of culture care diversity and universality. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Leininger’s culture care diversity and universality: A worldwide nursing theory (pp. 1–34). Burlington, MA: Jones and Bartlett Learning. National Center for Cultural Competence. (n.d.a). Definitions of cultural competence. (Georgetown University Center for Child and Human Development). Retrieved September 12, 2014, from Curricula Enhancement Module Series: http://www.nccccurricula.info/culturalcompetence.html National Center for Cultural Competence. (n.d.c). Organizational cultural competence. Retrieved from http://www.nccccurricula.info/culturalcompetence.html National Center for Cultural Competence (NCCC). (n.d.b). Foundations of cultural and linguistic competence. Retrieved September 10, 2014 from http://nccc.georgetown.edu/ foundations/index.html National Institute on Deafness and Other Communication Disorders. (2014, August 12). National Institute on Deafness and Other Communication Disorders (NIDCD). U.S. Department of Health and Human Services. Retrieved September 12, 2014, from National Institutes of Health: http://www.nidcd.nih.gov/Pages/default.aspx Oelke, N. D., Thurston, W. E., & Arthur, N. (2013). Intersections between interprofessional practice, cultural competence, and primary healthcare. Journal of Interprofessional Care, 27(5), 267–272. doi: 10.3109/13561820.2013.785502 Office of Minority Health. (2013). The national CLAS standards. Retrieved from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=15 Office of Minority Health. (2014, June 19). The Center for Linguistic and Cultural Competency in Health Care. U.S. Department of Health and Human Services. Retrieved September 12, 2014, from Office of Minority Health website: http://minorityhealth.hhs.gov/omh/browse.aspx? lvl=2&lvlid=34 Office of Minority Health. (n.d.). National standards for cul turally and linguistically appropriate services in health and health care. Retrieved from https://www. thinkculturalhealth.hhs.gov/pdfs/NationalCLASStan dardsFactSheet.pdf Office of Minority Health & Equity (OMHHE). (2013, March 22). Minority health. Centers for Disease Control and Prevention. Retrieved September 13, 2014, from Centers

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for Disease Control and Prevention website: http://www. cdc.gov/minorityhealth/omhhe.html Purnell, L. (2014). Guide to culturally competent health care. Philadelphia, PA: F.A. Davis Company. Purnell, L., & Paulanka, B. J. (Eds.). (2013). Transcultural health care: A culturally competent approach. Philadelphia, PA: F. A. Davis. Purnell, L., Davidhizar, R., Giger, J., Fishman, D., Strickland, O., & Allison, D. (2011). Guide to developing a culturally competent organization. Journal of Transcultural Nursing, 22(1), 5–14. Ray, M. (2010a). Creating caring organizations and cultures through communitarian ethics. Journal of the World Universities Forum, 3(5), 41–52. Ray, M. (2010b). Transcultural caring dynamics in nursing and health care. Philadelphia, PA: F.A. Davis Company. Roberts, S., Warda, M., Garbutt, S., & Curry, K. (2014). Use of high-fidelity simulation to teach cultural competence in the nursing curriculum.” Journal of Professional Nursing, 30(3), 259–265. Siaki, L. (2011). Translating a questionnaire for use with Samoan adults: Lessons learned. Journal of Transcultural Nursing, 22(2), 122–128. Spector, R.E. (2013). Cultural diversity in health and illness. (8th ed.). Upper Saddle River, NJ: Pearson. Talabere, L. R. (1996). Meeting the challenge of culture care in nursing: Diversity, sensitivity, and congruence. Journal of Cultural Diversity, 3(2), 53–61. Timmins, F. (2006). Critical practice in nursing care: Analysis, action and reflexivity. Nursing Standard, 20, 49–54.

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Title VII of the Civil Rights Act of 1964 (Public Law 88–352) retrieved at http://www.eeoc.gov/laws/statutes/ada.cfmwww.eeoc.gov/laws/statutes/titlevii.cfm Titles I and V of the Americans with Disabilities Act of 1990 (Pub. L. 101–336) (ADA) retrieved at http://www.eeoc. gov/laws/statutes/ada.cfm U.S. Census Bureau. (2012). Selected social characteristics in the United States. http://factfinder2.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?pid=ACS_12_ 1YR_DP02&prodType=table U.S. Census Bureau. (2013a). Language use. (U.S. Department of Commerce) Retrieved September 12, 2014, from U.S. Census Bureau https://www.census.gov/hhes/socdemo/ language/about/faqs.html#Q3 U.S. Census Bureau. (2013b). Language Use in the United States: 2011. Retrieved from http://www.census.gov/ prod/2013pubs/acs-22.pdf U.S. Department of Health and Human Services (2012). HHS Action Plan to reduce racial and ethnic health disparities. Washington, DC: U.S. Department of Human Services. World Health Organization. (2014, February). Deafness and hearing loss. Retrieved from http:// www.who.int/ mediacentre/factsheets/fs300/en/ World Health Organization. (n.d.). What are the social determinants of health? Retrieved at http://www.int/social_ determinants/en/ World Health Organization (WHO). (2010). Framework for action on interprofessional education and collaborative practice. Geneva, Switzerland: World Health Organization.

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Cultural Competence in the Health History and Physical Examination

●●Margaret M. Andrews and Margaret Murray-Wright

Key Terms Albinism Addison’s disease Biocultural variations Cafe’ au lait spots Clinical decision making Copy-number variants Cultural assessment Cultural care accommodation or negotiation Cultural care repatterning or restructuring Cultural care preservation or maintenance

Cultural norms Culture-bound syndromes Cyanosis Ecchymoses Epigenetics Erythema Ethnohistory Evaluation Genetics Genome Genomics Genotyping Jaundice Leukoedema Lactose intolerance

Mongolian spots Oral hyperpigmentation Pain Pallor Petechiae Pharmacogenomics Presbycusis Single-nucleotide polymorphisms Steatorrhea Uremia Vitiligo

Learning Objectives 1. Explore the process and content needed for a comprehensive cultural assessment of clients from diverse cultures. 2. Identify biocultural variations in health and illness for individuals from diverse cultures. 3. Integrate concepts from the fields of genetics and genomics into the cultural assessment of clients from diverse cultural backgrounds. 4. Discuss biocultural variations in common laboratory tests. 5. Critically review transcultural perspectives in the health history and physical examination.

Part One Foundations of Transcultural Nursing

In this chapter, we provide cultural prompts or cues that enable nurses to customize or tailor their cultural assessment according to the client’s genetic background, biographic makeup, and his/her self-identified cultural affiliation(s). We define and describe the cultural assessment and then discuss transcultural perspectives on the health history, the physical examination, and clinical decision making and actions. In many instances, the health history and physical examination are interconnected and interrelated. For example, the client might complain about shortness of breath during the history, and the nurse might hear the client wheezing during the interview. After the interview is finished, the nurse gathers additional data during the physical examination by observing the client for clinical manifestations of cyanosis, nasal flaring, intercostal retraction, and by auscultating the lungs. Based on the findings in the physical examination, the nurse might ask additional questions, such as the length of time the client has experienced the symptoms, check for family history of respiratory disease, and pursue additional assessment related to the respiratory and cardiovascular systems. The health history includes cultural perspectives on biographic and genetic data, medications, reasons for seeking care, present health and history of the present illness, past health, family and social history, and the review of systems. In the physical examination, the nurse compares and contrasts normal and abnormal cultural variations in measurements, general appearance, skin, sweat glands, head (hair, eyes, ears, mouth), mammary plexus, and the musculoskeletal system. We also discuss biocultural variations in pain and illness and cultural considerations in selected laboratory tests for which there is evidence of racial and/or ethnic differences. Lastly, we explore transcultural perspectives in clinical decision making and actions. After completing a comprehensive cultural assessment through the health history, physical examination, and analysis of laboratory test results, the next steps are to analyze the subjective and objective data, set mutual goals with the client, develop a plan

of care, confer with and make referrals to other members of the interprofessional health care team as needed, and implement a plan of care, either alone or with others.

Cultural Assessment With 318 million people, the United States is the third most populous nation in the world (behind China and India). By the year 2050, nearly 50% of the U.S. population will be comprised of people from diverse racial and ethnic backgrounds, that is, non-white groups. Hispanic and Asian populations are expected to double between now and 2050 and are followed in growth by Blacks, Native Americans, Native Hawaiians, and other Pacific Islanders (U.S. Census Bureau, 2014a). With growing diversity comes the need for nurses to develop their knowledge and skills in cultural assessment. In the course of their professional careers, nurses might need to assess people from many different racial and ethnic groups and from numerous nonethnic cultures. Cultural assessment, or culturologic assessment, refers to a systematic, comprehensive examination of individuals, families, groups, and communities regarding their health-related cultural beliefs, values, and practices. Although the focus in this chapter is on the individual client, there are some instances in which clients’ families and others in close contact might need to be involved, for example, when the cultural assessment reveals the presence of a genetic, infectious, or communicable disorder. Cultural assessments form the foundation for the clients’ plan of care, providing valuable data for setting mutual goals, planning care, intervening, and evaluating the care. The goal of the cultural assessment is to determine the nursing and health care needs of people from diverse cultures and intervene in ways that are culturally acceptable, congruent, competent, safe, affordable, accessible, high quality, and based on current research, evidence, and best practices (Leininger & McFarland, 2002; McFarland & Wehbe-Alamah, 2015).

Chapter 3 Cultural Competence in the Health History and Physical Examination

Given that they deal with cultural values, belief systems, and lifeways, cultural assessments tend to be broad and comprehensive. It is sometimes necessary to conduct an abbreviated assessment when time is limited, the client’s reason for seeking care is urgent or time sensitive, the client is unable to provide all of the necessary data, or other circumstances require a shorter, more focused assessment. The cultural assessment consists of both process and content. Process refers to how to approach to the client, consideration of verbal and nonverbal communication, and the sequence and order in which data are gathered. The content of the cultural assessment consists of the actual data categories in which information about clients is gathered. Nurses are required to complete assessments before and/or at the time of admission to health care facilities, when opening home health care cases, and prior to many types of medical and surgical procedures. Depending on the circumstances, assessments may be very brief, or they may be detailed and in-depth. Ideally, the cultural assessment is integrated into the overall assessment of the client, family, and significant others. It is usually impractical to expect that nurses will have the time to conduct a separate cultural assessment, so questions aimed at gathering cultural data should be integrated into the overall assessment using the format provided by health care facilities, agencies, or organization for their admissions or intake assessment. Appendix A is the Andrews and Boyle Transcultural Nursing Assessment Guide for Individuals and Families for use when initially assessing clients from diverse backgrounds, for example, when conducting an admission assessment or opening a case in home health care or ambulatory settings. The major categories in this guide include cultural affiliations, values orientation, communication, health-related beliefs and practices, nutrition, socioeconomic considerations, organizations providing cultural support, education, religion, cultural aspects of disease incidence, biocultural variations, and developmental considerations across the lifespan. Appendix B is the Andrews and Boyle

Transcultural Nursing Assessment Guide for Groups and Communities. The major categories in this guide include family and kinship systems, social life and networks, political or government systems, language and traditions, worldview, values, norms, religious beliefs and practices, health beliefs and practices, and health care systems.

Transcultural Perspectives on the Health History The purpose of the health history is to gather subjective data—a term that refers to things that people say or relate about themselves. The health history provides a comprehensive overview of a client’s past and present health, and it examines the manner in which the person interacts with the environment. The health history enables the nurse to assess health strengths, including cultural beliefs and practices that might influence the nurse’s ability to provide culturally competent nursing care. The history is combined with the objective data from the physical examination and the laboratory results to form a diagnosis about the health status of a person. For the well client, the history is used to assess lifestyle, which includes activity, exercise, diet, and related personal behaviors and choices that nurses may gather to identify potential risk factors for disease. For the ill client, the health history includes a chronologic record of the health problem(s). For both well and ill clients, the health history is a screening tool for abnormal symptoms, health problems, and concerns. The health history also provides valuable information about the coping strategies and health-related behaviors and responses used previously by clients and family members. In many health care settings, the client is expected to fill out a printed history form or checklist. From a transcultural perspective, this approach has both positive and negative aspects. On the positive side, this approach provides the client with ample time to recall details such as relevant family history and the dates of h ealth-related

Part One Foundations of Transcultural Nursing

events such as surgical procedures and illnesses. It is expedient for nurses because it takes less time to review a form or a checklist than to elicit the information in a face-to-face or telephone interview. However, this approach has limitations. First, the form is likely to be in English. Those whose primary language is not English might find the form difficult or impossible to complete accurately. Although some health care facilities provide forms translated into Spanish, French, or other languages, translating forms can be costly and is not always effective. In some instances, the literal translation of medical terms is not possible. In other instances, the symptom or disease is not recognized in the culture with which the client identifies. For example, in asking about symptoms of depression, there might be many cultural factors that influence the client’s interpretation of the question. In Chinese languages, there is no literal translation for the word depression. In Chinese culture, it is more acceptable to somaticize emotional pain with expressions of physical discomfort such as chest pain or “heaviness of the heart” (Ryder & Chentsova-Dutton, 2012; Yu & Lee, 2012). In rural Guatemala, Mayans might refer to “dolor de corazón” or pain in the heart (Godoy-Paiz, Toner, & Vidal, 2011; Pedersen et al., 2012). “Nervios” may be cited by Guatemalan Mayan women as the cause of somatic disorders such as ulcers, diabetes, and dizziness (GodoyPaiz et al., 2011). If health care providers fail to understand the cultural meaning of the symptom “heaviness of the heart,” or “pain in the heart,” unnecessary, invasive, and costly tests might be performed to rule out cardiovascular disease. In some instances, clients might be unable to read or write in any language; thus, an assessment of the client’s literacy level should precede the use of printed history forms or checklists. Although there is wide variation in health history formats, most contain the following categories: biographic data, reason for seeking care, review of medications and allergies, present health or history of present illness, past history, family and social history, and review of systems. Genetic data are also an important area for the

transcultural nurse to consider as part of the health history. This chapter will not provide a comprehensive overview of these categories, but will present them as they relate to providing culturally congruent and culturally competent nursing care.

Biographic Data Although the biographic information (name, address, phone, age, gender, preferred language, and so forth) might seem straightforward, several cultural variations in recording age are important to note. In some Asian cultures, an infant is considered 1 year old at birth. Having an accurate age has many clinical implications, including assessing developmental milestones and determining appropriate medication dosages, and certain legal implications as well. For many reasons, age may not be reported correctly. Some clients may not wish to report their correct age; other clients may not know or be able to provide a specific age in the way health care providers may expect it. One of the first areas that nurses should assess is the client’s self-reported cultural affiliation. With what cultural group(s) does the client report affiliation? Where was the client born? What is the ancestry or ethnohistory of the client? When the client self-identifies with multiple races or ethnicities, it is often useful to determine with which group the client primarily identifies. Knowledge of the client’s ethnohistory is important in determining risk factors for genetic and acquired diseases and in understanding the client’s cultural heritage. In addition to the standard descriptive information about clients, it is necessary to record who has furnished the data. Whereas this is usually the client, the source might be a relative, guardian, or friend. Note whether an interpreter is used and indicate the relationship to the client.

Genetic Data Genetics is a branch of biology that studies heredity and the variations of inherited characteristics. A rapidly evolving science, genetics

Chapter 3 Cultural Competence in the Health History and Physical Examination

exerts a significant influence on the health of people from cultures around the world. Whereas genetics scrutinizes the functioning and composition of a specific gene, genomics addresses all genes and their interrelationship to identify their combined influence on the growth and development of the organism. To date, the locations of more than 25,000 genes have been mapped to a specific human chromosome and most to a specific region on the chromosome. A genome is an organism’s complete set of DNA, including all of its genes. Each genome contains all of the information needed to build and maintain that organism. In humans, a copy of the entire genome—more than 3 billion DNA base pairs—is contained in all cells that have a nucleus. Genetic mapping is continuing at a rapid rate, and these numbers and discoveries are constantly being updated. Epigenetics is the study of how genes are influenced by forces such as the environment, obesity, or medication. Although the children in Figure 3-1 are twins, epigenetic modifications can cause individuals with the same DNA sequences to have different disease profiles (McCance & Huether, 2014). As a result of epigenetic research,

the critical role played by external forces is better understood and can now be integrated into client assessment and care. While each person has approximately 30,000 genes, any two individuals share 99.9% of their DNA sequence, reflecting that the diversity among individuals accounts for approximately 0.1% of the DNA (Porth, 2015). Although humans are more alike than different, the growing inventory of human genetic variation facilitates an understanding of why susceptibility to common diseases differs among individual clients and populations. These genetic variations provide the knowledge needed to safely administer medications and counsel clients regarding the prevention and risk of disease. This discussion provides a foundation in genetic and genomic science to ensure that the nursing assessment is customized according to each client’s unique background and current care needs. Human genetic variation contributes significantly to the physical variation occurring among individuals. The two most important components of human genetic variation are single-nucleotide polymorphisms (SNPs) and copy-number

Figure 3-1. Due to diet, environment, and lifestyle, these identical twins may have entirely different disease profiles as they mature into adulthood (Felix Mizioznikov/Shutterstock.com).

Part One Foundations of Transcultural Nursing

variants. SNPs are single DNA base pairs that

differ among individual DNA sequences; copynumber variants are larger blocks of DNA sequence that vary. Most common SNPs are shared among populations from different continents, which reflect continued migration and gene flow among humans through history. Many studies have shown that 85% to 90% of genetic variation can be found within any human population. Samples of persons from Great Brain and Ghana have genetic similarity. Only an additional 10% to 15% of variation is gained when the entire human population is considered. A genetic variation may be relatively common in one population, but absent in another due to a recent emergence of a variant that has not yet had time to spread. Hereditary hemochromatosis, a disorder that causes the body to absorb too much iron from food, is common in Europe, but very rare elsewhere. Hereditary lactase is prevalent among European and African pastoral populations where milk consumption beyond childhood has had a selective advantage (Rotimi & Jorde, 2010). Genetic research studies are now readily available regarding the safety and efficacy of medications for a variety of conditions. This information extends far beyond traditional inherited disease such as sickle cell anemia or cystic fibrosis. This growing inventory of human variation facilitates an understanding of why susceptibility to common disease varies among individuals and populations. Analyses of two key heart failure (HF) trials comparing African Americans to Whites reveal significant ethnic differences in response to treatment. The African-American Heart Failure Trial (A-HeFT) demonstrates that therapy with fixeddose combined isosorbide dinitrate/hydralazine (BiDil) added to customary therapy significantly improved survival in self-identified African American men and women with advanced heart failure (Bress et al., 2013). The 2013 American College of Cardiology Foundation/American Heart Association guide lines recommend combined isosorbide dinitrate (ISDN) and hydralazine to reduce mortality and

morbidity for African Americans with s ymptomatic heart failure as earlier studies reflected a significant reduction in death and improvement in outcomes. Hypertension contributes to HF, especially in African Americans. The A-HeFT and its substudies demonstrated improvements in ventricular performance based on echocardiogram, morbidity, and mortality as well as a decrease in hospitalizations, potentially affecting burgeoning HF health care costs. The importance of genetic characteristics in determining response to ISDN– hydralazine was reinforced a decade after the original study. The Genetic Risk Assessment in Heart Failure substudy confirmed an important hypothesis and generated relevant pharmacogenomic data (Ferdinand et al., 2014). Investigators have focused on genetic variations in populations, which may yield a more complete characterization of risk, and thereby permit more specifically targeted treatment of heart failure clients. In the future, more precise selection of β-blocker therapy for heart failure and hypertension based on genotype may be superior to selecting therapy based on a client’s race/ethnicity. Recent attention has been drawn to the association of chronic traumatic encephalopathy (CTE) with contact sports such as boxing, American football, soccer, hockey, and wrestling. Chronic CTE is a progressive neurodegenerative disease that is a long-term consequence of single or repetitive closed head injuries for which there is no treatment and no definitive premortem diagnosis. Researchers from Boston University discovered significant cases of CTE in college and professional football players. Subsequently, it was discovered that a significant number of these athletes had two copies of the ApoE4 gene variant; this version of the ApoE gene has been shown to substantially increase the risk of Alzheimer’s disease. This raises questions about offering genetic screening for the ApoEv4 to linebackers, boxers, and parents whose children play sports that put players at risk for CTE. Sports transcend all cultures, yet may be more prevalent in certain racial and ethnic groups, for example, 68% of all NFL football players are African American (National

Chapter 3 Cultural Competence in the Health History and Physical Examination

Football League, 2014). Juvenile traumatic brain injury leaves survivors facing a potential lifetime of cognitive, somatic, and emotional symptoms; therefore, prevention and education are currently the most compelling ways to combat CTE and are emphasized by nurses with parents, athletic trainers, and coaches (Hwang et al., 2011). Apolipoprotein genotype also has a potential role in cognitive function of postmenopausal women with early-stage breast cancer (American Cancer Society, n.d.; Domchek, 2014). Koleck et al. (2014) examine the role of apolipoprotein E (APOE) in the cognitive function of postmenopausal women with early-stage breast cancer prior to the initiation of adjuvant therapy, that is, assisting in the prevention, amelioration, or cure of the disease. Performance or changes in performance on tasks of executive function, attention, verbal/visual learning, and memory were influenced. APOE genotype along with other biomarkers may be used in the future to assist nurses in identifying women with breast cancer most at risk for cognitive decline. Nurses should consider how the client will use genetic and genomic information and be prepared to provide support if clients experience moral or ethical issues. Most hospitals have ethics committees, chaplains, pastoral teams, and other resources to assist clients facing moral and ethical dilemmas. The addition of genetics and genomics to the traditional nursing assessment will inform and engage clients to make key decisions in their personal health care plan. By virtue of their race or ethnicity, clients are sometimes said to be “at risk” for certain diseases. Examples include diabetes mellitus among Native Americans, breast cancer among Ashkenazi Jews, and prostate cancer among African Americans. Particular forms of treatment are also believed to be more (or less) effective among certain racial/ethnic groups compared with others. Among African Americans (compared with Whites), angiotensin-converting enzyme (ACE) inhibitors are less effective for essential hypertension and a therapeutic response to selective serotonin reuptake inhibitor (SSRI) antidepressants occurs at lower doses. Considerations

about health by racial and ethnic groups require the context that environmental factors and health disparities as well as genetic factors are operative in determining health risk. The nurse should avoid oversimplifying the relationship between race/ethnicity and genetics when communicating to clients and their families. Knowledge of race or ethnicity might prompt genetic testing or detailed family history taking in particular instances; however, the issues are often too complex for the nurse to make unqualified assertions to clients that they are “at risk” for a particular illness or unlikely to respond to therapies solely on the basis of their racial/ethnic background. In most instances, the full interprofessional health care team will be the best catalyst for client information and interventions. Table 3-1 provides an overview of the distribution of selected genetic traits and disorders by population or ethnic group. Knowledge of the client’s race or ethnicity might prompt the nurse to gather a detailed family history and/or collaborate with physicians and nurse practitioners to order genetic testing. Human genetic information is accumulating at a rapid pace, and more than 2,700 diseases can now be diagnosed by testing for specific mutations (National Center for Biotechnology, 2014). The following genetic screenings may be useful to clients, nurses, and other members of the health care team: ●●

Drug efficacy or sensitivity: Pharmacogenomics, the study of the role of inherited and acquired genetic variation in drug response, is an evolving field that facilitates the identification of biomarkers that can help health providers optimize drug selection, dose, and treatment duration as well as eliminate adverse drug reactions. For example, researchers have identified an HLA allele that is associated with hypersensitivity reactions to the anticonvulsant and moodstabilizing drug carbamazepine (Tegretol) in persons of European descent (McCormack et al., 2011). For other drugs such as warfarin (Coumadin) and clopidogrel (Plavix), genetic testing for variants in specific genes may be warranted to help guide the drug dosage.

Part One Foundations of Transcultural Nursing

Table 3-1: Selected Genetic Diseases and Clinical Implications Disease or Condition

Group Impacted

Clinical Implications

Alpha-1 antitrypsin deficiency (AAT)

Northern European, Scandinavian, and Iberian ancestry. Rare in Jewish, Black, and Japanese populations.

Consider diagnosis in adults with emphysema with onset at ≤40 years old and without risk factors (no history of smoking or occupational dust exposure)

Autosomal recessive disorder resulting in early-onset emphysema and liver disease

Breast cancer

AAT deficiency affects 1%–2% of patients with chronic obstructive pulmonary disease.

Ashkenazi Jewish women

BRCA1 and BRCA2

Estimated that 0.2%–0.33% of general population have gene Autosomal dominant; accounting for ~5% US cases mutations

G6PD deficiency (glucose-6-phosphate dehydrogenase deficiency) X-linked genetic defect with clinical manifestations of neonatal jaundice and/or acute or chronic hemolytic anemia triggered by medications, infections, and fava beans

Highest frequency found in: Africa, southern Europe (Mediterranean region), Middle East, Southeast Asia, central and southern Pacific islands Deficiency is found in 10% of Blacks and can occur in Sephardic Jews, Greeks, Iranians, Chinese, Filipinos, and Indonesians with a frequency ranging from 5% to 40% Kurdish Jews 50% of males reported to be affected Most common human enzyme defect worldwide

Leiden V The most common hereditary abnormality of hemostasis predisposing to thrombosis Autosomal dominant inheritance single mutation causes mild hypercoagulable state

Highest in US and European white populations. Prevalence may be higher in some Middle Eastern countries including Jordan (12.3%) and Lebanon (14.4%).

Diagnosis made by serum alpha-1 antitrypsin levels and confirmed with genetic testing. Counseling: U.S. Preventive Services Task Force recommends genetic counseling and evaluation for BRCA testing for Ashkenazi Jewish women with any first-degree relative with breast or ovarian cancer or second-degree relatives on same side of family with breast or ovarian cancer. Relevant history: Ask about family history of G6PD deficiency and hemolytic factors that can be transmitted to infants via mother’s milk (such as fava bean ingestion, drugs, or herbal remedies). Hemolytic anemia occurs about 24hours after ingestion of fava beans. Medication history: Ask about recent history of medications that may have precipitated hemolytic anemia, such as antimalarials, nitrofurantoin (urinary tract infections), phenazopyridine (for dysuria), and topical application of henna. Relevant assessment: May have no clinical symptoms Mutation is present in about 15%–20% patients with first deep vein thrombosis and up to 50% of patients with recurrent venous thromboembolism. Medication history: Risk for thromboembolism increased with oral contraceptives, hormonal replacement therapy (HRT), and selective estrogen receptor modulators (SERMs)

Table 3-1: Selected Genetic Diseases and Clinical Implications (continued) Disease or Condition

Group Impacted

Clinical Implications

Sickle cell disease

African, Mediterranean, Middle Eastern, Indian ancestry, Caribbean, and parts of Central and South America

Relevant assessment:

Autosomal recessive genetic disorder; patients with same genotype may have highly variable phenotypes, ranging from asymptomatic to lifethreatening complications; interaction of environmental factors with genetic polymorphisms may explain disease variation Chronic inflammation, ischemia, and vasoocclusion contribute to chronic organ damage

Most prevalent disease detected by neonatal blood screening Alpha-thalassemia and betathalassemia may be coinherited Sickle cell trait occurs in 1 out of every 12 blacks Sickle cell disease affects 90,000 to 100,000 Americans; occurs in 1 out of every 500 Blacks; occurs in 1 out of every 36,000 Hispanic American births

Affected infants not identified through neonatal screening usually present clinically during infancy/ early childhood with painful swelling of the hands and feet (dactylitis), pneumococcal sepsis or meningitis, severe anemia and acute splenic enlargement (splenic sequestration), acute chest syndrome, jaundice, pallor. Counseling: Many adolescents and young adults are unaware of their sickle cell trait status—higher risk for rhabdomyolysis during rigorous sports. Prenatal diagnosis may be made in first and second trimester. Preimplantation genetic diagnosis is available during in vitro fertilization. Embryos not affected with sickle cell disease may be selected.

Tay–Sachs disease

Ashkenazi Jews

Relevant assessment

Neurodegenerative disorder caused by inborn error of metabolism

Incidence of 1/3,600 among Ashkenazi Jewish births

Classic or acute infantile is the most common type.

Carrier rate of 1/30 among Jewish Americans of Ashkenazi descent

Infants appear normal at birth.

Genetic mutation results in central nervous system degeneration and loss of organ function

Alpha-thalassemia Hereditary anemia caused by defect during hemoglobin production; various clinical phenotypes—from silent carrier to more severe

Additional at-risk groups include French Canadians living in Eastern Quebec or New England; select Cajun communities in Louisiana; and Pennsylvania Dutch semi-isolates Inhabitants or descendants of Southeast Asia, Middle East, and Mediterranean countries 80%–90% may be carriers of alpha-thalassemia in tropical and subtropical regions. About 30% of African Americans

Beta-thalassemia An autosomal recessive inherited anemia caused by absent or decreased betaglobin chain synthesis during hemoglobin production. Also referred to as Cooley’s or Mediterranean anemia

Inhabitants or descendants of Mediterranean countries, Middle East, Central Asia, India, Southern China, Far East, South America, and north coast of Africa

Rapidly progressive neurodegenerative disorder characterized by progressive motor weakness beginning at 3–6 months old; loss of developmental milestones and death within first few years of life. Relevant assessment: Patients can be asymptomatic or have mild symptoms of anemia including fatigue and dyspnea, poor growth in children, and jaundice Abnormal physical findings occur with more severe phenotypes. Relevant assessment: Symptoms emerge at 6–12 months: failure to thrive, feeding problems, diarrhea, fever, and progressive enlargement of abdomen due to hepatosplenomegaly

Estimated annual incidence of symptomatic individuals: 1 in 100,000 Symptoms in patients who have not people globally; 1 in 10,000 people in been treated or who have received European community inadequate transfusion treatments may include growth retardation, jaundice, and craniofacial changes. continued

Part One Foundations of Transcultural Nursing

Table 3-1: Selected Genetic Diseases and Clinical Implications (continued) Disease or Condition

Group Impacted

Clinical Implications

von Willebrand disease

Type three may be more prevalent in Swedish communities

Preoperative assessment:

7:3 female-to-male ratio

All patients having major surgery should be screened.

Bleeding disorder resulting in platelet and clotting defect Vary from mild to more severe forms

Racial characteristics of all patients:

Three types exist, most commonly autosomal dominant

10.9% Hispanic

75.1% White 7.5% Black 2.6% Asian/Pacific Islander 0.4% American Indian/Alaska native

May be asymptomatic

Symptoms typical of bleeding disorder, most commonly mucosal bleeding such as nosebleed, gingival bleeding, easy bruising, or menorrhagia (most common bleeding disorder in women who present with menorrhagia, 12%–20%).

Data from Centers for Disease Control and Prevention. (2014). Sickle cell disease: Data and statistics. Retrieved from www. CDC.gov/NCBDD/sicklecell/data.html; deSerres, F. J., & Blanco, L. (2012). Prevalence of α1-antitrypsin deficiency alleles PI*S and PI*Z worldwide and effective screening for each of the five phenotypic classes PI*MS, PI*MZ, PI*SS, PI*SZ, and PI*ZZ: A comprehensive review. Therapeutic Advances in Respiratory Disease, 6(5), 277–295; Galanello, R., & Origa, R. (2010). Betathalassemia. Orphanet Journal of Rare Diseases, 5, 11; Harteveld, C. L., & Higgs, D. R. (2010). Alpha-thalassaemia. Orphanet Journal of Rare Diseases, 5, 13; Kaback, M., & Desnick, R. J. (2011). Hexosaminidase A deficiency. Gene Reviews, 8(11); McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Elsevier, Inc.; Mohr, H. (2006). Acquired von Willebrand syndrome: Features and management. American Journal of Hematology, 81(8), 616–623; Porth, C. M. (2015). Essentials of pathophysiology: Concepts of altered health states (4th ed.). Philadelphia, PA: Lippincott; Rotimi, C. N., & Jorde, L. B. (2010). Ancestry and disease in the age of genomic medicine. New England Journal of Medicine, 36, 1551–1558; Taylor, C., Kavanagh, P., & Zuckerman, B. (2014). Sickle cell train-neglected opportunities in the era of genomic medicine. JAMA, 311(15), 1495–1496.

●●

Carrier screening: Genetic tests can identify heterozygous carriers for many recessive diseases such as cystic fibrosis, sickle cell disease, and Tay–Sachs disease. A couple may wish to undergo carrier screening to help make reproductive decisions, especially in populations where specific diseases are relatively common, for example, Tay–Sachs disease in Ashkenazi Jewish populations and β-thalassemia in Mediterranean populations. Prenatal diagnosis: Amniocentesis is usually performed at 16 weeks’ gestation; chorionic villus sampling (CVS) is carried out at 10 to 12 weeks’ gestation; preimplantation genetic diagnosis (PGD) is carried out on early embryos (8 to 12 cells) prior to implantation; and fetal DNA analysis in maternal circulation is done at 6 to 8 weeks’ gestation (Center for Disease Control and Prevention, 2013; Dotson et al., 2014; National Center for Biotechnology, 2014).

Review of Medications and Allergies The review of medications includes all current prescription, over the counter, and home remedies, including herbs that a client might purchase or grow in a home garden. During the health history, note the name, dose, route of administration, schedule, frequency, purpose, and length of time that each medicine that has been taken. Because of cultural differences in clients’ perceptions of what substances are considered medicines, it is important to ask about specific items by name. Inquire about vitamins, birth control pills, aspirin, antacids, herbs, teas, inhalants, poultices, vaginal and rectal suppositories, ointments, and any other items taken by the client for therapeutic purposes. The nurse also gathers data on the client’s allergies to medicines and foods. Table 3-2 provides an overview of commonly used herbs, their sources, uses, dosage, and

Chapter 3 Cultural Competence in the Health History and Physical Examination

Table 3-2: Herbal Remedies Aloe Vera Source

Leaf of Aloe barbadensis

Action

Topical analgesic, anti-inflammatory, antioxidant, and antifungal agent

Traditional uses

Applied as topical ointment for treatment of inflammation, minor burns, sunburn, cuts, bruises, and abrasions; administered orally as a laxative

Current uses

Promotes wound healing in soft tissue injuries and is used as a folk or traditional remedy for diabetes, asthma, epilepsy, and osteoarthritis Aloe vera gel, contained in the leaves of the plant, is found in skin products such as lotions and sunblocks Prevents wound pain by inhibiting the action of the pain-producing agent bradykinin

Dosage

Apply topically as needed; the FDA ruled that aloe is not safe as a stimulant laxative

Warnings

Rarely, skin rash follows topical application Can cause diarrhea and abdominal cramps when taken orally and can decrease the absorption of many drugs

Dong-Quai (Chinese angelica, Angelica sinensis) Source

Dried root of a member of the parsley family

Action

Smooth muscle relaxant; antispasmodic

Traditional uses

A highly regarded herb in Chinese medicine, also used in traditional Korean and Japanese medicine Has been called “female ginseng” because it is used for health conditions in women Used for both men and women to treat heart conditions, high blood pressure, inflammation, headache, infections, and nerve pain Believed to help nourish the blood and balance energy

Current uses

Used for menstrual cramps, anemia during menstruation, pregnancy, premenstrual syndrome (PMS), pelvic pain, recovery from childbirth or illness, muscle spasms, and fatigue or low energy Used in combination with other herbs for liver and spleen problems

Dosage

Varies by condition: Available in capsule, liquid extract, or in tea form

Warnings

Contraindicated for pregnant and breast-feeding women and persons with abdominal distention or diarrhea Not recommended for use with aspirin, ibuprofen, anticoagulants, antiplatelet drugs, diabetic clients taking insulin, or other herbs, such as Ginkgo biloba Large doses may cause contact dermatitis and photosensitivity.

Echinacea (Echinacea angustifolia, E. pallida, E. purpurea) Source

Member of the daisy family; also known as purple coneflower

Action

Reduces cold symptoms

Traditional uses

Used to treat wounds and skin problems, such as acne or boils

Current uses

Enhances the immune system to fight infection and to treat colds, flu, and other illnesses. The parts of the plant above ground are used to make teas, juice, or extracts. continued

Part One Foundations of Transcultural Nursing

Table 3-2: Herbal Remedies (continued) Dosage

Follow directions on label; needed at onset of symptoms; usually taken for no longer than 2weeks

Warnings

Contraindicated for pregnant or breast-feeding women, children, and those who are allergic to plants in the daisy family, including ragweed, chrysanthemums, marigolds, and daisies. Not recommended for people with severely compromised immune systems such as those with HIV/AIDS, tuberculosis, or multiple sclerosis

Evening Primrose Oil (Oenothera biennis) Source

Seeds of the wildflower evening primrose

Action

Antihypertensive, immunostimulant, weight reduction

Traditional uses

Used as a folk remedy to treat eczema since the 1930s

Current uses

Believed to help inflammation, PMS, diabetes mellitus, eczema, fatigue, diabetic neuropathy, and rheumatoid arthritis

Dosage

Follow directions on label; will take at least 1month to experience benefits

Warnings

Side effects include occasional reports of headache, nausea, and abdominal discomfort; not recommended for children. Some capsules may be altered with other types of oil such as soy or safflower.

Ginger Current uses

Currently is used to treat postsurgery nausea; nausea caused by motion, chemotherapy, and pregnancy; rheumatoid arthritis; osteoarthritis, and joint and muscle pain

Dosage

Boil 1-oz dried ginger root in 1 cup water for 15–20 minutes. Follow label directions on ginger supplements.

Ginkgo (Ginkgo biloba) Source

Extract from leaves of the ginkgo tree, one of the oldest types of trees in the world; is cultivated worldwide for its medicinal properties

Action

Antioxidant; improves blood circulation

Traditional uses

Used in traditional Chinese medicine for asthma, bronchitis, fatigue, circulatory disorders, sexual dysfunctions, and tinnitus

Current uses

Promotes vasodilation and improves memory, attention span, and mood in early stages of Alzheimer’s disease or dementia by improving oxygen metabolism in the brain; used to treat intermittent claudication, sexual dysfunction, multiple sclerosis, tinnitus, and other health conditions

Dosage

Available in tablets, capsules, teas, and occasionally skin products Follow labels on supplements.

Warnings

Side effects may include headaches, diarrhea, nausea and vomiting, and dizziness. Some people have reported allergic skin reactions. Fresh ginkgo seeds can cause serious adverse reactions—including seizures and death. Contraindicated for women who are pregnant or breast-feeding Contraindicated for persons with clotting disorders or those who are about to have surgery Not recommended for children

Chapter 3 Cultural Competence in the Health History and Physical Examination

Table 3-2: Herbal Remedies (continued) Ginseng (Panax quinquefolius [American], Panax ginseng [Asian]) Source

Dried root of several species of the genus Panax of the family Araliaceae

Action

Tonic

Traditional uses

Treatment of anemia, atherosclerosis, edema, ulcers, hypertension, influenza, colds, inflammation, and disorders of the immune system (American) Treatment of shock, diaphoresis, dyspnea, fever, thirst, irritability, diarrhea, vomiting, abdominal distention, anorexia, and impotence; considered a “heat-raising” tonic for the blood and circulatory system (Asian)

Current uses

Used to enhance sexual experience and treat impotence, though there is no current research to support this claim Also used to improve athletic performance, strength, and stamina, as well as to treat diabetes and cancer (American) Used to treat diabetes, cancer, HIV/AIDS, and as an immunostimulant or to improve athletic performance (Asian) Improved sense of well-being (Asian)

Dosage

American: Follow directions on label. Asian: 100mg BID

Warnings

American: May cause headaches, insomnia, anxiety, breast tenderness, rashes, asthma attacks, hypertension, cardiac arrhythmias, and postmenopausal uterine hemorrhage Should be used with caution for the following conditions: pregnancy, insomnia, hay fever, fibrocystic breasts, asthma, emphysema, hypertension, clotting disorders, and diabetes mellitus Asian: Same as American

Gotu Kola (Centella asiatica) Source

Dried and powdered leaves of a member of the parsley family

Action

Improves memory

Traditional uses

In ancient India, considered a rejuvenating herb that increases intelligence, longevity, and memory while slowing the aging process In China, used as a tea for colds and for lung and urinary tract infections; used topically for snakebite, wounds, and shingles

Current uses

Acceleration of wound healing, diuretic, treatment of phlebitis, varicose veins, and scleroderma

Dosage

Follow directions on label; lower dose needed for children and older adults

Warnings

Sides effects include headaches and skin rash. Contraindicated for pregnant or breast-feeding women and children younger than 18years Contraindicated for those diagnosed with liver disease

Saint John’s wort (Hypericum perforatum) Source

Tea made from the leaves and flowering tops of the perennial H. perforatum, which is particularly abundant in late June, the feast of St. John the Baptist continued

Part One Foundations of Transcultural Nursing

Table 3-2: Herbal Remedies (continued) Action

Antidepressant

Traditional uses

Used first in ancient Greece and historically to treat mental disorders and nerve pain. Also used to treat malaria, as a sedative, and topically for wounds, burns, and insect bites Also used by Native Americans to treat wounds, snake bites, and diarrhea

Current uses

Treatment of mild to moderate depression, anxiety, seasonal affective disorder, and sleep disorders

Dosage

300mg daily

Warnings

Fair-skinned people may experience photosensitivity. Reduces effectiveness of some anticancer agents Can interact with antidepressants, birth control pills, cyclosporine, heart medications, HIV medications, anticoagulants, and seizure control medications Clinical manifestations of depression should be considered seriously. Encourage client to see a mental health care provider.

Valerian (Valeriana officinalis) Source

Dried rhizome and roots of the tall perennial V. officinalis

Action

Mild tranquilizer and sedative

Traditional uses

Used as medicinal herb since Ancient Greece and Rome for insomnia

Current uses

Used as a mild tranquilizer and sedative; relieves muscle spasms, anxiety, headaches, depression, irregular heartbeat and trembling Especially effective for insomniac persons and older adults

Dosage

Available in capsules, tablets, liquid extracts, and teas

Warnings

Reported side effects include headache, gastrointestinal upset, and dizziness. Must not be taken in combination with other tranquilizers or sedatives Client should be cautioned against operating a motor vehicle after ingesting. Should discontinue use at least 1week before surgery because it may interact with anesthesia

Table based on data from Bongki, P., Jun, J. H., Jung, J., You, S., & Lee, M. S. (2014). Herbal medicines for cancer cachexia: Protocol for a systematic review. British Medical Journal Open, 4, e005016. doi: 10.1136/bmjopne-2014-005016; Retrieved from Mayo Clinic (http://www.mayoclinic.org); Memorial Sloan-Kettering Cancer Center: About Herbs, Botanicals and Other Products (http://www.mskcc.org/cancer-care/integrative-medicine/about-herbs-botanicals-other-products), National Center for Complementary and Integrative Health. (2015). Herbs at a glance. Retrieved from https://nccih.nih.gov/health/herbsataglance.htm; University of Maryland Medical Center (https://umm.edu/health/medical/altmed/herb); Luca, A., Jimenez-Fonseca, P., & Gascon, P. (2013). Clinical evaluation and optimal management of cancer cachexia. Critical Reviews in Oncology/Hematology, 88(4), 625–636.

warnings, such as contraindications (e.g., pregnancy, childhood, people with compromised immune systems) and interactions with prescription drugs. Many of the active ingredients in herbs or plant-derived drugs are unknown and remain largely unregulated by government agencies, except for customs officials who make

efforts to control the flow of illegal drugs. Fresh or dried herbs are usually brewed into a tea, with the dosage adjusted according to the chronicity or acuteness of the illness, age, and size of the client. Traditional Chinese medicine usually is used only as long as symptoms persist. Some clients extend the same logic to prescription

Chapter 3 Cultural Competence in the Health History and Physical Examination

medicines. For example, they might stop taking an antibiotic as soon as the symptoms subside instead of completing the course of treatment for the prescribed length of time. Be sure to consider the potential interaction of herbs with prescription medicines. The root of the shrub ginseng, for example, is widely used for the treatment of arthritis, back and leg pains, and sores. Because ginseng is known to potentiate the action of some antihypertensive drugs, nurses need to ask clients whether they are experiencing side effects or toxicity and should frequently monitor the client’s blood pressure. It might be necessary to withhold doses of the prescribed antihypertensive medicine if the blood pressure is low or to ask the client to discontinue or reduce the strength of the ginseng. When assessing the client’s use of traditional Chinese medicine, nurses should be aware that some Chinese Americans who use herbs topically do not consider them drugs; therefore, nurses might not know that the person is taking these medicines. For further information about herbs, ask the client and family, consult an herbalist, search for reputable sources on the Internet, or check reference books on herbal remedies. People sometimes fail to disclose that they are taking herbs or plantbased medicines because they’re concerned that their health care provider will disapprove. The National Center for Complementary and Integrative Health (2012) provides fact sheets with basic information about specific herbs or botanicals—common names, what the science says, potential side effects and cautions, and resources for more information. For many years, people have attempted to identify plants, marine organisms, arthropods, animals, and minerals with healing properties. According to the World Health Organization (2013), 80% of people residing in less developed countries use indigenous medicinal plants for many of their primary health care needs. The estimated global market for botanical and plant-derived drugs is valued at $22.1 billion and is projected to grow to $26.6 billion by 2017 (BCC Research, 2013). Currently,

r espiratory problems such as asthma represent the largest medical application of plant-derived drugs, accounting for 24% of total sales of plant-derived medicines. Cancer treatment is expected to become the largest application of plant-derived drugs, capturing 30% of the market by 2017 (BCC Research, 2013). In particular, nurses should be aware of the widespread use of plant-derived medications among various cultures (see Table 3-2). The client’s genetic makeup results in distinctive patterns of drug absorption, metabolism, excretion, and effectiveness. Knowledge of clients’ individual genotypes guides pharmacologic treatment and allows customization of choice of drug and dosage to ensure a therapeutic response and avoid toxicity (Casorbi, Bruhn, & Werk, 2013). For example, Evidence-Based Practice 3-1 describes genetically linked racial and ethnic differences in the conversion of codeine to morphine for analgesia. Another example concerns the possibility of reduced effectiveness of the widely prescribed platelet aggregation inhibitor clopidogrel (Plavix), which is used in the prevention of myocardial infarction and stroke. The cause of the reduced effectiveness is related to genetic variations in cytochrome P-450 and polypeptide 19 (CYP2C19). A black box warning from the U.S. Food and Drug Administration recommends that all clopidogrel users be tested. It is estimated that between 2% and 14% of the U.S. population are poor metabolizers. While previous studies have explored the impact of this variation in metabolism on heart disease, researchers found that a proportion of the poor/intermediate clopidogrel metabolizers have an increased risk of recurrent cerebrovascular events, including stroke. Only 26% of whites are intermediate or poor metabolizers, compared with 47% nonwhites. This finding is comparable to cardiovascular studies and warrants routine CYP2C19 testing and monitoring of people taking clopidogrel (Spokoyny et al., 2014). Table 3-3 identifies drug categories for which clients from certain racial or ethnic backgrounds respond differently from the general population.

Evidence-Based Practice 3-1

Racial and Ethnic Variations in the Conversion of Codeine to Morphine for Analgesia CYP2D6 is one of the most important enzymes involved in the metabolism of xenobiotics in the body. In particular, CYP2D6 is responsible for the metabolism and elimination of approximately 25% of clinically used drugs. Xenobiotics are foreign chemical substances found within an organism that are not normally naturally produced by or expected to be present within it. In humans, antibiotics are xenobiotics because the human body doesn’t produce them itself nor are they typically part of normal food. There is considerable variation in the efficiency and amount of CYP2D6 enzyme produced by individuals from different racial and ethnic backgrounds. For drugs that are metabolized by CYP2D6, certain individuals eliminate the drugs quickly (ultrarapid metabolizers) while others eliminate them slowly (poor metabolizers). If a drug is metabolized too quickly, it may decrease the drug’s efficacy. If the drug is metabolized too slowly, toxicity may result. CYP2D6 catalyzes the conversion of codeine to morphine. In 7% to 10% of US whites, an active form of the CYP2D6 enzyme, which is necessary to convert codeine into its active metabolite, morphine, is missing. These individuals experience the side effects of morphine without pain relief. Other variations in metabolic efficiency among ethnic groups are apparent. For example, Chinese produce less morphine from codeine than do Whites and also are less sensitive to morphine’s effects. The reduced sensitivity to morphine may be due to decreased production of morphine-6-glucuronide.

Clinical Implications: In approximately 10% of US Whites, codeine is ineffective as an analgesic, and 4% to 5% of the US population and 16% to 28% of North Africans, Ethiopians, and Arabs are ultrarapid metabolizers with increased sensitivity to codeine’s effects, and therefore, nurses need to observe for the following signs of toxicity: ●● ●●

Bluish-colored fingernails and lips Slow and labored breathing, shallow breathing, and no breathing

●● ●● ●● ●● ●● ●● ●● ●● ●● ●● ●● ●● ●●

Cold, clammy skin Coma (decreased level of consciousness and lack of responsiveness) Confusion Dizziness Drowsiness Fatigue Lightheadedness Low blood pressure Muscle twitches Pinpoint pupils Spasms of the stomach and intestines Weakness Weak pulse

Consider the possibility of metabolic genetic variations in any client who experiences toxicity or does not receive adequate analgesia from codeine or other opioid drugs (e.g., hydrocodone and oxycodone). Red heads also have variations. Dysfunctional melanocortin 1 receptor on certain cells that gives people their red hair also increases production of a hormone that causes heightened pain sensitivity. References Binkley, C. J., Beacham, A., Neace, W., Gregg, R. G., Liem, E. B., & Sessler, D. I. (2010). Genetic variations associated with red hair color and fear of dental pain, anxiety regarding dental care and avoidance of dental care. Journal of the American Dental Association, 140(7), 896–905 Liu, F., Struchalin, M. V., van Duijn, K., Hofman, A., Uitterlinden, A. G., van Duijn, C., …, Kayser, M. (2011). Detecting low frequent loss-of-function alleles in genome wide association studies with red hair color as example. PLoS One, 6(11), e28145 Sammer, C. F., Daali, Y., Wagner, M., Hopfgartner, G., Eap, C. B., Rebsamen, M. C., …, Desmueles, J. A. (2010). The effects of CYP2D6 and CYP3A activities on the pharmacokinetics of immediate release oxycodone. British Journal of Pharmacology, 160(4), 907–918 Teh, L. K., & Bertilsson, L. (2012). Pharmacogenomics of CYP2D6: Molecular genetics, interethnic differences and clinical importance. Drug Metabolism and Pharmacokinetic, 27(1), 55–67 Walko, C. M., & McLeod, H. (2012). Use of CYP2D6 genotyping in practice: Tamoxifen dose adjustment. Pharmacogenomics, 13(6), 691–707.

Chapter 3 Cultural Competence in the Health History and Physical Examination

Table 3-3: Cultural Differences in Response to Drugs Drug Category

Group

Remarks

Analgesics

Blacks

Despite decreased sensitivity to pain-relieving therapeutic action of drugs, there are increased gastrointestinal side effects, especially with acetaminophen.

Narcotic analgesics

Chinese

May be less sensitive to the respiratory depressant and hypotensive effects of morphine but more likely to experience nausea; have a significantly higher clearance of morphine

Antiarrhythmics

Arab Americans

Some may need lower dosage

Anticoagulants

Asian

Require lower doses of warfarin (Coumadin) than White counterparts

Blacks

Require higher doses of warfarin (Coumadin) than White or Asian counterparts

Anticonvulsants

Chinese, Filipinos, Malaysians, Thai, Singaporeans, Taiwanese, East Indians, and Japanese

Higher toxicity observed with use of carbamazepine (Tegretol) including incidence of drug-induced Stevens–Johnson syndrome

Antihypertensives

Arab Americans

Some may need lower dosage

Asian/Pacific Islanders

Respond best to calcium antagonists

Blacks

Respond best to treatment with a single drug (vs. combined antihypertensive therapy) Research suggests favorable response to diuretics, calcium antagonists, and alpha-blockers Less responsive to beta-blockers (e.g., propranolol) and ACE inhibitors (e.g., enalapril, imidapril) Increased side effects such as mood response (e.g., depression) to thiazides (e.g., hydrochlorothiazide), which may explain reluctance to take drug as prescribed

Fat-soluble drugs

Asian Americans

Due to average lower percentage of body fat, dosage adjustments must be made for fat-soluble vitamins and other drugs, for example, vitamin K used to reverse the anticoagulant effect of Coumadin (warfarin); consider dietary intake of vitamins when calculating doses.

Immunosuppressants

Blacks

Black clients with kidney failure require higher doses of tacrolimus (Prograf, Advagraf, Protopic) to reach trough concentrations similar to those observed in White counterparts

Muscle relaxants

Native Alaskans

May experience prolonged muscle paralysis and an inability to breathe without mechanical ventilation for several hours postoperatively when succinylcholine has been administered in surgery continued

Part One Foundations of Transcultural Nursing

Table 3-3: Cultural Differences in Response to Drugs (continued) Drug Category

Group

Remarks

Mydriatics

Blacks

Higher dose required; less dilation occurs with darkcolored eyes.

Neuroleptics

Arab Americans

Some may need lower dosage.

Asian/Pacific Islanders

Require lower dose than Whites or Blacks

Oxidizing drugs

Greeks, Italians, and others of The following drugs may precipitate a hemolytic crisis: primaquine, quinidine, thiazolsulfone, Mediterranean descent with furazolidone, haloperidol, nitrofural, naphthalene, G6PD deficiency toluidine blue, phenylhydrazine, chloramphenicol, aspirin

Psychotropics

Asian/Pacific Islanders

Require lower dose, sometimes as little as half the normal dose for lithium and tricyclic antidepressants (TCAs) such as desipramine and trimipramine

Blacks

Increased extrapyramidal side effects with TCAs such as haloperidol; relatively prolonged clearance and half-life of carbamazepine

Hispanics

May require lower dosage and experience higher incidence of side effects with TCAs

Jewish North Americans (Ashkenazi)

Agranulocytosis develops in 20% when clozapine (Clozaril or ODT) is used to treat schizophrenia; thus, the granulocyte count should be checked before the drug is administered.

Steroids

Blacks

When methylprednisolone is used for immunosuppression in renal transplant clients, there is increased toxicity such as steroid-associated diabetes; although Blacks are four times as likely to develop end-stage renal disease as Whites, they have the poorest long-term graft survival of any ethnic group.

Tranquilizers

Blacks

15%–20% are poor metabolizers of Valium (diazepam).

Table based partially on data from Bress, A., Han, J., Patel, S. R., Desai, A. A., Mansour, I., Groo, V., …, Cavallari, R. L. (2013). Association of Aldosterone Synthase Polymorphism (CYP11B2 -344T>C) and genetic ancestry with atrial fibrillation and serum aldosterone in African Americans with heart failure. PLoS One, 8(7), e71268; Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice. St. Louis, MO: Elsevier; Casorbi, I., Bruhn, O., & Werk, A. N. (2013). Challenges in pharmacogenetics, European Journal of Pharmacology, 69 (Suppl. 1), S17–S23; Center for Disease Control and Prevention. (2013). Genetic testing. Retrieved from http://www.cdc.gov/genomics/gtesting/index.htm; Marino, S. E., Birnbaum, A. K., Leppik, I. E., Conway, J. M., Musib, L. C., Brundage, R. C., … ,Cloyd, J. C. (2012). Steady-state carbamazepine pharmacokinetics following oral and stable-labeled intravenous administration in epilepsy clients: Effects of race and sex. Clinical Pharmacology & Therapeutics, 91(3), 483–488.

Reason for Seeking Care The reason or reasons for seeking care refers to a brief statement in the client’s own words describing why he/she is visiting a health care provider. This part of the health history previously was called the chief complaint, a term that is now avoided

because it focuses on illness rather than wellness and tends to label the person as a complainer. Symptoms are defined as phenomena experienced by individuals that signify a departure from normal function, sensation, or appearance and that might include physical aberrations. By

Chapter 3 Cultural Competence in the Health History and Physical Examination

comparison, signs are objective abnormalities that the examiner can detect on physical examination or through laboratory testing. As individuals experience symptoms, they interpret them and react in ways that are congruent with their cultural norms, unconscious behavior patterns that are typical of specific groups. Such behaviors are learned from parents, teachers, peers, and others whose values, attitudes, beliefs, and behaviors take place in the context of their own culture. Some cultural norms are healthy; others are not. Symptoms cannot be attributed to another person; rather, individual clients experience symptoms from their knowledge of bodily function and sociocultural interactions. Symptoms are perceived, recognized, labeled, reacted to, ritualized, and articulated in ways that make sense within the cultural worldview of the person experiencing them. Symptoms are defined according to the client’s perception of the meaning attributed to the event. This perception must be considered in relation to other sociocultural factors and biologic knowledge. People develop culturally based explanatory models to explain how their illnesses work and what their symptoms mean. The search for cultural meaning in understanding symptoms involves a translation process that includes both the nurse’s worldview and the client’s. Assess the symptoms within the client’s sociocultural and ethnohistorical context. It is important to use the same terms for symptoms that the client uses. For example, if the client refers to “swelling” of the leg, nurses should refrain from medicalizing that to “edema.” Knowledge of the cultural expression of symptoms influences the decisions nurses make and will facilitate their ability to provide culturally congruent and culturally competent nursing care (Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015).

Present Health and History of Present Illness Although all illnesses are defined and conceptualized through the lens of culture, the term ulture-bound syndromes refers to more than c

200 disorders created by personal, social, and cultural reactions to malfunctioning biological or psychological processes and can be understood only within defined contexts of meaning and social relationships (American Psychiatric Association, 2013; Kleinman, 1980; Simons & Hughes, 1985). When assessing clients with a culture-bound syndrome, it is important for the nurse to find out what the client, family, and other concerned individuals believe is happening; what prior efforts for help or cure have been tried; and what the results or outcomes from the treatment were.

Past Health Past illnesses are important for multiple reasons. First, past illnesses may have residual effects on the current state of health or have sequelae that appear many months or years later. For example, the varicella-zoster virus responsible for chicken pox may remain latent until a person notices the characteristic rash or blisters of shingles; chicken pox and shingles are caused by the same herpes zoster virus. Although there has been a varicella vaccine available in the United States since 1995, protection from one dose is not lifelong, and a second dose is necessary 5years after the initial immunization. Further, those born prior to 1995 and those born outside the United States may not be immunized. Second, the assessment of past illnesses includes other childhood conditions with known sequelae such as rheumatic fever, scarlet fever, and poliomyelitis. The nurse also gathers information about the date and nature of accidents, serious and chronic illnesses, hospitalizations, surgeries, obstetric history, and the last examination (Jarvis, 2015).

Family and Social History In this era of genetics and genomics, a comprehensive and accurate family history highlights those diseases and disorders for which a client may be at increased risk. Table 3-4 provides an alphabetical listing of common diseases and identifies racial and ethnic groups for which the conditions are more prevalent. When conducting the

Part One Foundations of Transcultural Nursing

Table 3-4: Biocultural Aspects of Disease Disease

Remarks

Alcoholism

American Indians have double the rate of Whites and 12% of all Native American deaths linked to alcohol; lower tolerance to alcohol among Chinese and Japanese Americans.

Anemia

High incidence among Vietnamese because of the presence of infestations among immigrants and low-iron diets; low hemoglobin and malnutrition found among 18.2% of Native Americans, 32.7% of Blacks, 14.6% of Hispanics, and 10.4% of White children under 5years of age

Arthritis

Increased incidence among Native Americans Blackfoot

1.4%

Pima

1.8%

Chippewa

6.8%

Asthma

Six times greater for Native American infants Whites Adulthood

Blacks < Whites

Tohono O’odham (Pima) Indians 50–60mL/100mL < Whites Clinical significance: Prevention, treatment, and nursing care of clients with cardiovascular disease continued

Table 3-7: Biocultural Variations and Clinical Significance for Selected Laboratory Tests (continued) Test

Remarks

High-density lipoproteins (HDLs)

Biocultural variation in adults Blacks > Whites Asians ≥ Whites Mexican Americans < Whites

Ratio of HDL to total cholesterol

Blacks < Whites

Low-density lipoproteins (LDLs)

Biocultural variation in adults Blacks < Whites Clinical significance: Prevention, treatment, and nursing care of clients with cardiovascular disease

Blood glucose

Biocultural variation in adults North American Indians, Hispanics, Japanese > Whites Blacks = Whites (for equivalent socioeconomic groups) Clinical significance: Diagnosis, treatment, and nursing care of adults and children with hypoglycemia and diabetes mellitus

Creatinine

For patients >49 years of age, the average creatinine level is 0.6–1.2mg/dL in adult males and 0.5–1.1mg/dL in adult females. (In the metric system, a milligram is a unit of weight equal to one-thousandth of a gram, and a deciliter is a unit of volume equal to one-tenth of a liter.) A person with only one kidney may have a normal level of about 1.8 or 1.9. Creatinine levels that reach 10.0 or more in adults indicate severe kidney impairment and the need for dialysis to remove wastes from the blood. For blacks, the normal average is 13% higher than counterparts in the general population. Clinical significance: Interpretation of test results for Blacks with suspected or diagnosed renal disease needs to take racial difference into account.

Estimated glomerular filtration rate (eGFR)

Blacks have more extreme rate of eGFR, followed by Hispanics, Whites, and Asians.

Multiple marker screening

Biocultural variations in blood levels for protein and hormones in pregnant women.

Clinical significance: eGFR predicts onset of end-stage renal disease (ESRD) and need for dialysis and renal transplantation. Projected kidney failure during chronic kidney disease stages 3 and 4 was high in blacks, Hispanics, and Asians relative to whites. Mortality for those with projected kidney failure is highest in whites. Differences in eGFR decline and mortality contribute to racial disparities in ESRD incidence. Alpha-fetoprotein (AFP), hCG, and estriol levels in Black and Asian women > Whites. Clinical significance: High AFP levels signal that the woman is at increased risk for being delivered of an infant with spina bifida and neural tube defects, whereas low levels may signal Down syndrome; Down syndrome also is associated with low levels of estriol and high levels of hCG. Black and Asian American women have higher average levels of AFP, hCG, and estriol than White counterparts. Using a single median for women of all cultures: ●●

●●

Causes Black and Asian women to be falsely identified as being at risk for having infants with spina bifida and neural tube defects; by being classified as high risk, women are more likely to be subjected to invasive and expensive procedures such as amniocentesis; some may elect to abort the pregnancy based on screening test results. Inappropriately lowers the identified Down syndrome risk for Black and Asian women.

Chapter 3 Cultural Competence in the Health History and Physical Examination

Table 3-7: Biocultural Variations and Clinical Significance for Selected Laboratory Tests (continued) Test

Remarks

Lecithin/ sphingomyelin ratio

Biocultural variations in amniotic fluid measures of fetal pulmonary maturity. Blacks have higher ratios than Whites from 23 to 42weeks’ gestation. Clinical significance: The ratio is used to calculate the risk of respiratory distress in premature infants: Lung maturity in Blacks is reached 1week earlier than in Whites (34 vs. 35weeks); racial differences should be considered in making decisions about inducing labor or delivering by caesarean section.

Table based on data from Allanson, A., Michie, S., & Matreau, T. M. (1997). Presentation of screen negative results on serum screening for Down’s syndrome. Journal of Medical Screening, 4(1), 21–22; Chapman, S. J., Brumfield, C. G., Wenstrom, K. D., & DuBard, M. B. (1997). Pregnancy outcomes following false-positive multiple marker screening test. American Journal of Perinatology, 14(8), 475–478; Chan, R. L. (2014). Biochemical markers of spontaneous preterm birth in asymptomatic women. Biomedical Research, 2014. doi: 10.1155/2014/164081PMCID: PMC3914291; Derose, S. F., Rutkowski, M. P., Crooks, P. W., Shi, J. M., Wang, J. Q., Kalantar-Zadeh, K., …, Jacobsen, S. J. (2013). Racial differences in estimated Glomerular Filtration decline, ESDR, and mortality in an integrated health system. American Journal of Kidney Disease, 62(2), 236–244; O’Brien, J. E., Dvorin, E., Drugan, A., Johnson, M. P., Yaron, Y., & Evans, M. I. (1997). Race-ethnicity-specific variation in multiple-marker biochemical screening: Alpha-fetoprotein, hCG, and estriol. Obstetrics and Gynecology, 89(3), 355–358; National Down Syndrome Society, 2014; Overfield, T. (1995). Biologic variation in health and illness: Race, age, and sex differences. New York, NY: CRC Press.

Caution should be used in interpreting genetic data as population categories are not discrete and separate entities. African Americans and Latinos have complex recent ancestral histories. African Americans on average are estimated to have approximately 20% European ancestry, and this proportion varies substantially among different African American populations within North America. Genetic analysis of individual ancestry indicates that some selfidentified European Americans have substantial recent African genetic ancestry. Population categories including race and ethnic groups are inadequate and misleading to fully describe the pattern and range of variation among individual clients. The more accurate assessment of disease risk is obtained by genotyping. Genotyping refers to the process of identifying differences in genetic makeup using biological testing rather than assuming their population affiliation as a surrogate. Although the reasons for differences aren’t always known, genetics, environment, diet, socioeconomic background, race, ethnicity, and lifestyle factors contribute to the differences in test results.

Transcultural Perspectives in Clinical Decision Making and Actions After completing a comprehensive cultural assessment through the health history and physical examination, analyze the subjective and objective data. Leininger suggests three major modalities to guide nursing decisions and actions for the purpose of providing culturally congruent care that is beneficial, satisfying, and meaningful to clients: cultural care preservation or maintenance, cultural care accommodation or negotiation, and cultural care repatterning or restructuring (Leininger, 1991; Leininger & McFarland, 2002; McFarland & Wehbe-Alamah, 2015). Cultural care preservation or maintenance

refers to those professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death (Leininger, 1991; Leininger & McFarland, 2002; McFarland & Wehbe-Alamah, 2015). Cultural care accommodation or negotiation refers to professional

Part One Foundations of Transcultural Nursing

actions and decisions that help people of a designated culture to adapt to or to negotiate with others for beneficial or satisfying health outcomes with professional care providers (Leininger, 1991; Leininger & McFarland, 2002; McFarland & Wehbe-Alamah, 2015). Cultural care repatterning or restructuring refers to professional actions and decisions that help clients reorder, change, or greatly modify their lifeways for new, different, and beneficial health care patterns while respecting the clients’ cultural values and beliefs and yet providing more beneficial or healthier lifeways than before the changes were coestablished with the clients (Leininger, 1991; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015). Whether the nurse uses Leininger’s three modes for decisions and actions or engages in other analytic processes, the next step in the process leading to culturally competent decision making and actions is to set mutual goals with the client, develop a plan of care, confer with and make referrals to other members of the interprofessional health care team (when needed), and implement a plan of care, either alone or with others. This process is presented primarily from

the nurse’s vantage point, is based on the health histories and physical examinations by the nurse and other team members, and focuses on the nurse–client interaction and those aspects of the care plan that fall within the scope of practice and responsibilities of professional nurses. Credentialed or licensed health professionals (e.g., physicians, pharmacists, social workers, dieticians, and physical, occupational, respiratory, and other therapists) have been educated to follow a similar process. Although some folk, traditional, religious, and spiritual healers may follow a comparable process, others might rely on a different approach, for example, reliance on subjective data from the client that is based on a spiritual assessment. They may prefer to practice their healing interventions with the client in private and may or may not want to collaborate with other members of the team. Be mindful that the federal Health Insurance Portability and Accountability Act (HIPAA) regulations may prohibit the sharing of some information, especially when the client is too ill to provide informed consent to release medical information with family, friends, and healers without authorization.

Figure 3-3. When conducting a comprehensive cultural assessment, the nurse collaborates with the client and physician as a members of an interprofessional health care team (Dragon Images/Shutterstock.com).

Chapter 3 Cultural Competence in the Health History and Physical Examination

Once the plan has been implemented, it should be evaluated in collaboration with the client, the client’s family and significant others, and with other credentialed, licensed, folk, traditional, religious, and spiritual healers who are members of the team. The evaluation includes a comprehensive analysis of the plan’s effectiveness in meeting mutually established goals and desired outcomes. As indicated in Figure 3-3, nurses collaborate with clients, physicians, and other members of the health care team to determine if the care delivered was culturally acceptable, congruent and competent, safe, affordable, accessible, high quality, and based on research, scientific evidence, and best professional practices. Gather additional subjective and objective data to determine the effectiveness of the intervention(s) and the client’s overall satisfaction with care delivery and outcomes. Health care facilities, home and community health agencies, and related health care organizations usually have comprehensive evaluation processes and instruments that they administer to clients or patients and then subsequently review individually and in the aggregate for the purpose of improving the quality of care.

Summary Many biocultural variations in health and illness are apparent in the health assessment and physical examination. For example, nurses will note differences based on the client’s gender, age, race, ethnicity, and/or genetic makeup. In gathering subjective and objective assessment data, note biocultural differences in body measurements, pain perception, general appearance, and symptom manifestation For example, in assessing the skin of lightly and darkly pigmented clients, there are notable differences in the manifestations of cyanosis, jaundice, pallor, erythema, petechiae, and ecchymoses. From the head to the toes, systematically use multiple techniques to gather data through observation, inspection, auscultation, palpation, and smell to conduct a comprehensive physical examination of the client. Upon

completion of the health assessment and physical examination, analyze and synthesize subjective and objective findings from the assessment, review the results of laboratory tests, and collaborate with the client and other members of the health care team to develop mutual goals, make clinical decisions, plan care, implement the plan, and evaluate the care. After evaluating the care, it may be necessary to ask the client additional questions, conduct a more focused physical examination on a particular body system, and/or revise the plan of care to ensure that it provides safe, culturally acceptable, congruent, competent, affordable, accessible, high-quality care that is evidence based and reflects best professional practices.

Review Questions 1. In your own words, describe the key compo-

nents of a comprehensive cultural assessment.

2. Compare and contrast your approach to the

assessment of light- and dark-skinned clients for cyanosis, jaundice, pallor, erythema, and petechiae. 3. Review the biocultural variations in laboratory tests for hemoglobin, hematocrit, serum cholesterol, serum transferrin, creatinine, eGFR, multiple marker screening, and amniotic fluid constituents. 4. Critically analyze the reasons for the current interest in herbal medicines by nurses, physicians, pharmacists, and other health care providers. How does knowledge of these medicines facilitate the nurse’s ability to provide culturally competent and congruent nursing care?

Critical Thinking Activities 1. Critically analyze the instrument, tool, or

form used by nurses when conducting an initial client or resident admission assessment at a hospital, extended care facility, or other health care agency in terms of its relevance to the health and nursing needs of persons from diverse cultures. From a transcultural nursing

Part One Foundations of Transcultural Nursing

perspective, identify the strengths and limitations of the admission assessment instrument. What suggestions would you make to enhance the effectiveness of the instrument in assessing the cultural needs of newly admitted clients or residents? Be sure to consider the practical constraints that nurses face in the current health care environment, such as time limitations, external forces that require nurses to care for increasingly large numbers of clients, and other constraints, before you suggest modifications to the existing instrument. 2. Using the Andrews and Boyle Transcultural

Nursing Assessment Guide for Individuals and Families (Appendix A), answer the questions in each data category as they apply to you. As you write your responses to the questions, critically reflect on your own health-related cultural values, attitudes, beliefs, and practices.

3. Using the Andrews and Boyle Transcultural

Nursing Assessment Guide for Individuals and Families (Appendix A), interview someone

from a cultural background different from your own to assess his or her health-related cultural values, attitudes, beliefs, and practices. After you have completed the interview, compare and contrast those responses with your own responses in Question 2. Identify the ways in which you are alike. Critically analyze the differences as potential sources of cross-cultural conflict, and explore ways in which they might influence the nurse–client interaction. 4. Conduct a head-to-toe physical examination

of a person from a racial background different from your own. Summarize your findings in writing. In a constructively self-critical manner, reflect on what aspects of the exam were (1) easiest and (2) most difficult for you. Try to determine the reason(s) why some aspects were relatively easy or difficult for you. What further information or skill development would assist you in gaining confidence in your ability to conduct physical examinations on people from diverse racial backgrounds?

References Allen, K. D., Oddone, E. Z., Coffman, C. J., Keefe, F. J., Lindquist, J. H., Bosworth, H. B. (2010). Racial differences in osteoarthritis pain and function: Potential explanatory factors. Osteoarthritis and Cartilage, 18, 160–167. American Cancer Society. (n.d.). Genetics and breast cancer. Retrieved from http://www.cancer.org/cancer/ breastcancer/index American Heart Association. (2014). African Americans and heart disease, stroke. Retrieved on 10/10/14 at http://www.heart.org/HEARTORG/Conditions/More/ MyHeartandStrokeNews/African-Americans-and-HeartDisease_UCM_444863_Article.jsp American Psychiatric Association. (2013). Diagnostic statistical manual of mental disorders (5th ed.) Arlington, VA: Author. BCC Research. (2013). Botanical and plant-derived drugs [Report]. Retrieved September 2014 from http://www. bccresearch.com/market-research/biotechnology/ botanical-plant-derived-drugs-markets-bio022f.html Becares, L., Shaw, R., Nazroo, S., Stefford, M., Albor, C., & Atkin, K. (2012). Ethnic diversity effects on physical morbidity, mortality, and health behaviors: A systematic review of the literature. American Journal of Public Health, 102(12), e33–e66.

Becker, W. C., Starrels, J. L., Heo, M., Li, X., Weiner, M. G., & Turner, B. J. (2011). Racial differences in primary care opioid risk reduction strategies. Annals of Family Medicine, 9, 219–225. Bongki, P., Jun, J. H., Jung, J., You, S., & Lee, M. S. (2014). Herbal medicines for cancer cachexia: Protocol for a systematic review. British Medical Journal Open, 4, e005016 doi: 10.1136/bmjopne-2014-005016. Retrieved from http://www.mayoclinic.org Bress, A., Han, J., Patel, S. R., Desai, A. A., Mansour, I., Groo, V., …, Cavallari, R. L. (2013). Association of Aldosterone Synthase Polymorphism (CYP11B2 -344T>C) and genetic ancestry with atrial fibrillation and serum aldosterone in African Americans with heart failure. PloS One, 8(7), e71268. Browning, B. L., & Browning, S. R. (2013). Detecting identity by descent and estimating genotype error rates in sequence data. American Journal of Human Genetics, 93(5), 840–851. Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & SandbergCook, J. (2013). Primary care: A collaborative practice. St. Louis, MO: Elsevier. Casorbi, I., Bruhn, O., & Werk, A. N. (2013). Challenges in pharmacogenetics, European Journal of Pharmacology, 69(Suppl. 1), S17–S23.

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National Down Syndrome Society. (2014). Prenatal testing. Retrieved from http://www.ndss.org/About-NDSS/ Me di a-Kit/Po sition-Pap ers/C D C-Study -onPrevalence-of-Down-Syndrome-/ National Football League. (2014). NFL consensus data on players’ race, weight, and height. Retrieved from http://heavy. com/sports/2014/09/what-percentage-of-nfl-playersare-black-white/ National Institute of Dental and Craniofacial Research. (2014). Dental caries, race, and ethnicity. Retrieved from http://www.nidcr.nih.gov/ National Institute on Alcohol Abuse and Alcoholism. (2014). Minority health and health disparities. Rockville, MD: National Institutes of Health, Alcohol Research Centers. Retrieved at http://www.niaaa.nih.gov/alcoholhealth/special-populations-co-occurring-disorders/ diversity-health-disparities National Institutes of Health. (2013). Cleft lip and cleft palate. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0002046/?report=printable National Organization for Albinism and Hypopigmentation. (2014). What is albinism? Retrieved from The National Organization for Albinism and Hypopigmentation: http:// www.albinism.org/publications/what_is_albinism.html Nicholls, P. (2014). The poverty of conservatism. Nation, 21(16), 3–4. O’Brien, J. E., Dvorin, E., Drugan, A., Johnson, M. P., Yaron, Y., & Evans, M. I. (1997). Race-ethnicity-specific variation in multiple-marker biochemical screening: Alphafetoprotein, hCG, and estriol. Obstetrics and Gynecology, 89(3), 355–358. Obeig-Odoom, F. (2012). Health, wealth, and poverty in developing countries: Beyond the state, market, and civil society. Health Sociology Review, 21(2), 156–162. Orton, N. C., Innes, A. M., Chudley, A. E., & Bech-Hansen, N. T. (2014). Unique disease heritage of the Dutch-German Mennonite population. American Journal of Medical Genetics Part A, 146A(8), 1072–1087. Overfield, T. (1995). Biologic variation in health and illness: Race, age and sex differences. New York, NY: CRC Press. Palit, S., Kerr, K., Kuhn, B., Terry, E., DelVentura, J., Bartley, E., …, Rhudy, J. (2013). Exploring pain processing differences in Native Americans. Health Psychology, 32(11), 1127–1136. Pardasani, M., & Bandyopadhyay, S. (2013). Ethnicity matters: Experiences of minority groups in public health. Journal of Cultural Diversity, 21(3), 90–98. Pedersen, D., Errazuriz, C., Kienzler, H., Lopez, V., Sharma, B., Bustamante, I., et al. (2012). Political violence, natural disasters and mental health outcomes: Developing innovative health policies and interventions. McGill University, Douglas Mental Health University Institute. Montreal, Quebec: Global Health Research Initiative. Porth, C. M. (2015) Essentials of pathophysiology: Concepts of altered health states (4th ed.). Philadelphia, PA: Lippincott.

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The Influence of Cultural and Health Belief Systems on Health Care Practices ●●Margaret M. Andrews

Key Terms Allopathic medicine Alternative medicine Complementary and integrative health Cultural belief systems Dietary supplements Folk healers Folk healing system

Health behavior Health belief systems Holistic paradigm Hot/cold theory of disease Humors Illness behavior Integrative health Magico-religious paradigm Metaphor Mechanism

Objective materialism Paradigm Professional care systems Reductionism Scientific paradigm Self-care Sick role behavior Worldview Yin and yang

Learning Objectives 1. 2. 3. 4. 5.

Describe the major cultural belief systems of people from diverse cultures. Compare and contrast professional and folk healing systems. Identify the major complementary and alternative health care therapies. Describe the influence of culture on symptoms and illness behaviors. Critically analyze the efficacy of selected herbal remedies in the treatment of health problems.

In this chapter, we examine the major cultural belief systems embraced by people from diverse cultures and explore the characteristics of three of the most prevalent worldviews, or paradigms, related to health–illness beliefs: magico-religious, scientific, and holistic. We explore selftreatment, professional care systems, and folk

( indigenous, traditional, generic) care systems and their respective healers. After analyzing the influence of culture on symptoms and sick roles, as well as illness behaviors, we examine selected complementary and alternative therapies used to treat physical and psychological diseases and illnesses.

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Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices

Cultural Belief Systems Cultural meanings and cultural belief systems develop from the shared experiences of a social group and are expressed symbolically. The use of symbols to define, describe, and relate to the world around us is one of the basic characteristics of being human. One of the most common expressions of symbolism is metaphor. In metaphor, one aspect of life is connected to another through a shared symbol. For example, the phrase “what a tangled web we weave” expresses metaphorically the relationship between two normally disparate concepts—human deception and a spider’s web. People often use metaphors as a way of thinking about and explaining life’s events. Every group of people has found it necessary to explain the phenomena of nature. From these explanations emerges a common belief system. The explanations usually involve metaphoric imagery of magical, religious, natural/holistic, scientific, or biological form. The range of explanations is limited only by the human imagination. The set of metaphoric explanations used by a group of people to explain life’s events and offer solutions to life’s mysteries can be viewed as the group’s worldview or major paradigm. A paradigm is a way of viewing the world and the phenomena in it. A paradigm includes the assumptions, premises, and linkages that hold together a prevailing interpretation of reality. Paradigms are slow to change and do so only if and when their explanatory power has been exhausted. The worldview reflects the group’s total configuration of beliefs and practices and permeates every aspect of life within the group’s culture. Members of a culture share a worldview without necessarily recognizing it. Thinking itself is patterned on or derived from this worldview because the culture imparts a particular set of symbols to be used in thinking. Because these symbols are taken for granted, people do not normally question the cultural bias of their thoughts. The use in the United States of the term American reflects such an unconscious cultural bias. This term is

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understood by citizens of the United States to refer only to themselves collectively, although in reality, it is a generic term referring to people in the Americas, the combined continental landmasses of North America and South America and their islands in the Western Hemisphere, including Canadians, Mexicans, Colombians, and all others living in the Americas. Another example of symbolism and worldview can be seen in the way nurses use terms such as nursing care, health promotion, and illness and disease. Nurses often take for granted that all their clients define and relate to these concepts in the same way they do. This reflects an unconscious belief that the same cultural symbols are shared by all and therefore do not require reinterpretation in any given nurse–client context. Such an assumption accounts for many of the problems nurses face when they try to communicate with others who are not members of the health profession culture.

Health Belief Systems Generally, theories of health and disease or illness causation are based on a group’s prevailing worldview. These worldviews include a group’s health-related attitudes, beliefs, and practices, frequently referred to as health belief systems. People embrace three major health belief systems or worldviews: magico-religious, scientific (or biomedical), and holistic, each with its own corresponding system of health beliefs. In two of these worldviews (magico-religious and holistic), disease is thought of as an entity separate from self, caused by an agent external to the body but capable of “getting in” and causing damage. This causative agent has been attributed to a variety of natural and supernatural phenomena. Furthermore, many people sometimes adhere to or believe in aspects of two or even three of the systems at any one time. For example, a person who is ill may understand that the illness has an identified causative agent; at the same time, the person may pray to recover quickly and perhaps

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embark on a sacred journey to see a vortex specialist to unite body, mind, and spirit.

Magico-Religious Health Paradigm In the magico-religious paradigm, the world is an arena dominated by supernatural forces. The fate of the world and those in it, including humans, depends on the actions of God, the gods, or other supernatural forces for good or evil. In some cases, the human individual is at the mercy of such forces regardless of behavior. In other cases, the gods punish humans for their transgressions. Many Latino, African American, and Middle Eastern cultures are grounded in the magico-religious paradigm. Magic involves the calling forth and control of supernatural forces for and against others. Some African and Caribbean cultures, such as Voodoo, have aspects of magic in their belief systems. In Western cultures, there are examples of this paradigm in which metaphysical reality interrelates with human society. For instance, Christian Scientists believe that physical healing can be effected through prayer alone. Ackernecht (1971), in an article about the history of medicine, states that “magic or religion seems to satisfy better than any other device a certain eternal psychic or ‘metaphysical’ need of mankind, sick and healthy, for integration and harmony.” Magic and religion are logical in their own way, but not based on empiric premises; that is, they defy the demands of the physical world and the use of one’s senses, particularly observation. In the magico-religious paradigm, disease is viewed as the action and result of supernatural forces that cause the intrusion of a disease-producing foreign body or health-damaging spirit. Throughout the world, five categories of events are believed to be responsible for illness in the magico-religious paradigm. These categories, derived from the work of Clements (1932), are sorcery, breach of taboo, intrusion of a disease object, intrusion of a disease-causing spirit, and loss of soul. One of these belief categories, or any combination of them, may be offered to

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explain the origin of disease. Alaska Natives, for example, refer to soul loss and breach of taboo (breaking a social norm, such as committing adultery). West Indians and some Africans and African Americans believe that the malevolence of sorcerers is the cause of many conditions. Mal ojo, or the evil eye, common in Latino and other cultures, can be viewed as the intrusion of a disease-causing spirit. In the magico-religious paradigm, illness is initiated by a supernatural agent with or without justification, or by another person who practices sorcery or engages the services of sorcerers. The cause-and-effect relationship is not organic; rather, the cause of health or illness is mystical. Health is seen as a reward given as a sign of God’s blessing and goodwill. Illness may be seen as a sign of God’s special favor insofar as it gives the affected person the opportunity to become resigned to God’s will, or it may be seen as a sign of God’s possession or as a punishment. For example, in many Christian religions, the faithful gather communally to pray to God to heal those who are ill or to practice healing rituals such as laying on of hands or anointing the sick with oil. In addition, in this paradigm, health and illness are viewed as belonging first to the community and then to the individual. Therefore, one person’s actions may directly or indirectly influence the health or illness of another person. This sense of community is virtually absent from the other paradigms.

Scientific or Biomedical Health Paradigm In the scientific paradigm, life is controlled by a series of physical and biochemical processes that can be studied and manipulated by humans. Several specific forms of symbolic thought processes characterize the scientific paradigm. The first is determinism, which states that a cause-andeffect relationship exists for all natural phenomena. The second, mechanism, assumes that it is possible to control life processes through mechanical, genetic, and other engineered interventions. The

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Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices

third form is reductionism, according to which all life can be reduced or divided into smaller parts; study of the unique characteristics of these isolated parts is thought to reveal aspects or properties of the whole, for example, the human genome and its component parts. The final thought process is objective materialism, which states that what is real can be observed and measured. There is a further distinction between subjective and objective realities in this paradigm. The scientific paradigm considers only forces that cannot be observed and measured. Members of most Western cultures, including the dominant cultural groups in the United States, Canada, Europe, and Australia, espouse this paradigm. When the scientific paradigm is applied to matters of health, it is often referred to as the biomedical model. In the biomedical model, all aspects of human health can be understood through the natural sciences, biology, chemistry, physics, and mathematics. This fosters the belief that psychological and emotional processes can be reduced to the study of biochemical exchanges. Only the observable is real and worthy of study. Effective treatment consists of physical and chemical interventions, often without regard to human relationships. In this model, disease is viewed metaphorically as the breakdown of the human machine because of wear and tear (stress), external trauma (injury, accident), external invasion (pathogens), or internal damages (fluid and chemical imbalances, genetic or other structural changes). Disease causes illness, has a more or less specific cause, and has a predictable time course and set of treatment requirements. This paradigm is similar to the magico-religious belief in external agents, having replaced supernatural forces with infectious and genetic agents. Using the metaphor of the machine, biomedicine uses specialists to take care of the “parts:” “fixing” a part restores the machine’s ability to function. The computer is the analogy for the brain; engineering is a task for biomedical practitioners. The discovery of DNA and human genome research has led to the field of genetic e ngineering,

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an eloquent biomedical metaphor. The symbols used to discuss health and disease reflect the US cultural values of aggression and mastery. For example, microorganisms attack the body, war is waged against the invaders, money is donated for the campaign against cancer, and illness is a struggle in which the patient must put up a good defense. The biomedical model defines health as the absence of disease or the signs and symptoms of disease. To be healthy, one must be free of all disease. By comparison, the World Health Organization defines health more holistically as “a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity” (WHO, 1948, p. 100). The definition is often cited and has not been amended since 1948.

Holistic Health Paradigm In the holistic paradigm, the forces of nature itself must be kept in natural balance or harmony. Human life is only one aspect of nature and a part of the general order of the cosmos. Everything in the universe has a place and a role to perform according to natural laws that maintain order. Disturbing these laws creates imbalance, chaos, and disease. The holistic paradigm has existed for centuries in many parts of the world, particularly in American Indian and Asian cultures. It is gaining increasing acceptance in the United States and Canada because it complements a growing sense that the biomedical view fails to account fully for some diseases as they naturally occur. The holistic paradigm seeks to maintain a sense of balance between humans and the larger universe. Explanations for health and disease are based on imbalance or disharmony among the human, geophysical, and metaphysical forces of the universe. For example, in the biomedical model, the cause of tuberculosis is clearly defined as the invasion of mycobacterium. In the holistic paradigm, whereby disease is the result of multiple environment–host interactions, tuberculosis is caused by the interrelationship of poverty, malnutrition, overcrowding, and mycobacterium.

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The term holistic, coined in 1926 by Jan Christian Smuts, defines an attitude or mode of perception in which the whole person is viewed in the context of the total environment. Its IndoEuropean root word, kailo, means “whole, intact, or uninjured.” From this root have come the words hale, hail, hallow, holy, whole, heal, and health. The essence of health and healing is the quality of wholeness we associate with healthy functioning and well-being. In this paradigm, health is viewed as a positive process that encompasses more than the absence of signs and symptoms of disease. It is not restricted to biologic or somatic wellness but rather involves broader environmental, sociocultural, and behavioral determinants. In this model, diseases of civilization, such as unemployment, racial discrimination, ghettos, and suicide, are just as much illnesses as are biomedical diseases. Metaphors used in this paradigm, such as the healing power of nature, health foods, and Mother Earth, reflect the connection of humans to the cosmos and nature. The belief system of Florence Nightingale, who emphasized nursing’s control of the environment so that patients could heal naturally, was also holistic. A strong metaphor in the holistic paradigm is exemplified by the Chinese concept of yin and yang, in which the forces of nature are balanced to produce harmony. The yin force in the universe represents the female aspect of nature. It is characterized as the negative pole, encompassing darkness, cold, and emptiness. The yang, or male force, is characterized by fullness, light, and warmth. It represents the positive pole. An imbalance of forces creates illness (see Evidence-Based Practice 4-1). Illness is the outward expression of disharmony. This disharmony may result from seasonal changes, emotional imbalances, or any other pattern of events. Illness is not perceived as an intruding agent but as a natural part of life’s rhythmic course. Going in and out of balance is seen as a natural process that happens constantly throughout the life cycle. Health and illness are aspects of the same process, in which

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the individual organism changes continually in relation to the changing environment. In the holistic health paradigm, because illness is inevitable, perfect health is not the goal. Rather, achieving the best possible adaptation to the environment by living according to society’s rules and caring appropriately for one’s body is the ultimate aim. This places a greater emphasis on preventive and maintenance measures than typically occurs in biomedicine. Another common metaphor for health and illness in the holistic paradigm is the hot/cold theory of disease. This is founded on the ancient Greek concept of the four body humors: yellow bile, black bile, phlegm, and blood. Humors are vital components of the blood found in varying amounts. The four humors work together to ensure the optimum nutrition, growth, and metabolism of the body. When the humors are balanced in the healthy individual, the state of ecrasia exists. When the humors are in a state of imbalance, this is referred to as dyscrasia (Osborn, 2015). The treatment of disease becomes the process of restoring the body’s humoral balance through the addition or subtraction of substances that affect each of these four humors. Foods, beverages, herbs, and drugs are all classified as hot or cold depending on their effect, not their actual physical state. Disease conditions are also classified as either hot or cold. Imbalance or disharmony is thought to result in internal damage and altered physiologic functions. Medicine is directed at correcting the imbalance as well as restoring body function. Although the concept of hot and cold is itself widespread, found in Asian, Latino, Black, Arab, Muslim, and Caribbean societies, each cultural group defines what it believes to be hot and cold entities, and little agreement exists across cultures.

Health and Illness Behaviors The series of behaviors typifying the health-seeking process have been labeled health and illness behaviors. These behaviors are expressed in the

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Evidence-Based Practice 4-1

Chronic Disease Self-Management and Health Literacy inFour Ethnic Groups An interdisciplinary team of investigators studied chronic disease, self-management, and health literacy in four U.S. ethnic groups: Vietnamese, African Americans, Whites, and Latinos. The researchers defined health literacy as the wide range of skills and competencies that people develop to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and improve quality of life. The facilitators of self-management of disease included speaking and listening skills that promote better clinician–patient communication; math skills, such as sliding scales for insulin dosage based on blood glucose levels; reading skills to read educational materials about disease processes and treatment; social support from family members, such as spouse and adult children; and social support from neighbors and friends who have higher levels of literacy than the patient and, in some instances, more financial resources. For example, a Vietnamese participant with diabetes who lives in a rooming house reported that his landlord’s wife buys extra vegetables for him whenever she goes shopping. Barriers to disease self-management include confusion about the name of the diagnosis and the underlying cause of the chronic health problem(s), such as confusing certain aspects of their conditions with other conditions, for example, misunderstanding the differences among high blood pressure, high blood sugar, and high cholesterol. One Vietnamese patient stated that he thought his diabetes had been caused by imprisonment during the Vietnam War and by the poor diet and forced labor he endured more than 40years ago. Another

patient indicated that hypertension means that the blood is flowing very fast, and he stated that a complication of the rapid heartbeat is that the “heart is going to become very agitated,” resulting in high cholesterol and obstruction of the veins.

roles people assume after identifying a symptom. Related to these behaviors are the roles individuals assign to others and the status given to the role players. People assume various types of behaviors once they have recognized a symptom. Health behavior is any activity undertaken by a person who believes himself or herself to be healthy for

the purpose of preventing disease or detecting disease in an asymptomatic stage. Illness behavior is any activity undertaken by a person who feels ill to define the state of his or her health and discover a suitable remedy. Sick role behavior is any activity undertaken by a person who considers himself ill to get well or to deal with the illness.

Clinical Implications: ●●

●●

Nurses and other members of the health care team should recognize that patients’ cultural health belief systems and explanatory models are interrelated with their health and linguistic literacy, educational background, and socioeconomic status. Cultural health beliefs exert important influences on the self-management of chronic diseases such as diabetes and hypertension. Cultural health beliefs are part of internally consistent explanatory models constructed by the patient in an effort to make sense of his/her diagnosis and the clinical manifestations of the underlying cause(s) of illness. Sometimes the patient’s yin/yang or hot/cold theories fail to align with the biomedical explanation, and the patient may decide to disregard the information and refrain from adhering to the biomedical recommendations and advice provided by nurses, physicians, and other health professionals.

Reference: Shaw, S. J., Armin, J., Torres, C. H., Orzech, K. M., & Vivian, J. (2012). Chronic disease self-management and health literacy in four ethnic groups. Journal of Health Communication, 17, 67–81.

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Three sets of factors influence the course of behaviors and practices carried out to maintain health and prevent disease: (1) one’s beliefs about health and illness; (2) personal factors such as age, education, knowledge, or experience with a given disease condition; and (3) cues to action, such as advertisements in the media, the illness of a relative, or the advice of friends. A useful model of illness behavior has been proposed by Mechanic (1978), who outlines 10 determinants of illness behavior that are important in the help-seeking process (see Table4-1). Awareness of these motivational factors can

help nurses offer the appropriate assistance to clients as they work through the illness process.

Types of Healing Systems The term healing system refers to the accumulated sciences, arts, and techniques of restoring and preserving health that are used by any cultural group. In complex societies in which several cultural traditions flourish, healers tend to compete with one another and/or to view their

Table 4-1: Mechanic’s Determinants of Illness Behavior Determinant

Description

Quality of symptom

The more frightening or visible the symptom, the greater the likelihood that the individual will intervene.

Seriousness of symptom

The perceived threat of the symptom must be serious for action to be taken. Often others will step in if the person’s behavior is considered dangerous (e.g., suicidal behavior) but will be unaware of potential problems if the person’s behavior seems natural (“he always acts that way”).

Disruption of daily activities

Behaviors that are very disruptive in work or other social situations are likely to be labeled as illness much sooner than the same behaviors in a family setting. An individual whose activities are disrupted by a symptom is likely to take that symptom seriously even if on another occasion he would consider the same symptom trivial (e.g., acne just before a date).

Rate and persistence of symptom

The frequency of a symptom is directly related to its importance; a symptom that persists is also likely to be taken seriously.

Tolerance of symptom

The extent to which others, especially family, tolerate the symptom before reacting varies; individuals also have different tolerance thresholds.

Sociocognitive status

A person’s information about the symptom, knowledge base, and cultural values all influence that person’s perception of illness.

Denial of symptom

Often, the individual or family members need to deny a symptom for personal or social reasons. The amount of fear and anxiety present can interfere with perception of a symptom.

Motivation

Competing needs may motivate a person to delay or enhance symptoms. Aperson who has no time or money to be sick will often not acknowledge the seriousness of symptoms.

Assigning of meaning

Once perceived, the symptom must be interpreted. Often people explain symptoms within normal parameters (“I’m just tired”).

Treatment accessibility

The greater the barriers to treatment—whether psychological, economic, physical, or social—the greater the likelihood that the symptom will not be interpreted as serious or that the person will seek an alternative form of care.

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scopes of practice as separate from one another. In some instances, however, practitioners may make referrals to different healing systems. For example, a nurse may contact a rabbi to assist a Jewish patient with spiritual needs, or a curandero may advise a Mexican American patient to visit a health care provider for an antibiotic when traditional practices fail to heal a wound.

Self-Care For common minor illnesses, an estimated 70% to 90% of all people initially try self-care with over-the-counter medicines, megavitamins, herbs, exercise, and/or foods that they believe have healing powers. Many self-care practices

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have been handed down from generation to generation, frequently by oral tradition. Self-care is the largest component of the American health care system and accounts for billions of dollars in revenue (Lillyman & Farquharson, 2013; Shaw, 2012). The use of over-the-counter medications, or nonprescription medications, is a common form of self-care. Dietary supplements such as herbs, vitamins, minerals, or other substances are very popular and used extensively in the United States. Box 4-1 shows tips for making informed decisions and evaluating information about dietary supplements. When self-treatment is ineffective, people are likely to turn to professional and/or folk (indigenous, generic, traditional) healing systems.

Box 4-1 Tips for Making Informed Decisions and Evaluating Information About Dietary Supplements Basic Points to Consider 1. Do I need to think about my total diet? Yes, dietary supplements are intended to supplement your diet, not to replace the varieties of food that are important for your health 2. Should I check with my doctor or health care provider before using a supplement? Yes, this is a good idea. Dietary supplements are not always risk free. Always check with your health care provider if you are pregnant, breast-feeding, or if you have a chronic medical condition such as diabetes, hypertension, or heart disease.

Some supplements may interact with prescription and over-the-counter medicines. ●● Some supplements can have unwanted effects during surgery. ●● Adverse effects from the use of dietary supplements should be reported to the FDA by calling 1-800-FDA-1088. ●●

3. Evaluate product websites and labels carefully; under the law, manufacturers of dietary

supplements are responsible for making sure their products are safe before they are marketed. ●● ●● ●● ●●

Who operates the website? What is the purpose of the website? What is the source of the information on the site and does the site have references? Is the information current?

4. Think twice about believing what you read. Here are some assumptions that raise safety concerns: “Even if a product may not help me, it at least will not hurt me.” “When I see the term ‘natural,’ it means that a product is healthful and safe.” “A product is safe when there is no cautionary information on the product label.” “A recall of a harmful product guarantees that all such harmful products will be immediately and completely removed from the marketplace.”

5. Contact the manufacturer for more information about the specific product that you are purchasing.

From: U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition (2014).

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Professional Care Systems According to Leininger (1991, 1997; Leininger & McFarland, 2002; Leininger & McFarland, 2006), professional care systems, also referred to as scientific or biomedical systems, are formally taught, learned, and transmitted professional care, health, illness, wellness, and related knowledge and practice skills that prevail in professional institutions, usually with multidisciplinary personnel to serve consumers. Professional care is characterized by specialized education and knowledge, responsibility for care, and expectation of remuneration for services rendered. Nurses, physicians, physical therapists, and other licensed health care providers are examples of professionals who comprise professional care systems in the United States, Canada, Europe, Australia, and other parts of the world.

Folk Healing System A folk healing system is a set of beliefs that has a shared social dimension and reflects what people actually do when they are ill versus what society says they ought to do according to a set of social standards (Andrews, Ybarra, & Matthews, 2014). According to Leininger (1991) and Leininger and McFarland (2002), all cultures of the world have had a lay health care system, which is sometimes referred to as indigenous or generic. The key consideration that defines folk systems is their history of tradition: many folk healing systems have endured over time through oral transmission of beliefs and practices from one generation to the next. A folk-healing system uses healing practices that are often divided into secular and sacred components. Most cultures have folk healers (sometimes referred to as traditional, lay, indigenous, or generic healers), most of whom speak the native tongue of the client, sometimes make house calls, and usually charge significantly less than health care providers in the professional care system (Leininger, 1997; Leininger & McFarland, 2002, 2006). In addition, many cultures have lay midwives (e.g., parteras for Hispanic women),

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doulas (support women for new mothers and babies), or other health care providers available for meeting the needs of clients. Table 4-2 identifies indigenous or folk healers for selected groups. If clients use folk healers, these healers should be an integral part of the health care team and included in as many aspects of the client’s care as possible. For example, a nurse might include the folk healer in obtaining a health history and in determining what treatments already have been used in an effort to bring about healing. In discussing traditional remedies, it is important to be respectful and to listen attentively to healers who combine spiritual and herbal remedies for a wide variety of illnesses, both physical and psychological in origin. Chapter 13 provides detailed information about the religious beliefs and spiritual healers in major religious groups.

Complementary, Integrative, and Alternative Health System Complementary, integrative, and alternative health is an umbrella term for hundreds of therapies based on health care systems of people from around the world. Some of these therapies have ancient origins in Egyptian, Chinese, Greek, and American Indian cultures. Others, such as osteopathy and magnet therapy, have evolved more recently. Allopathic or biomedicine is the reference point, with all other therapies being considered complementary (in addition to), integrative (combined with selected magicoreligious or holistic therapies whose efficacy has been scientifically documented), or alternative to (instead of ). Integrative health care is defined as a comprehensive, often interdisciplinary approach to treatment, prevention, and health promotion that brings together complementary and conventional therapies. The use of an integrative approach to health and wellness has grown within care settings across the United States, including hospitals, hospices, and military health facilities (National Center for Complementary and Integrative

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Table 4-2: Healers and Their Scope of Practice Culture/Folk Practitioner

Preparation

Scope of Practice

Family member

Possesses knowledge of folk medicine

Common illnesses of a mild nature that may or may not be recognized by modern medicine

Curandero

May receive training in an apprenticeship; may receive a “gift from God” that enables him or her to cure; knowledgeable in use of herbs, diet, massage, and rituals

Treats almost all of the traditional illnesses; some may not treat illness caused by witchcraft for fear of being accused of possessing evil powers; usually admired by members of the community

Espiritualista or spiritualist

Born with the special gifts of being able to analyze dreams and foretell future events; may serve apprenticeship with an older practitioner

Emphasis on prevention of illness or bewitchment through use of medals, prayers, amulets; may also be sought for cure of existing illness

Yerbero

No formal training; knowledgeable in growing and prescribing herbs

Consulted for preventive and curative use of herbs for both traditional and Western illnesses

Sabador

Knowledgeable in massage and manipulation of bones and muscles

Treats many traditional illnesses, particularly those affecting the musculoskeletal system; may also treat nontraditional illnesses

“Old lady”

Usually an older woman who has successfully raised her own family; knowledgeable in child care and folk remedies

Consulted about common ailments and for advice on child care; found in rural and urban communities

Spiritualist

Called by God to help others; no formal training; usually associated with a fundamentalist Christian church

Assists with problems that are financial, personal, spiritual, or physical; predominantly found in urban communities

Voodoo priest and priestess or Houngan and Mambo

May be trained by other priests/priestesses In the United States the eldest son of a priest becomes a priest; the daughter of a priest(ess) becomes a priestess if she is born with a veil (amniotic sac) over her face

Knowledgeable about properties of herbs; interpretation of signs and omens; able to cure illness caused by voodoo; uses communication techniques to establish a therapeutic milieu like a psychiatrist; treats Blacks, Mexican Americans, and Native Americans

Herbalist

Knowledgeable in diagnosis of illness and herbal remedies

Both diagnostic and therapeutic; diagnostic techniques include interviewing, inspection, auscultation, and assessment of pulses

Acupuncturist

3½ –4½ years (1,500–1,800hours) of courses on acupuncture, Western anatomy and physiology, Chinese herbs; usually requires a period of apprenticeship, learning from someone else who is licensed or certified Licensure required in the United States

Diagnosis and treatment of yin/yang disorders by inserting needles into meridians, pathways through which life energy flows; when heat is applied to the acupuncture needle, the term moxibustion is used May combine acupuncture with herbal remedies and/or dietary recommendations. Acupuncture is sometimes used as a surgical anesthetic

Hispanic

Black

Chinese

continued

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Table 4-2: Healers and Their Scope of Practice (continued) Culture/Folk Practitioner

Preparation

Scope of Practice

Braucher or baruch-doktor

Apprenticeship

Men or women who use a combination of modalities including physical manipulation, massage, herbs, teas, reflexology, and brauche, a folk-healing art with origins in 18th and 19th century Europe; especially effective in the treatment of bedwetting, nervousness, and women’s health problems; may be generalist or specialist in practice; some set up treatment rooms; some see non-Amish as well as Amish patients

Lay midwives

Apprenticeship

Care for women before, during, and after delivery

Magissa “magician”

Apprenticeship

Woman who cures matiasma or evil eye; may be referred to as doctor

Bonesetters

Apprenticeship

Specialize in treating uncomplicated fractures

Amish

Greek

Priest (Orthodox) Ordained clergy Formal theological study

May be called on for advice, blessings, exorcisms, or direct healing

Native American Shaman

Spiritually chosen Apprenticeship

Uses incantations, prayers, and herbs to cure a wide range of physical, psychological, and spiritual illnesses

Crystal gazer, hand trembler (Navajo)

Spiritually chosen Apprenticeship

Diviner diagnostician who can identify the cause of a problem, either by using crystals or by placing hand over the sick person; does not implement treatment

Adapted with permission from Hautman, M. A. (1979). Folk health and illness beliefs. Nurse Practitioner, 4(4), 23–31.

Health, 2014). The NCCIH’s mission is to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health approaches and their roles in improving health and health care. The center’s research priorities include the study of complementary approaches such as spinal manipulation, meditation, and massage, to manage pain and other symptoms that are not always well-addressed by conventional biomedical t reatments. The center’s research also encourages self-care methods that support healthier lifestyles and uncovers potential usefulness and safety issues of natural products (National Center for Complementary and

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Integrative Health, 2014). NCCIH was formerly known as the National Center for Complementary and Alternative Medicine. Consider a client who has been diagnosed with breast cancer. Worldwide, an estimated 33% to 47% of individuals use complementary or integrative therapies to manage symptoms, prevent toxicities, and improve quality of life during cancer treatment (Hoerner, et al., 2014; Richardson, et al., 2014). An estimated 48% to 80% of North American breast cancer survivors use complementary and integrative therapies following diagnosis (Greenlee et al., 2014; Link et al., 2013). Examples of complementary or integrative

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Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices

therapies that are recommended by oncologists in clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer include acupuncture, massage therapy, and biofeedback for the management of pain, nausea associated with chemotherapy, and other aspects of care for people with breast cancer. An example of an alternative therapy such as using a special diet to treat cancer instead of undergoing the treatment recommended by an oncologist is not recommended for the treatment of breast care (Greenlee et al.,2014). Complementary Health Approaches The National Institutes of Health categorizes complementary and integrative health approaches as follows: 1. Alternative medical systems are built on

complete systems of theory and practice. Often these systems have evolved apart from and earlier than the conventional medical approach used in the United States or Canada. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in Eastern cultures include traditional Chinese medicine and Ayurveda, which originated in India. 2. Natural Products include herbs (also known as botanicals), vitamins, minerals, and probiotics. They are often marketed to the public as dietary supplements. Interest in and use of natural products have continued to grow each year for the past decade. Data from the 2012 National Health Survey (Centers for Disease Control and Prevention [CDC], 2014) reveal that 17.7% of US adults reported they had used nonvitamin, nonmineral dietary supplements during 2012. 3. Mind and body practices include a diverse group of techniques administered by a trained practitioner or teacher that are designed to enhance the mind’s capacity to affect bodily

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functions and symptoms. The most commonly used mind and body practices include deep breathing, meditation, massage, yoga, progressive relaxation, hypnosis, and guided imagery. In the United States, 8.4% of adults use mind and body practices (CDC, 2014). 4. Manipulative and body-based methods are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation and massage therapy; they are used by 8.5% of US adults. 5. Energy therapies involve the use of energy fields in two ways: ●● Biofield therapies are intended to affect energy fields that surround and penetrate the human body. (The existence of such fields has not yet been scientifically proven.) Some forms of energy therapy manipulate biofields by applying pressure and/ or manipulating the body by placing the hands in, or through, these fields. Examples include qigong, Reiki, and Therapeutic Touch. ●●

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

Nonvitamin, nonmineral dietary supplements (17.9%), practitioner-based chiropractic or osteopathic manipulation (8.5%), yoga with deep breathing or meditation (8.4%), and massage therapy (6.8%) were the most prevalent complementary health approaches used by US adults. Regional differences exist in the use of complementary health approaches: 16.4% of adults in the West North Central region and 11.4% of adults in the Mountain region used chiropractic or osteopathic manipulation, compared to the national average of 8.5%. The Southern and Pacific regions have significantly lower use (CDC, 2014). Box 4-2 identifies and describes some of the complementary and alternative therapies most commonly used by people in the United States and Canada to promote health

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Box 4-2 Selected Complementary and Alternative Therapies Acupuncture refers to a family of procedures involving stimulation of anatomical points on the body by a variety of techniques. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. When heat is applied to the needles, it is referred to as moxibustion. Aromatherapyinvolves the use of essential oils (extracts or essences) from flowers, herbs, and trees to promote health and well-being. Ayurvedaincludes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment. Chiropractic focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. Dietary supplementsare products (other than tobacco) taken by mouth that contain a dietary ingredient intended to supplement the diet. Dietary ingredients may include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, and metabolites. Dietary supplements come in many forms, including extracts, concentrates, tablets, capsules, gelcaps, liquids, and powders. The United States and Canada have special requirements for labeling and regulate them as foods, not drugs. Guided imageryrefers to a wide variety of techniques, including simple visualization and direct suggestion using imagery, metaphor and story-telling, fantasy exploration and game playing, dream interpretation, drawing, and active imagination where elements of the unconscious are invited to appear as images that can communicate with the conscious mind (Academy for Guided Imagery, 2014). Homeopathic medicine is an alternative medical system. In homeopathic medicine, there is a belief that “like cures like,” meaning that

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small, highly diluted quantities of medicinal substances are given to cure symptoms, even though the same substances given at higher or more concentrated doses would actually cause those symptoms. Massagetherapists manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being. Naturopathy is an alternative medical system based on the premise that there is a healing power in the body that establishes, maintains, and restores health. Practitioners work with the patient with a goal of supporting this power through treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and traditional Chinese medicine. Osteopathic medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system. There is an underlying belief that all of the body’s systems work together, and disturbances in one system may affect function elsewhere in the body. Some osteopathic physicians practice osteopathic manipulation, a full-body system of hands-on techniques to alleviate pain, restore function, and promote health and well-being. Qigong (“chee-GUNG”) is a component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (pronounced “chee” and meaning vital energy) in the body, improve blood circulation, and enhance immune function. Reiki (“RAY-kee”) is a Japanese word representing Universal Life Energy. Reiki is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient’s spirit is healed, which in turn heals the physical body. Therapeutic touch is based on the premise that the healing force of the therapist affects the patient’s recovery; healing is promoted when the body’s energies are in balance. By

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Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices

passing their hands over the patient, healers can identify energy imbalances. Traditional Chinese medicine (TCM)is the current name for an ancient system of health care from China. TCM is based on a concept of balanced qi, or vital energy, which is believed to flow throughout the body. Qi regulates a person’s spiritual, emotional, mental, and physical balance, and is influenced by the opposing forces of yin (negative energy) and yang (positive energy). Disease is proposed to result

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from the flow of qi being disrupted and yin and yang becoming imbalanced. Among the components of TCM are herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage. Yoga is a term derived from a Sanskrit word meaning yoke or union. Yoga involves a combination of breathing exercises, meditation, and physical postures that are used to achieve a state of relaxation and balance of mind, body, and spirit.

Source: Center for Disease Control (2014) and National Center for Complementary and Alternative Medicine (2014).

and prevent and treat disease. Figure 4-1 provides the percentage of US adults who used selected complementary health approaches in the past 12months by type of approach. Other mind–body techniques are still considered complementary and integrative, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance. Efficacy of Complementary Health Approaches Research on complementary health approaches has focused on seven main areas: medicinal plants, chiropractic and low back pain, acupuncture and 20

pain, cell processes and diseases (e.g., cancer, asthma), the oxidative degradation of lipids, and diabetes and insulin. Research is also being done on the quality-of-life impact of complementary health approaches, including the influence of exercise and physical therapies on pain and endof-life care (Moral-Munoz, Cobo, Peis, ArroyoMorales, & Herrer-Viedman, 2014). For further information on evidence related to the efficacy of specific health approaches and the reliability and validity of the research conducted, you are encouraged to visit the Cochrane Library, which is the repository for the Cochrane Collaboration, a worldwide organization that prepares systematic reviews of health care therapies.

17.9

Percent

15 10

8.5

8.4

6.8 4.1

3.0

0 Nonvitamin, nonmineral dietary supplement

Chiropractic or osteopathic manipulation

Yoga

Massage

Meditation

Special diets

Figure 4-1. Percentage of U.S. adults who used selected complementary health approaches in the past 12 months by type of approach. (Source: CDC/ NCHS, National Health Interview Survey, 2012 in Center for Disease Control. (2014). National Center for Health Statistics Data Brief: Regional variation in use of complementary health approaches. Retrieved on October 18, 2014 at http:// www/cdc.gov/nchs/data/databriefs/db146.htm)

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Summary Cultural belief systems develop from the shared experiences of a social group and are expressed symbolically. The use of symbols to define, describe, and relate to the world around us is one of the basic characteristics of being human. The major cultural belief systems embraced by people of the world are the magico-religious, scientific, and holistic health paradigms or worldviews. In the magico-religious cultural belief system, a supernatural agent or agents are responsible for health and illness. Health often is seen as a reward given as a sign of blessing and goodwill by a supernatural agent, and illness may be seen as a sign of punishment by a supernatural agent or agents. Most physicians and nurses are formally educated in the scientific or biomedical belief system, in which life is controlled by a series of physical and biochemical processes that can be studied and manipulated by humans through allopathic medicine or professional care systems. In the holistic cultural belief system, the forces of nature must be kept in natural balance or harmony. Human life is only one aspect of nature and a part of the general order of the cosmos. Disturbing the laws of nature creates imbalance, chaos, and disease. Examples of the holistic cultural belief system include the yin/yang and hot/ cold theories of health and illnesses.

REVIEW QUESTIONS 1. In your own words, describe what is meant by

the following terms: (a) cultural belief system, (b) worldview, and (c) paradigm. 2. What are the primary characteristics of the three major health belief systems: magico-religious, scientific, and holistic paradigms? 3. What are the differences between professional and folk care systems? 4. What is allopathic medicine? 5. What is the primary mission of the National Center for Complementary and Integrative Health (NCCIH)?

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6. Identify the five major categories of comple-

mentary or integrative approaches.

CRITICAL THINKING ACTIVITIES 1. Select a complementary health approach that

you would like to know more about, for example, acupuncture, chiropractic, or homeopathy. Search the Internet for information about this practice, and go to a library to conduct background research. After you have learned more about the practice, contact a healer who uses that health approach and ask the following questions: a. How did you prepare to be a practitioner of________? b. What do you believe are the major benefits of ________ to clients or patients? c. What health-related conditions do you believe respond best to ________? d. Are there any risks to clients resulting from the use of ________?

2. According to the World Health Organization,

80% of the people in the world use complementary or integrative health approaches for the treatment of common illnesses. Select a common illness, such as upper respiratory infection, arthritis, gastrointestinal upset, or a similar condition, and identify the various complementary and integrative approaches to allopathic medicine that clients might use. What is the efficacy of each intervention that you have identified? How effective do you think the complementary and alternative practices are compared with allopathic medicine? Compare the cost of each practice as well as its efficacy.

3. Please view the video “Scientific Results of

Yoga for Health and Well-being,” which can be found on the NCCIH website (nccih.nih.gov, on the Training tab) as part of their Online Continuing Education Series. The presentation will help you to learn more about the use of yoga and tai chi to improve balance and prevent falls, especially in the elderly. After

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Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices

viewing the video, identify the areas for which you’re convinced there is adequate evidence to support incorporating yoga as a complementary health approach into your nursing practice. 4. The herb Echinacea is frequently used for the

prevention and treatment of the common cold. If a patient asked your opinion about the use of Echinacea, how would you reply? Would you recommend that the patient use this herb for treatment of a cold? Explain why or why not.

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5. Visit three websites in the Internet Resources

list on thePoint for further information about specific types of alternative and complementary medicine. Select a disease for which you think a complementary or alternative intervention might be helpful, for example, breast cancer, hypertension, osteoarthritis, or other chronic condition. Critically analyze the potential benefits and adverse effects of the intervention on clients with this disease. Indicate whether you believe there is sufficient evidence to support recommending the intervention to a client.

REFERENCES Academy for Guided Imagery. (2014). What is guided imagery? Retrieved from http://acadgi.com/whatisguidedimagery/index.html Ackernecht, E. (1971). Natural diseases and rational treatment in primitive medicine. Bulletin of the History of Medicine, 19, 467–497. Andrews, T. J., Ybarra, V., & Matthews, L. L. (2014). For the sake of our children: Hispanic immigrant and migrant families’ use of folk healing and biomedicine. Medical Anthropology Quarterly, 27(3), 385–413. Center for Disease Control (2012). National Health Interview Survey. Retrieved from http://www.cdc.gov/nchs/nhis/ nhis_2012_data_release.htm Center for Disease Control. (2014). National Center for Health Statistics Data Brief: Regional variation in use of complementary health approaches. Retrieved from http://www/ cdc.gov/nchs/data/databriefs/db146.htm Clements, F. E. (1932). Primitive concepts of disease. University of California Publications in Archeology and Ethnology, 32(2), 185–252. Greenlee, H. G., Balneaves, L. G., Carlson, L. E., Cohen, M., Deng, G., Hershman, D., …, Tripahy, D. (2014). Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. Journal of the National Cancer Institute Monographs, 50(3), 346–358. Hautman, M. A. (1979). Folk health and illness beliefs. Nurse Practitioner, 4(4), 23–31. Horner, M., Bueschel, G., Dennert, G., Less, D., Ritter, E., & Zwahlen, M. (2014). How many cancer patients use complementary and alternative medicine: A systematic review and metaanalysis. Integrative Cancer Therapies, 11(3), 187–203. Leininger, M. M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press.

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Leininger, M. M. (1997). Founder’s focus alternative to what? Generic vs. professional caring, treatments and healing modes. Journal of Transcultural Nursing, 91(1), 37. Leininger, M. M., & McFarland, M. R. (2002). Transcultural nursing: Concepts, theories, research and practices. New York, NY: McGraw-Hill. Leininger, M. M. & McFarland, M. R. (2006). Culture care diversity & universality: A worldwide nursing theory (2nd ed.). Sudbury, MA: Jones & Bartlett, Publishers. Lillyman, S., & Farquharson, N. (2013). Self-care management education models in primary care. British Journal of Community Nursing, 18(11), 556–564. Link, A. R., Gammon, M. D., Jacobson, J. S., Abrahamson, P., Bradshaw, P., Terry, M. B., …, Greenless, H. (2013). Use of self-care practitioner-based forms of complementary and alternative medicine before and after breast cancer. Evidence-Based Complementary and Alternative Medicine, 2013, 301549. doi: 10.1155/2013/301549 Mechanic, D. (1978). Medical sociology (2nd ed.). New York, NY: Free Press. Moral-Munoz, J. A., Cobo, M. J., Peis, E., Arroyo-Morales, M., Herrer-Viedman, E. (2014). Analyzing the research in integrative and complementary medicine by means of science mapping. Complementary Therapies in Medicine, 22, 409–418. National Center for Complementary and Integrative Health. (2015). Complementary, alternative or integrative medicine: What’s in a name? Retrieved from https://nccih.nih. gov/health/integrative-health Osborn, D. K. (2015). Greek medicine: The four humors. Retrieved from http://www.greekmedicine.net/b_p/Four_ Humors.html Richardson, J., Loyola-Sanchez, A., Sinclair, S., Harris, J., Letts, L., MacIntyre, N. J., …, Ginnis, K. M. (2014). Selfmanagement interventions for chronic disease: A systematic scoping review. Clinical Rehabilitation, 28(11), 1067–1077.

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Shaw, S. J., Armin, J., Torres, C. H., Orzech, K. M., & Vivian, J. (2012). Chronic disease self-management and health literacy in four ethnic groups. Journal of Health Communication, 17, 67–81. U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. (2014). Questions and answers on dietary supplements. Retrieved from http://www.fda.gov/Food/ DietarySupplements/QADietarySupplements/default.htm

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World Health Organization. (1948). Preamble to the Consti tution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

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Part Two

Transcultural Nursing: Across the Lifespan

Transcultural Perspectives in Childbearing ●●Jana Lauderdale

Key Terms Abortion Childbearing Contraception Fertility controls

Imbalance Intimate partner violence Intrauterine device (IUD) Maternal morbidity Maternal mortality Postpartum depression

Pregnancy Prescriptive beliefs Restrictive beliefs Taboos

Learning Objectives 1. Analyze how culture influences the beliefs and behaviors of the childbearing woman and her family during pregnancy. 2. Recognize the childbearing beliefs and practices of diverse cultures. 3. Examine the needs of women making alternative lifestyle choices regarding childbirth and child rearing. 4. Explore how cultural ideologies of childbearing populations can impact pregnancy outcomes.

This chapter discusses how cultural diversity influences the experience of childbearing. The experiences of the woman and those of her significant other during pregnancy, birth, and the postpartum period are examined. Recommendations for practice are provided in each section for nurses caring for childbearing women and their families. Also presented for the reader’s consideration are discussions related to culturally specific circumstances and behaviors of the childbearing woman and her family. 120

Overview of Cultural Belief Systems and Practices Related to Childbearing Pregnancy and childbirth practices in contemporary Western society have seen dramatic changes over the past three decades. As global populations become increasingly mobile, we are seeing cultures converge, which calls for a reorientation of our nursing skills and nursing behaviors.

Chapter 5 Transcultural Perspectives in Childbearing

In light of global population shifts that are likely to continue for years to come, cultural beliefs regarding childbearing and childrearing need to be examined to enable nurses to offer our patients culturally congruent care throughout their pregnancy, birth, and the early postpartum. One aspect does remain static: Childbearing is universal and, as Chalmers (2013) notes, is a great leveler, as all women who give birth do so in one of two ways. This is also a time of transition and social celebration of central importance in any society, signaling a realignment of existing cultural roles and responsibilities, psychological and physiologic states, and social relationships. The differences in how women experience this transition lie in the cultural values and beliefs surrounding pregnancy, the birthing process, and postpartum practices. The dominant cultural practices or rituals include formal prenatal care (including childbirth classes), ultrasonography to view the fetus, and hospital delivery. Hospital deliveries routinely involve a highly specialized group of nurses, obstetricians, perinatologists, and pediatricians who actively monitor the mother’s physiologic status and the fetal status (see Figure 5-1), deliver

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the infant, and provide postpartum and newborn care. Routine hospital care can also include inducing labor, providing anesthesia for labor and delivery, and performing a cesarean section. There is not total cultural agreement about the value of these dominant practices, however, and some health care providers elect to offer their pregnant clients alternative health care services. These alternatives include in-hospital and freestanding birth centers (see Figure 5-2) and care by nurse practitioners and nurse midwives who promote family-centered care and emphasize pregnancy as a normal process requiring minimal technological intervention. It is a known fact that the United States spends more money than any other country on health care and more on maternal health than any other type of hospital care; however, women in the United States have a higher risk of dying of pregnancy-related complications than those in 40 other countries. Health disparities in the United States also play a role in increased maternal morbidity and maternal mortality, although it is unclear to what extent. For example, African American women are nearly four times more likely to die of pregnancy-related complications

Figure 5-1. Fetal monitoring (Tyler Olson/Shutterstock.com).

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f amily structure, and social support networks of women in the United States, many health care providers mistakenly assume that pregnancy and childbirth are experienced similarly by all people. In addition, some professional nurses view some traditional cultural beliefs, values, and practices related to childbirth as “old-fashioned,” “back in the day,” or “old wives’ tales.” Although some of these customs are changing rapidly, particularly for immigrants in the United States, many women and families are attempting to preserve their own valued patterns of experiencing childbirth (see EvidenceBased Practice 5-1).

Fertility Control and Culture

Figure 5-2. Family-oriented birth center (glenda/ Shutterstock.com).

than White women. These rates and disparities have not improved in more than 20 years (Amnesty International, USA, 2010). Subcultures within the United States have very different practices, values, and beliefs about childbirth and the roles of women, men, social support networks, and health care practitioners. One such subculture includes proponents of the “back to nature” movement, who are often vegetarian, use lay midwives for home deliveries, and practice herbal or naturopathic medicine. Other groups that might have distinct cultural practices include African Americans, American Indians, Hispanics, Middle Eastern groups, Orthodox Jewish groups, Asians, and recent immigrants, among others. Additionally, religious background, regional variations, age, urban or rural background, sexual preference, and other individual characteristics all might contribute to cultural differences in the experience of childbirth. Despite the great variations that can exist in relation to the social class, ethnic origin,

The professional literature lacks information specific to cultural beliefs and practices related to the control of fertility. A woman’s fertility depends on several factors, including the likelihood of sterility, the probability of conceiving, and of intrauterine mortality. In addition, the duration of a postpartum period, during which a woman is unlikely to ovulate or conceive, influences fertility. These variables are further modified by cultural and social variables, including marriage and residence patterns, diet, religion, the availability of abortion, the incidence of venereal disease, and the regulation of birth intervals by cultural or artificial means, all of which are influenced by cultural norms, values, and traditions. This section focuses on those societal factors that influence reproductive rights and population control.

Unintended Pregnancy In the United States, according to Finer and Zolna’s (2011) combined data study, 49% of pregnancies in 2006 were unintended—a slight increase from 48% in 2001. Among women aged 19 years and younger, more than four out of five pregnancies were unintended. The proportion of pregnancies that were unintended was highest among teens younger than age 15 years, at 98%.

Evidence-Based Practice 5-1

Pregnancy, Childbirth, and Motherhood: A Metasynthesis ofthe Lived Experiences of Immigrant Women One of the most joyous processes in human nature should be that of pregnancy, childbirth, and motherhood. However, for immigrant women resettling in a new country, pregnancy may prove to be an unsettling experience. The authors conducted a metasynthesis using the seven steps of Noblit and Hare’s (1988) metaethnography. The aim of the study was to synthesize qualitative research in the area of immigrant women’s perceptions of pregnancy, childbirth, and motherhood as migrants in their newly adopted country. Fifteen studies published between 2003 and 2013 were selected that represented the topic of interest. Four major themes were found to be common in all the studies: expectations of pregnancy and childbirth, experiences of motherhood, encountering confusion and conflict with beliefs, and dealing with migration challenges. The results from the study indicate immigrant women believe they have the right to receive quality and culturally congruent health care, regardless of background.

Clinical Implications: ●●

Provide increased emotional support to immigrant women during pregnancy as needed.

The largest increases in unintended pregnancy rates were among women with low education, low income, and cohabiting women. Mosher, Jones, and Abma (2012) reported similar fi ndings in data from the National Survey of Family Growth, which indicated no significant decline in the overall proportion of unintended births between the 1982 and the 2006 to 2010 surveys. The proportion of births that were unintended did decline during these years among married, non-Hispanic White women. Women more likely to experience unintended births included unmarried women, black women, women who are socioeconomically disadvantaged, and those with less education. The public cost of births

●●

Work to ensure that institutions provide linguistically informed and culturally congruent services to enhance antenatal visits. Make cross-cultural training available to providers in order to address cultural issues that could negatively impact childbirth, such as female excision. Maximize involvement of lay community outreach workers with the same cultural background, to inform women of available reproductive services. Respect and consider traditional practices in the women’s care to improve health outcomes for both mother and child. Learn as much as possible about the cultural belief systems of your patients in order to build an environment of trust and open communication to improve the childbearing experience.

Reference: Benza, S., & Liamputtong, P. (2014). Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery, 30, 575–584.

resulting from unintended pregnancies has been reported to be $8 billion; for teens, the average cost was even higher, topping out at $9.1 billion (Sonfield, Kost, & Gold, 2011). Figure 5-3 illustrates a teenager’s reaction to an unintended pregnancy. Women’s attitudes related to pregnancy, contraception, fertility, and childbearing have had limited exploration. Rocca and Harper (2012) used 2009 data from the National Survey of Reproductive and Contraceptive Knowledge to specifically investigate if contraceptive attitudes and knowledge explain disparities in method used. Using mediation analysis and regression models, they reported that Blacks and Latinas believe the 123

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Figure 5-3. Pregnant teenager (Diego Cervo/Shutterstock.com).

government encourages contraceptive use to limit minority population growth. They also indicated that although Blacks and Latinas used less effective methods than Whites, their attitudes did not explain the disparities in method used. For example, lower contraceptive knowledge only partially explained Latinas’ use of less effective methods. The investigators concluded that “other” variables needed study, including provider behavior and health system features. Unintended pregnancy can have numerous negative effects on the mother and the fetus, including a delay in prenatal care, continued or increased tobacco and other drug use, as well as increased physical abuse during pregnancy; any of these factors can lead to preterm labor or low-birth-weight (LBW) infants (Finer & Zolna, 2011). Consideration must also be given to what is influencing unintended pregnancy, which includes changes in social mores sanctioning motherhood outside of marriage, contraception availability including abortion, earlier sexual activity, and multiple partners. In addition to increasing access to contraception and targeting high-risk groups, programs aimed at reducing or preventing unintended pregnancy must build on the cultural meaning of the problem and focus on

the processes women and their partners use to make fertility decisions. The United States has established family planning goals in Healthy People 2020 aimed at improving pregnancy planning, spacing, and preventing unintended pregnancy. An objective is to increase the proportion of pregnancies that are intended to 56%. Family planning efforts that can help reduce unintended pregnancy include increasing access to contraception, particularly to the more effective and longer-acting reversible forms, and increasing correct and consistent use of contraceptive methods overall (U.S. Department of Health and Human Services, 2014). As of this printing, this goal has yet to be achieved.

Contraceptive Methods Commonly used methods of contraception in the United States include hormonal methods, intrauterine devices (IUDs), permanent sterilization, and, to a lesser degree, barrier and “natural” methods. Natural methods of family planning are based on the recognition of fertility through signs and symptoms and abstinence during periods of fertility. The religious beliefs of some cultural groups might affect their use

Chapter 5 Transcultural Perspectives in Childbearing

of fertility controls such as abortion or artificial regulation of conception; for example, Roman Catholics might follow church edicts against artificial control of conception, and Mormon families might follow their church’s teaching regarding the spiritual responsibility to have large families and promote church growth (Andrews & Hanson, 2012). Negative outcomes of religious family planning teachings have recently been studied. Pritchard, Roberts, and Pritchard (2013) analyzed WHO data from two continents sharing religious–cultural views on suicide and family planning those being Western European Catholic and Latin American Catholic countries. He reported that in Latin American female youth (15 to 24 years of age), less access to contraception contributed to unintended pregnancies and higher suicide rates. The ability to control fertility successfully also requires an understanding of the menstrual cycle and the times and conditions under which pregnancy is more or less likely to occur—in essence, an understanding of bodily functions. When these functions change, the woman might perceive the changes as abnormal or unhealthy. Because the use of artificial methods of fertility control might alter the body’s usual cycles, women who use them might become anxious, consider themselves ill, and discontinue the method. American Indian women monitor their

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monthly bleeding cycles closely and believe in the importance of monthly menstruation for maintaining harmony and physical well-being. Contraceptives such as the IUD are generally better accepted by American Indian women than hormonal methods because of the normal or increased flow associated with the IUD. Because the mechanism of action of an IUD might include the expulsion of a fertilized ovum, some women in this group oppose the use of the IUD for religious reasons.

Refugees and Reproductive Health Since the Rwandan crisis in 1994, an estimated 26 million individuals have been displaced across international borders (as of mid-2013) as part of a mass exodus from their homes due to war, ethnic and civil unrest, and political instability (UNHCR, 2013). Women and children account for approximately 80% of the world’s refugees, and displaced women are extremely vulnerable to poor reproductive illness and outcomes (CDC, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, 2014). The CDC has developed a refugee program with a focus on refugee reproductive health. The goals for the program are presented in Box 5-1. Women living in refugee situations encounter many barriers to contraceptive use,

Box 5-1 CDC Refugee Reproductive Health Activities Goals 1. Initiate epidemiologic studies to evaluate the reproductive health status of women in refugee and IDP settings to better provide information to improve service, quality, and accessibility. 2. Design, implement, and evaluate reproductive health rapid assessment tools and behavioral and epidemiologic surveillance systems appropriate to refugee settings. 3. Design, recommend, and evaluate interventions and “best practices” identified through

epidemiologic research, rapid assessment, and surveillance. 4. Strengthen the capacity of the refugee/IDP community, as well as the agencies providing health services, to collect and use data to improve reproductive health status and services. 5. Translate and communicate study findings and best practices to refugees and supporting agencies.

CDC, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA. (2006). Retrieved from http://www.cdc.gov

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and even with the development of programs that target refugee women in the United States, sponsored refugee women continue to experience barriers to reproductive health. For example, Somali Bantu women relocated to Hartford, CT, reported that a major barrier to unmet health needs was the ethnic distinction/language barrier (Gurnah, Khoshnood, Bradley, & Yuan , 2011). The authors attributed this finding to the interpreter translation being conducted in a Somali language that the Somali Bantu did not understand.

Religion and Fertility Control The influence of religious beliefs on birth control choices varies within and between groups, and adherence to these beliefs may change over time. Cultural practices tend to arise from religious beliefs, which can influence birth control choices. For example, the Hindu religion teaches that the right hand is clean and the left is dirty. The right hand is for holding religious books and eating utensils, and the left hand is used for dirty things, such as touching the genitals. This belief complicates the use of contraceptives requiring the use of both hands, such as a diaphragm (Bromwich & Parsons, 1990). In many cases, birth control is seen as an act of God. Purnell and Selekman (2008) describe the Muslim belief that abortion is “haram” unless the mother’s life is in danger; consequently, unintended pregnancies are dealt with by praying a miscarriage will occur. A fact that is perhaps of greater significance to fertility in Muslim women is that a woman’s sterility can be reason for abandoning or divorcing her. The authors go on to say that Islamic law forbids adoption; infertility treatment is allowed, but is limited to artificial insemination using the couple’s own sperm and eggs. A pregnant Muslim woman is shown in Figure 5-4. According to Orthodox Jewish beliefs, infertility counseling and intervention such as sperm and egg donation (from the couple) meet with religious approval; adoption is viewed as a last resort (Washofsky, 2000). The use of condoms and birth control pills are acceptable; abortion and sterilization are the least-supported birth

Figure 5-4. Pregnant woman (ZouZou/Shutterstock. com).

control methods. However, in cases where the mother’s life is in jeopardy, abortion is not opposed (Kolatch, 2000). In some African cultures, there are strongly held beliefs and practices related to birth spacing. Because postpartum sexual activity has traditionally been taboo, some women leave their home for as long as 2 years to avoid pregnancy (Miller, 1992). See Figure 5-5 for a photo of an African woman and her children.

Cultural Influences on Fertility Control It is common for health professionals to have misconceptions about contraception and the prevention of pregnancy in cultures different from their own. A qualitative study by Eckhardt and Lauderdale (2013) sought to identify and

Chapter 5 Transcultural Perspectives in Childbearing

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Figure 5-5. Traditional African mother and children (Sylvie Bouchard/Shutterstock.com).

describe the barriers to family planning in North Kamagambo, Kenya, to understand the cultural context in which they exist. Since the Lwala Community Hospital’s opening in the North Kamagambo region of Kenya in 2007, the number of patients seeking contraceptives and family planning counseling has increased. However, maternal mortality remains high and the culture expects women to bear many children. Although this places a large burden on women’s health and increases a lifetime risk of maternal mortality, cultural and religious hesitance toward family planning persists. See Evidence-Based Practice 5-2. Nurses providing family planning services must take care to be culturally sensitive so that women can be assisted in examining their own attitudes, beliefs, and sense of gynecologic wellbeing regarding fertility control.

Pregnancy and Culture All cultures recognize pregnancy as a special transition period, and many have particular customs and beliefs that dictate activity and

behavior during pregnancy. Recent reports of childbirth customs in the United States have focused on accounts of differing beliefs and practices relative to pregnancy among various ethnic and cultural groups. This section describes some of the biologic and cultural variations that might influence nursing care during pregnancy.

Biologic Variations Knowledge of certain biologic variations resulting from genetic and environmental backgrounds is important for nurses who care for childbearing families. For example, pregnant women who have the sickle cell trait and are heterozygous for the sickle cell gene are at increased risk for asymptomatic bacterial and urinary tract infections such as pyelonephritis. This places them at greater-thannormal risk for premature labor as well. Although heterozygotes are found most commonly among African Americans (8% to 14%), individuals living in the United States and Canada who are of Mediterranean ancestry, as well as those of Germanic and Native North American descent,

Evidence-Based Practice 5-2

The Impact of Culture on Knowledge, Attitude, and Practice of Family Planning Methods in Rural North Kamagambo, Kenya The purpose of the study was to explore how culture impacts knowledge, attitude, and practice regarding family planning in order to design an effective family planning education program tailored to the needs of Lwala and surrounding communities. This exploratory, descriptive, qualitative study employed six focus groups to collect data and included local men, women, Umama Salamas (lay community birth attendants), maternal child health workers, religious community leaders, and Lwala hospital family planning clinic staff. Data were collected using an open-ended interview guide. Constant comparative analysis was used for analyzing interview data. Five themes emerged: preparing the ground (education), cultural barriers and beliefs regarding family planning, health care system issues and health care access, protecting our women and ourselves, and “war” of contradictions and fears. The findings suggest the community is open to learning and engaging in family planning. Furthermore, the community will likely benefit from this education, as misconceptions of side effects and myths regarding family planning were similar across groups.

Clinical Implications:

might also carry the trait (Overfield, 1985; Perry, 2000). If both parents are heterozygous, there is a one-in-four chance that the infant will be born with sickle cell disease. Another important biologic variation relative to pregnancy is diabetes mellitus. The incidence of non–insulin-dependent and gestational diabetes is much higher than normal among some American Indian groups—a problem that increases maternal and infant morbidity. Illnesses that are common among European Americans might manifest themselves differently in American Indian clients. For example, an American Indian woman might have a high blood sugar level but be asymptomatic for diabetes mellitus. The mortality rate in

pregnant American Indian women with diabetes is higher than in White European American women. Diabetes during pregnancy, particularly with uncontrolled hyperglycemia, is associated with an increased risk of congenital anomalies, stillbirth, macrosomia, birth injury, cesarean section, neonatal hypoglycemia, and other problems. Because long-term studies have been conducted among the Pima Indians of Arizona, we know that, for the last 40 years or so, they have a very high incidence of gestational diabetes and other health problems during pregnancy (Pettitt, Baird, Aleck, Bennett, & Knowler, 1983). Because some of the children born to Pima mothers after the studies began are now 30 to 40 years old, we

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Tailor family planning education based on cultural/community needs as well as education/literacy level. ●● Train educators as needed. ●● Ensure the privacy of women seeking family planning in the hospital. ●● Show respect for differing family planning beliefs. ●● Standardize information communicated by health care providers to improve consistency. ●● Target men for education to decrease burden of secrecy for women seeking care. ●● Discuss with women and men the societal, cultural, and religious hesitance toward male condom use. ●● Identify alternative methods for contraception when government contraceptive supply is low. ●●

Reference: Eckhardt, S., & Lauderdale, J. (2013). The impact of culture on knowledge, attitude, and practice of family planning methods in rural North Kamagambo, Kenya. Unpublished study.

Evidence-Based Practice 5-3

Childbirth Postexcision Excision has been described by the WHO (2010) as a complete or partial removal of the clitoris and the labia minora, with or without the labia majora. Although communal advantages and some personal benefits have been cited in the literature for female excision, deleterious outcomes have been noted to occur, including psychological stress, adverse obstetric and perinatal outcomes such as postpartum hemorrhage, and newborn risks of stillbirth, death, need for resuscitation at birth, and LBW (United Nations Children’s Fund, 2005; WHO, 2008). In order to understand the impacts of excision on childbirth, hermeneutic phenomenology was used to analyze the narratives of four women who had been excised.

Clinical Implications: ●●

Break the “taboo of silence.” The women prefer an open, respectful discussion regarding their excision.

can see how a mother’s d iabetes can influence her child’s health in adulthood. Researchers have found that the children of women with diabetes during pregnancy have a higher risk of becoming obese and getting diabetes earlier in life than those born to mothers who had normal blood sugar (Chamberlain, n.d.; The Pima Indians: Obesity and Diabetes, 2010). Pregnant American Indians and Alaskan Native women with type 2 diabetes are at an increased risk of having babies born with birth defects. Gestational diabetes increases the baby’s risk for problems such as macrosomia (large body size) and neonatal hypoglycemia (low blood sugar). Although the blood glucoses of American Indian and Alaskan Native women usually return to normal after childbirth, these women have an increased risk of developing gestational diabetes in future pregnancies. In addition, studies show that many women with gestational diabetes will develop type 2 diabetes later in life (The Diabetes Monitor, 2011).

●●

Share explicit care plans to identify and share each woman’s wishes regarding her excision, particularly when multiple providers are involved. Provide language/dialect interpreters when sharing information to prevent frustration for the women. Ensure that the provider’s approach to excised women is as respectful as it is for any other woman seeking maternity care. Remember, the woman in front of you is a “woman who has been excised” versus an “excised woman.”

Reference: d’Entremont, M., Smythe, L., & McAra-Couper, J. (2014). The sounds of silence: A hermeneutic interpretation of childbirth post excision. Health Care for Women International, 35, 300–319.

Cultural Variations Influencing Pregnancy Several cultural variations may influence pregnancy. Those highlighted in this section include alternative lifestyle choices, nontraditional support systems, cultural beliefs related to parental activity during pregnancy, and food taboos and cravings. Nurses must be able to differentiate among beliefs and practices that are harmful and those that are benign. Few cultural customs related to pregnancy are dangerous and many are health promoting. However, one practice that is dangerous is female excision. This cultural practice occurs in approximately 28 African countries and affects 100 to 140 million girls and women (WHO, 2008). The emotional and psychological impact of this practice on childbirth is important to recognize when providing childbearing care for women having undergone this procedure. See d’Entremont, Smythe, McAra-Couper’s (2014) study description in Evidence-Based Practice 5-3. 129

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Alternative Lifestyle Choices Although the dominant cultural expectation for North American women remains motherhood within the context of the nuclear family, recent cultural changes have made it more acceptable for women to have careers and pursue alternative lifestyles. Changing of cultural expectations has influenced many middle-class North American women and couples to delay childbearing until their late 20s and early 30s and to have small families. Many of today’s women are career oriented, and they may delay childbirth until after they have finished college and established their career. Some women are making choices regarding childbearing that might not involve the conventional method of conception and childrearing. Lesbian childbearing couples are a distinct subculture of pregnant women with special needs (see Figure 5-6). Randi (2012) reports that the way intake forms are completed needs to be re-evaluated in light of these social changes. How the patient became pregnant is one such example. Instead of assuming she became pregnant via intercourse, Randi suggests asking the patient to tell you “the story” of how she became pregnant,

thus keeping the interview less threatening and nonjudgmental. The author underscores the need to be aware of the language used in the first encounter with a pregnant woman in order to set the tone for future provider–patient encounters. The most common fear reported by lesbian mothers is the fear of unsafe and inadequate care from the practitioner once the mother’s sexual orientation is revealed. Reluctance to disclose sexual orientation to one’s health care provider can act as a barrier to a woman receiving appropriate services and referrals (Snowden, 2011). In their review of the literature, McManus, Hunter, and Rennus (2006) found four areas that are significant in regard to lesbians considering parenting: (1) sexual orientation disclosure to providers and finding sensitive caregivers, (2) conception options, (3) assurance of partner involvement, and (4) how to legally protect both the parents and the child. Lesbian and heterosexual pregnancies have many similarities. Issues of sexual activity, psychosocial changes related to attaining the traditionally defined maternal tasks of pregnancy (Rubin, 1984), and birth education all need to be addressed with lesbian couples. Special needs of the lesbian couple requiring

Figure 5-6. Couple with child (Dubova/Shutterstock.com).

Evidence-Based Practice 5-4

Vulnerable and Strong: Lesbian Women Encountering Maternity Care Phenomenology was used to interpret pregnant lesbian couples’ descriptions of their maternity experiences. Vulnerability, responsibility, and caring were woven throughout the narratives, which reveal that pregnant lesbian women who disclose their sexuality to their health care provider risk judgment and discrimination. The findings highlighted three themes: being open, being exposed, and being confirmed.

Clinical Implications: ●●

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Understand that being pregnant and living in a lesbian relationship increase visibility, thus enhancing vulnerability. Couples may take responsibility for acts of caring as they are accustomed to health care providers being uncertain and anxious regarding their relationship.

assessment include social discrimination, family and social support networks, obstacles in becoming pregnant (i.e., coitus versus artificial insemination), maternal role development, legal issues of adoption by the partner, and coparenting roles (Spidsberg, 2007). Buchholz’s (2000) qualitative study was one of the first to examine the childbirth experiences of lesbian couples. The researcher focused on the positive aspects of the experience and the reasons why they were positive for the mother. Preparation of the nursing staff before the couple’s arrival in the delivery area was seen by the couples as helpful. This preparation assisted the staff with the execution of the couple’s birth plan and helped identify, ahead of time, nurses who would prefer not to work with the couple. The nurses’ inclusion of the mother’s partner in the labor and delivery process, by acknowledging their approaching parenthood and allowing the partner to assist with newborn care after

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Lesbian pregnant couples prefer that health care providers not focus on their sexuality, but rather treat them as any other laboring couple. The need to be accepted, cared for, and communicated with are essential with this group of women. Not using words such as “lesbian” or “partner” can be viewed as discriminating and reinforce a feeling of invisibility. Comprehend the responsibility of ethical caring for patients different than themselves.

Reference: Spidsberg, B. D. (2007). Vulnerable and stronglesbian women encountering maternity care. Journal of Advanced Nursing, 60(5), 478–486.

delivery, was seen as positive. The nursing staff conveyed support by using comforting gestures, checking with the couple frequently, answering questions, and just “being there” for them (Buchholz, 2000). Buchholz’s study identified two major concerns of lesbian couples. The first centered on legal issues, such as power of attorney, visiting restrictions for the partner, and birth certificate information (father identification). The second concern dealt with the couple’s attention to nurses’ behavioral cues and questioning whether “busyness” on the part of the nurses might somehow equate to discomfort with the situation. To further illustrate the issues surrounding nursing care and lesbian childbearing needs, a study by Spidsberg (2007) used a phenomenological hermeneutical approach to describe the meaning given to the maternity care experience by lesbian couples. See Evidence-Based Practice 5-4. 131

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Health care providers, policy makers, and the public need to be mindful of research findings and exercise increased sensitivity when providing care and establishing evidence-based practice standards and policies, in order to meet the needs of the expanding view of “family.” Maternal Role Attainment Maternal role attainment is often taken for granted in Western culture. If you give birth and become a mother, the assumption is that you automatically become “maternal” and successfully care for and nurture your infant. However, many factors can affect maternal role attainment, including separation of mother and infant in cases such as illness, incarceration, or adoption, to name only a few. An example of successful maternal role attainment superimposed with a chronic illness is described in a phenomenological study that explored factors affecting maternal role attainment in HIV-positive Thai mothers selected for their successful adaptation to the maternal role. The results indicated six internal and external factors used to assist in attainment: (1) setting a purpose of raising their babies; (2) keeping their HIV status secret; (3) maintaining feelings of autonomy and optimism by living as if nothing were wrong, that is, normalization; (4) belief of quality versus quantity of support from husbands, mothers, or sisters; (5) hope for a cure; and (6) belief that their secret is safe with their health care providers. The study results indicated that while the diagnosis of HIV created challenges in attaining the mothering role, the women’s feelings of shame of infection (seen as a disease of prostitutes in Thai culture) were buffered by their will to live and their love of and hope for a future with their children. The researcher notes that in Thai society, women are the major agents of socialization in a child’s life. As such, the knowledge gained by studying how HIV-positive Thai mothers managed the dual demands of survival and the attainment of the maternal role will help health care providers as they work to care for and

provide support to women in similar circumstances (Jirapaet, 2001). Nontraditional Support Systems A cultural variation that has important implications is a woman’s perception of the need for formalized assistance from health care providers during the antepartum period. Western medicine is generally perceived as having a curative rather than a preventive focus. Indeed, many health care providers view pregnancy as a physiologic state that at any moment will become pathologic. Because many cultural groups perceive pregnancy as a normal physiologic process, not seeing pregnant women as ill or in need of the curative services of a doctor, women in these diverse groups often delay seeking, or even choose not to seek, prenatal care. Pregnant women and their partners have been placing increased emphasis on the quality of pregnancy and childbirth for some time, with many childbearing women relying on nontraditional support systems. For couples who are married, white, middle class, and infrequent users of their extended family for advice and support in childbirth-related matters, this kind of support might not be crucial. However, for other, more traditional cultural groups, including African Americans, Hispanics, Filipinos, Asians, and Native Americans, the family and social network (especially the grandmother or other maternal relatives) may be of primary importance in advising and supporting the pregnant woman. A number of factors influence childbearing practices for Filipino women including cultural beliefs, socioeconomic factors, and, in recent years, Western medicine. Approximately 41% of Filipino births are supported by indigenous attendants called hilots. The attendants act as a consultant throughout the pregnancy. During the postpartum period, the hilot performs a ritualistic sponge bath with oils and herbs, which is believed to have both physical and psychological benefits. The extended family is involved in the care of the baby, mother, and the household. Breast-feeding

Chapter 5 Transcultural Perspectives in Childbearing

is encouraged and hot soups are encouraged to increase milk production (Pacquiao, 2008). In Arab countries, labor and delivery is considered the business of women. Traditionally, dayahs and midwives presided over home deliveries. The dayahs provide support during the pregnancy and labor and are considered by traditional Arab women to be most knowledgeable due to their experience in caring for other pregnant women. Hospital births are on the rise in most Arab countries, with a decrease in the number of traditional home births (Purnell, 2012). A thorough cultural assessment to ascertain a pregnant woman’s use of nontraditional support systems and/or Western health care during her pregnancy is essential. Once this assessment is complete and a trusting relationship has been established, the woman’s pregnancy can be managed with consideration given to all the components that both she and the nurse believe are important for a successful outcome. Support during labor is known to have positive effects, such as reduced labor pain, reduced stress, shorter duration of labor, less medication need, increased maternal satisfaction, and a positive attitude going into motherhood (Chalmers & Wolman, 1993; Gordon et al., 1999). The decision for the type of support desired by a woman often has cultural underpinnings and must be explored in order to make appropriate cultural accommodations in care when possible. Cultural Beliefs Related to Activity During Pregnancy Cultural variations also involve beliefs about activities during pregnancy. A belief is something held to be actual or true on the basis of a specific rationale or explanatory model. Prescriptive beliefs, which are phrased positively, describe what should be done to have a healthy baby; the more common restrictive beliefs, which are phrased negatively, limit choices and behaviors and are practices/behaviors that the mother should not do in order to have a healthy baby. Taboos, or restrictions with serious supernatural

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consequences, are practices believed to harm the baby or the mother. Many people believe that the activities of the mother—and to a lesser extent of the father—influence newborn outcome. Box 5-2 describes some traditional prescriptive and restrictive beliefs and taboos that provide cultural boundaries for parental activity during pregnancy. These beliefs are attempts to increase a sense of control over the outcome of pregnancy. Negative or restrictive beliefs are widespread and numerous. They include activity, work, and sexual, emotional, and environmental prescriptions. Taboos include the Orthodox Jewish avoidance of baby showers, divulgence of the infant’s name before the infant’s official naming ceremony, and laws, customs, and practices during labor and delivery (Noble, Rom, NewsomeWicks, Engelhardt, & Woloski-Wruble, 2009). One Hispanic taboo involves the traditional belief that an early baby shower will invite bad luck, or mal ojo, the evil eye (Spector, 2008). Positive beliefs often involve wearing special articles of clothing, such as the muneco worn by some traditional Hispanic women to ensure a safe delivery and prevent morning sickness. Other beliefs and practices involve ceremonies and recommendations about physical and sexual activity. A cultural belief may cause harm if there is a poor neonatal outcome and the mother blames herself. For example, the mother whose fetus has died as a result of a cord accident, and who believes that hanging laundry caused the cord to encircle the baby’s neck or body, might experience severe guilt. The nurse who is sensitive to the mother’s anguish might say, “Many people say that if you reach over your head during pregnancy, it will cause the cord to wrap around the baby’s neck. Have you heard this belief?” Once the woman responds, the nurse can explore her feelings about the practice. Do others in her family or social support network share her belief? The nurse might share her own views by saying, “I have not read in any medical or nursing books that this practice is related to cord problems, although I know many people share your belief.” The discussion can then continue focusing on the

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Box 5-2 Cultural Beliefs Regarding Activity and Pregnancy Prescriptive Beliefs ●● ●●

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Remain active during pregnancy to aid the baby’s circulation (Crow Indian) Keep active during pregnancy to ensure a small baby and an easy delivery (Mexican and Cambodian) Remain happy to bring the baby joy and good fortune (Pueblo and Navajo Indian, Mexican, Japanese) Sleep flat on your back to protect the baby (Mexican) Continue sexual intercourse to lubricate the birth canal and prevent a dry labor (Haitian, Mexican) Continue daily baths and frequent shampoos during pregnancy to produce a clean baby (Filipino)

Restrictive Beliefs ●● ●●

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Avoid cold air during pregnancy to prevent physical harm to the fetus (Mexican, Haitian, Asian) Do not reach over your head or the cord will wrap around the baby’s neck (African American, Hispanic, White, Asian) Avoid weddings and funerals or you will bring bad fortune to the baby (Vietnamese) Do not continue sexual intercourse or harm will come to you and baby (Vietnamese, Filipino, Samoan)

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Do not tie knots or braid or allow the baby’s father to do so because it will cause difficult labor (Navajo Indian) Do not sew (Pueblo Indian, Asian)

Taboos ●●

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Avoid lunar eclipses and moonlight or the baby might be born with a deformity (Mexican) Do not walk on the streets at noon or 5 o’clock because this might make the spirits angry (Vietnamese) Do not join in traditional ceremonies like Yei or Squaw dances or spirits will harm the baby (Navajo Indian) Do not get involved with persons who cast spells or the baby will be eaten in the womb (Haitian) Do not say the baby’s name before the naming ceremony or harm might come to the baby (Orthodox Jewish) Do not have your picture taken because it might cause stillbirth (African American) During the postpartum period, avoid visits from widows, women who have lost children, and people in mourning because they will bring bad fortune to the baby (South Asian Canadian)

Information on Cambodian Canadian, Asian, Iranian Canadian, Japanese, South Asian Canadian, Vietnamese, and Haitian cultures from Waxler-Morrison, N., Andrews, J., & Richardson, E. (1990). Cross-cultural caring: A handbook for health professionals. Vancouver, BC: University of British Columbia Press.

feelings and perceptions of the event as experienced by the woman and her family. Food Taboos and Cravings Many cultures traditionally believed that the mother had little control over the outcome of pregnancy except through the avoidance of certain foods. Another traditional belief in many cultures is that a pregnant woman must be given the food that she smells to eat; otherwise, the fetus

will move inside of her and a miscarriage will result (Spector, 2008). Spicy, cold, and sour foods are often believed to be foods that a pregnant woman should avoid during pregnancy. Some pregnant women experience pica: the craving for and ingestion of nonfood substances, such as clay, laundry starch, or cornstarch. Some Hispanic women prefer the solid milk of magnesia that can be purchased in Mexico, whereas other women eat the ice or frost that forms inside refrigerator units. The causes of pica are poorly

Chapter 5 Transcultural Perspectives in Childbearing

understood, but there are some cultural implications because women from certain ethnic or cultural groups experience this disorder more frequently than others. In the United States, pica is common in African American women raised in the rural South and in women from lower socioeconomic levels. It is not uncommon to see small balls of clay in plastic bags sold in country stores in the rural South. The phenomenon of pica has also been described in other countries including Kenya, Uganda, and Saudi Arabia (Boyle & Mackey, 1999).

Cultural Issues Impacting PrenatalCare Mexican American childbearing women seem to represent a healthy model for preventing LBW infants. However, acculturation to US lifestyle may put them at an increased risk for poor birth outcomes, according to a study conducted by Martin et al. (2004). An ethnographic study in California examined the influence of acculturation on pregnancy beliefs and practices of Mexican American childbearing women. Lagana (2003) reported that “selective biculturalism” emerged as a protective approach to stress reduction and health promotion. The women interviewed indicated that regardless of the level of acculturation to US culture, during pregnancy, they returned to traditional Mexican practices. Such practices include a low-fat, high-protein, natural diet (eat right—come bien); exercise for well-being (walk—camina); and avoidance of worry or stress, which could have a negative effect on the pregnancy outcome (don’t worry— no se preocupe). The women described the family as a major support during pregnancy, but also valued the economic and personal freedom available to women in the United States. These conflicting values lead to the adoption of a “selective bicultural perspective.” This perspective allowed the women to maintain or reject cultural practices as needed. The fact that the women in this study lived in a largely Latino town might have limited their bicultural stress; pregnant Mexican

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women living in a more heterogeneous environment might experience higher levels of stress related to cultural conflicts. The author suggests, “It is likely that some cultural traits protective of pregnancy are lost through the process of acculturation” (Lagana, 2003, p. 123). This statement indicates that health care providers need to not only consider the support from family and social support networks but also explore the impact of stress from cultural conflicts on pregnancy outcomes. Some research has shown that preventive and health-promoting behaviors in pregnant minority women can be used to encourage healthy lifestyles and optimal utilization of health services and to obtain better outcomes of pregnancy (Feng, Zhang, & Owen, 2007). Cultural Interpretation of Obstetric Testing Many women do not understand the emphasis that Western prenatal care places on urinalysis, blood pressure readings, and abdominal measurements. For traditional Islamic women from the Middle East, the vaginal examination can be so intrusive and embarrassing that they avoid prenatal visits or request a female physician or midwife. For women of other cultural groups, common discomforts of pregnancy might be managed with folk, herbal, home, or over-the-counter remedies on the advice of a relative (generally the maternal grandmother) or friends (Spector, 2008). Health care providers can attempt to meet the needs of women from traditional cultures by explaining health regimens so that they have meaning within the cultural belief system. However, such explanations are only an initial step. Nursing visits can be made to the home, or group prenatal visits might be made based on self-care models instituted by nurses in local community centers. Additionally, nurses can incorporate significant others into the plan of care. During prenatal visits, nurses can provide information on normal fetal growth and development, and they can discuss how the health and behavior of the mother and those around her can influence fetal outcome.

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Cultural Preparation for Childbirth Women from diverse cultural backgrounds often use culturally appropriate ways of preparing for labor and delivery. These methods might include assisting with childbirth from the time of adolescence, listening to birth and baby stories told by respected elderly women, or following special dietary and activity prescriptions during the antepartal period. Most commonly in American culture, pregnant women and their significant others attend childbirth classes/or get pregnancy information from the Internet. Preparation for childbirth can be developed through programs that allow for cultural variations, including classes during and after the usual clinic hours in busy urban settings, teen-only classes, single-mother classes, group classes combined with prenatal checkups at home, classes on rural reservations, and presentations that incorporate the older “wise women” of the community. In addition, nurses can organize classes in languages other than English and conduct these classes in community settings that are culturally appropriate and welcoming to women.

Birth and Culture Beliefs and customs surrounding the experience of labor and delivery can vary, despite the fact that the physiologic processes are basically the same in all cultures. Factors such as cultural attitudes toward the achievement of birth, methods of dealing with the pain of labor, recommended positions during delivery, the preferred location for the birth, the role of the father and the family, and expectations of the health care practitioner might vary according to the degree of acculturation to Western childbirth customs, geographic location, religious beliefs, and individual preference. Traditionally, cultures have viewed the birth of a child in one of two very different ways. For example, the birth of the first son may be considered a great achievement worthy of celebration, or the birth may be viewed as a state of defilement or pollution requiring various purification

ceremonies. Western culture generally views birth as an achievement. This achievement is not always attributed solely to the mother, but extends to the medical staff as well. Gifts and celebrations are often centered on the newborn rather than the mother. Increasingly, pregnant women and their partners are assuming more active roles in the management of their own health and birth experiences. Playing an active role, however, does not always ensure the desired outcome. For example, some women who have prepared themselves for a “natural” childbirth might ultimately require analgesia or a cesarean section, potentially causing feelings of disappointment or a sense of failure.

Traditional Home Birth All cultures have an approach to birth rooted in a tradition of home birth, being within the province of women. For generations, traditions among the poor included the use of “granny” midwives by rural Appalachian Whites and southern African Americans and parteras by Mexican Americans. A dependence on self-management, a belief in the normality of labor and birth, and a tradition of delivery at home might influence some women to arrive at the hospital in advanced labor. The need to travel a long distance to the closest hospital might also be a factor contributing to arrival during late labor or to out-of-hospital delivery for many American Indian women living on rural, isolated reservations. Liberian women are reluctant to share information about pregnancy and childbirth as these subjects are taboo to talk about with others. Husbands or male elders are the ones who make decisions about allowing a woman to seek care at a clinic or hospital when she is experiencing a difficult and arduous labor. Further complicating this situation, women are reluctant to seek professional health care at clinics or hospitals because they are more comfortable in their own homes with traditional (but untrained) birth attendants (Lori & Boyle, 2011). These findings highlight that the influence of culture on childbirth extends beyond the birth experience itself, often affecting the outcome. The literature offers another recent example of the impact culture has on childbearing care

Evidence-Based Practice 5-5

Reproductive Health in Indigenous Chihuahua: Giving Birth “Alone Like the Goat” Chopel (2014) examined the beliefs and practices of an indigenous, reclusive group of women in Chihuahua, Mexico. The women are from four ethnic groups collectively called the Tarahumaras. Due to their remote location, there is limited information regarding their reproductive health outcomes, risks, protective factors, and beliefs and behaviors. They provide for themselves through farming and goat herding. Using a qualitative, mixed methods approach, the author describes health inequities, health care barriers, and contextual issues that must be considered when developing interventions for indigenous women like the Tarahumaras. In-depth interviews (n = 31) were conducted with local health agents, key state officials, indigenous community leaders, traditional doctors, and indigenous trained parteras empiricas. Focus groups (n= 16) were also conducted with female and male community members along with participant observation and field notes. Analysis was aided by using the open source coding software, TAMS. Major concepts included disparities in biomedical knowledge, trust between nonindigenous providers and the patient, and structural issues impacting medical access.

ractices of a remote population of women in p Mexico (see Evidence-Based Practice 5-5). These findings indicate that as health care groups working with indigenous populations strive to design programs to improve health outcomes, integrating cultural beliefs into Western health care education might ultimately improve client satisfaction and health outcomes.

Support During Childbirth Despite the traditional emphasis on female support and guidance during labor, women from diverse cultures report a desire to have husbands or partners present for the birth. Spouses or p artners are now

Clinical Implications: ●●

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Include key community leaders and indigenous healers when developing, implementing, and evaluating interventions. Assist in increasing safe births and decreasing unplanned pregnancies by making a broad choice of family planning options available at every health encounter. Increase “safe birth” practices; encourage women to deliver their babies in a hospital or local clinic while simultaneously preparing for an emergency home birth. Advocate for solar electricity for local clinics, health houses, or health centers to improve proper lighting for births and radio communications with the nearest hospital. Advocate for “holistic hospitals,” which can provide both indigenous and medical assistance. Promote Kangaroo care for mothers and babies to enhance exclusive breast-feeding and bonding.

Reference: Chopel, A. (2014). Reproductive health in indigenous Chihuahua: Giving birth ‘alone like the goat’. Ethnicity & Health, 19(3), 270–296.

encouraged and even expected to make important contributions in supporting pregnant women during labor. Unfortunately, some US hospitals still enforce rules that limit the support person from attending the birth unless he or she has attended a formal childbirth education program. A description of the effects of Turkish fathers’ attendance during labor and delivery on the experience of childbirth is presented in Evidence-Based Practice 5-6. Many women also wish to have their mother or some other female relative or friend present during labor and birth. Because many hospitals have rules limiting the number of persons present, the mother-to-be might be forced to make a difficult choice among the persons close to her. 137

Evidence-Based Practice 5-6

Effects of Fathers’ Attendance to Labor and Delivery ontheExperience of Childbirth in Turkey This study was planned to experimentally determine the effects of fathers’ attendance to labor and delivery on the experience of childbirth. The concept of allowing a partner’s attendance in labor and delivery has not been popular in Turkey because of cultural and religious reasons, hospital policies, and environmental conditions in delivery units. Partner attendance has increased in recent years, but the opportunity is still limited and only available in a few hospitals. The study recruited 50 primigravida low-risk women and their partners, assigning half of the women and their partners to an experimental group and half to a control group. The Perception of the Birth Scale was used to measure women’s attitudes about the labor and delivery experience; the Father Interview Form was used to describe fathers’ participation styles and experiences in labor and delivery. Women in the control group did not have their husbands in the labor and delivery rooms where they received routine care. The fathers attending the labor indicated they were there “to support their wives.” All the fathers adopted active roles in supporting their wives with breathing, relaxation techniques, and emotional support; however, at the time of delivery, 44% of the fathers-to-be chose to leave the delivery room, while the other 56% stayed and continued

supporting their wives. Wives whose husbands adopted an active support role through the labor and birth reported more positive perceptions about their delivery experience and were more aware of events during the birth. The researchers concluded that the fathers’ presence and support had positive effects on all aspects of childbirth. This study supports other research that provides powerful evidence of improved outcomes such as shorter labors, less analgesia use, less operative vaginal delivery, or cesarean section when mothers are supported in labor.

For reasons of modesty, an Orthodox Jewish woman in labor may choose a woman from the community as a labor support person (Noble et al., 2009). The spouse may elect to stay in the labor room, provided the mother’s private parts are covered. Similar findings are reported from women of Islamic, Chinese, and Asian Indian backgrounds. Practices followed by these groups might include strict religious and cultural prohibitions against viewing the woman’s body by either the husband or any other man. Labor practices are explicit for Orthodox Jewish women. Men are expected to not

touch their wife or view their wife’s genital area; they may offer verbal support. The culturally sensitive nurse will make every effort to cover or drape the woman appropriately and to provide the husband with the opportunity to excuse himself during the delivery without fear of being viewed as being insensitive (Purnell & Selekman, 2008). Other noteworthy considerations when caring for laboring Orthodox Jewish couples include keeping the laboring mother’s head covered at all times, perhaps by providing her with a surgical cap, and allowing an Orthodox man to pick up his newborn directly

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Clinical Implications: ●●

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Support childbirth education and preparation for both fathers and mothers when culturally acceptable and appropriate. Encourage and support fathers to adopt an active role in childbirth. Work to change hospital policies and cultural myths that exclude fathers’ involvement in pregnancy, birth, and the postpartum period.

Reference: Gunger, I., & Beji, N. K. (2007). Effects of fathers’ attendance to labor and delivery on the experience of childbirth in Turkey. Western Journal of Nursing Research, 29, 213–231.

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Box 5-3 Intrapartum Nursing Care for Culturally Diverse Women 1. If you are unable to speak the woman’s language, make every effort to arrange for an interpreter. 2. If your nursing agency commonly cares for culturally diverse clients, find out whether other nurses have had experiences with similar clients. Share resources and your expertise with staff members. 3. Attempt to gain as much information as possible by completing a cultural assessment. (See Appendix A for the Andrews/Boyle Transcultural Nursing Assessment Guide for Individuals and Families.)

from the crib versus having a female nurse or physician hand him the newborn; practicing Orthodox men are not allowed contact with adult women other than their spouses (Noble et al., 2009). Nurses must determine how much personal control and involvement are desired by a woman and her family during the birth experience. It is always best practice for the nurse to ask patients directly about their cultural beliefs and preferences so that hospital practices can be aligned with individual needs. Economically disadvantaged women from culturally diverse backgrounds have few birth options; most labor and give birth in large public hospitals. Routine patterns of care and decreased individualization are common in these institutions. These and other problems, such as language barriers, make the provision of culturally competent care during the birth process a challenge. However, any special provisions or attempts to understand the client from her perspective will be received with cooperation and gratitude. Recommendations for intrapartum nursing care of the culturally diverse pregnant woman are presented in Box 5-3.

Cultural Expression of Labor Pain Although the pain threshold is remarkably similar in all persons, regardless of gender or social, e thnic,

4. Elicit the mother’s expectations about her labor and delivery experience. 5. Ask if she wants a support person with her. If so, have her identify that person. 6. Explore with her any cultural rituals she wants incorporated into her plan of care. If requests are manageable, honor them. 7. Be patient, draw pictures, gesture. Identify key words from family or the interpreter that you will need to be able to express yourself to her, for example, push, blow, pant, and stop.

or cultural differences, these differences play a definite role in a person’s perception and expression of pain. Pain is a highly personal experience, dependent on cultural learning, the context of the situation, and other factors unique to the individual (Ludwig-Beymer, 2008). In the past, it was commonly believed that because women from Asian and Native American cultures were stoic, they did not feel pain in labor (Bachman, 2000). In addition to the physiologic processes involved, cultural attitudes toward the normalcy and conduct of birth, expectations of how a woman should act in labor, and the role of significant others influence how a woman expresses and experiences labor pain. Callister and Vega (1998) reported that Guatemalan women in labor tend to vocalize their pain. Coping strategies include moaning or breathing rhythmically and massaging the thighs and abdomen. Japanese, Chinese, Vietnamese, Laotian, and other women of Asian descent maintain that screaming or crying out during labor or birth is shameful; birth is believed to be painful but something to be endured (Bachman, 2000).

Birth Positions Numerous anecdotal reports in the literature describe “typical” birth positions for women of diverse cultures, from the seated position in a

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birth chair favored by Mexican American women to the squatting position chosen by Laotian Hmong women. The choice of positions is influenced by many factors other than culture, and the socialization that occurs when a woman arrives in a labor and delivery unit might prevent her from stating her preference.

Cultural Meaning Attached to Infant Gender The meaning that parents attach to having a son or daughter varies from culture to culture. Historically in the United States, families saw males as being the preferred gender of the firstborn child for reasons including male dominated inheritance patterns, carrying on the family name, and becoming the “man” of the family should the need arise. However, modern societies report a preference for a gender mix. Although the “structural” conditions in which son preference was originated have eroded, the related “cultural” idea of boys providing higher utility for the family, etc., may have survived. Arnold (1997) found a high persistence of son preference even in the face of rapid modernization in developing countries. In undeveloped countries, depending on the population and the cultural belief system in place, sons continue to be desired as the firstborn. As a long tradition in Asian culture, the preferred sex of the firstborn child is male. One question related to gender preference that has not been studied until recently is, if a mother does not have the preferred firstborn sex, does this increase the likelihood of postpartum depression (PPD) or negatively impact mother–infant bonding? Pham and Hardie (2013) completed a study whose aim was to evaluate the association of a commonly reported cultural belief that there is a relationship between a mother’s mood and the gender of an Asian woman’s firstborn child. The authors used secondary analysis to address the aim of the study. The sample was obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) of 40 states in the United States and included 1,310 women of Asian origin who

delivered their first children during the prior 2 to 4 month period. Based on data from the PRAMS survey mailed 2 to 4 months postpartum, participants were selected who had given birth to their first children and were of Chinese, Japanese, Filipino, or other Asian origin. Chi-squared analyses and an independent sample test were used to assess the relationship between the child’s sex and the mother’s response to three PRAM mood questions; a single score was generated by summing the responses to the three questions. The analysis of each of the three questions found there were no significant differences between Asian women whose firstborn children were female or male in their reports of feeling depressed or sad. The hypothesis that the birth of a firstborn female child would have a measurable effect on the Asian mother’s mood was not supported. The practical implications, to provide care to detect symptoms of PPD in all women, remain the “pillar of care” (Pham & Hardie, 2013). For culturally competent care of Asian childbearing women, signs of impending depression may be more subtle such as constant physical complaints. Also, many Asian women may not be comfortable expressing their feelings regarding mood, and, as their cultural beliefs dictate, they may remain in bed for up to 1 month, to assist in healing. These practices should not be taken as signs of depression but rather as a trigger for nurses to learn more about their childbearing cultural belief system.

Culture and the PostpartumPeriod Western medicine considers pregnancy and birth the most dangerous and vulnerable time for the childbearing woman. However, other cultures place much more emphasis on the postpartum period. Many cultures have developed special practices during this time of vulnerability for the mother and the infant in order to mobilize support and strengthen the new mother for her new role (Lee, Yang, & Yang, 2013).

Chapter 5 Transcultural Perspectives in Childbearing

In a study by Igarashi, Horiuchi, and Porter (2013), the researchers investigated what influenced Japanese women’s postpartum experience either positively or negatively. Interestingly, the research revealed that lack of Japanese health literacy was more likely to obstruct positive communication between the patient and health care providers while in the hospital setting, leading to loneliness. When women felt loneliness, they rated their care satisfaction low. These findings underscore the need for nurses to include the patient’s health literacy level as part of their regular assessment and make culturally appropriate adjustments to ensure proper patient education and participation in care.

Postpartum Depression Postpartum depression (PPD) is reported

worldwide. However, identifying and reporting of PPD in non-Western cultures may be delayed by culturally unacceptable labeling of the disorder, varying symptoms, or differences in treatments from culture to culture (American Psychiatric Association, 2013; Committee on Cultural Psychiatry, 2002; Yoshida, Yamashita, Ueda, & Tashiro, 2001). Insights provided by the literature suggest nurses should assess new mothers for culture-specific signs of PPD with the understanding that not all cultures recognize PPD as a medical disorder. Symptoms we associate with PPD are viewed differently in other cultures, for example, as a sign of “spirit possession,” as in some traditional Muslim cultures. “Jinn” possession, as reported in a study conducted in the United Kingdom by Hanely and Brown (2014), includes possession by an evil spirit that has a negative power over the mind and the body. Symptoms include anxiety, crying, mood swings, and emotional instability, all of which are symptoms of PPD. However in this particular culture, the symptoms are not associated with PPD but are believed to be caused by the Jinn’s influence. The purpose of the study was to explore the maternal experience of Jinn possession compared with Western interpretations

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of PPD. The study, which took place in an Arabian Gulf state in a Muslim community, included 10 women who had recently given birth and identified themselves as experiencing Jinn possession. Data were collected using open-ended interviews in the Arabic language. Data analysis consisted of recorded interviews being transcribed verbatim, with coding, category development, and finally the identification of themes. The four major themes included shared knowledge of Jinn possession, symptoms of possession, risk factors for possession, and preventing and treating Jinn possession. The results confirmed that the symptoms of Jinn possession align with PPD symptoms. In Western culture, treatment for PPD typically follows a pharmaceutical approach. However, drug treatment may be culturally inappropriate for Muslim women experiencing such symptoms. Culturally appropriate care may instead include support through family and community (Hanely & Brown, 2014). Clinical implications include the importance of nurses acknowledging the illness and the feelings the woman expresses and allowing her to choose the treatment that she feels is right for her.

Hot/Cold Theory Central to the belief of perceived imbalance in the mother’s physical state is adherence to the hot/ cold theories of disease causation. Pregnancy is considered a “hot” state. Because a great deal of the heat of pregnancy is thought to be lost during the birth process, postpartum practices focus on restoring the balance between the hot and cold, or yin and yang. Common components of this theory focus on the avoidance of cold, in the form of air, water, or food. This real fear of the detrimental effects of cold air and water in the postpartum period can cause cultural conflict when the woman and infant are hospitalized. In order to avoid conflict, some women may pretend to follow the activities suggested by nurses, for example, pretending to shower. Nurses must assess the woman’s beliefs regarding bathing and other selfcare practices in a nonjudgmental manner.

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The common use of perineal ice packs and sitz baths to promote healing can be replaced with the use of heat lamps, heat packs, and anesthetic or astringent topical agents for those who prefer to avoid cold influences. The routine distribution of ice water to all postpartum women is another aspect of care that can be modified to meet a woman’s cultural needs. Offering women a choice of water at room temperature, warm tea or coffee, broth, or another beverage should satisfy most women’s needs for warmth, along with the offering of additional bed blankets. It is always appropriate to discuss cultural practices with the new mother to elicit her concerns, needs, and preferences.

Postpartum Dietary Prescriptions andActivity Levels Dietary prescriptions are also common in this period. The nurse might note that a woman eats little “hospital” food and relies on family and friends to bring food to her while she is in the hospital. If there are no dietary restrictions for health reasons, this practice should be respected. Fruits and vegetables and certainly cold drinks might be avoided because they are considered “cold” foods. Indeed, the nurse should assess what types of food are being eaten by the woman and document them as appropriate to ensure the foods are nutritious and not harmful. Regulation of activity in relation to the concept of disharmony or imbalance includes the avoidance of air, cold, and evil spirits. Hispanic women are encouraged to stay indoors and avoid strenuous work. Since pregnancy and birth are believed to cause a “hot” state, the woman should avoid “hot” activities such as excessive exercise, including sex, strenuous household chores, quarrelling, or crying (Sein, 2013) in order to achieve the balance between hot and cold. Some women from traditional cultural groups view themselves as “sick” during the postpartal lochia flow. They might avoid heavy work, showering, bathing, or washing their hair during this time. Cultural prescriptions vary regarding when women can

return to full activity after childbirth: Many traditional cultures suggest that a woman can resume normal activities in as little as 2 weeks; others suggest waiting up to 4 months.

Postpartum Rituals Placental burial rituals are part of the traditional Hmong culture, and with the continued growth in the number of Hmong Americans emigrating from California to different areas of the United States, cultural conflicts are common, especially in the areas of reproductive health (Clemings, 2001). In an effort to assimilate, many Hmong have continued to use animistic ceremonies and herbal remedies in addition to using Western medicine. Helsel and Mochel’s (2002) study explored Hmong Americans’ attitudes regarding placental disposition, cultural values affecting those attitudes, and perceptions of the willingness of Western providers to accommodate Hmong patients’ wishes regarding placental disposal. The Hmong believe the placenta is the baby’s “first clothing” and must be buried at the family’s home, in a place where the soul can find the afterlife garment once the person is deceased. If the soul is unable to find the placental “jacket,” it will not be able to reunite with its ancestors and will spend eternity wandering. Helsel and Mochel’s study (2002) suggests that even though Hmong immigrants have embraced Western culture, traditional Hmong beliefs about placental burial remain an important cultural belief. These beliefs should be respected and the staff should make every effort to accommodate their request.

Cultural Influences on Breast-Feeding and Weaning Practices Culturally, breast-feeding and weaning can be affected by a variety of values and beliefs related to societal trends, religious beliefs, the mother’s work activities, ethnic cultural beliefs, social support, access to information on breast-feeding, and the health care provider’s personal beliefs and experiences regarding breast-feeding and/or

Chapter 5 Transcultural Perspectives in Childbearing

weaning practices, to name a few. The World Health Organization and UNICEF (2010) recommend children worldwide be breast-fed exclusively for the first 6 months of life followed by the addition of nutritional foods, as they continue to breast-feed for up to 2 years, with no defined upper limit on the duration. Physiologically, children can successfully breast-feed for the first several years of life. While this is common in other cultures, few women in the United States participate in extended breast-feeding (longer than 3 years) for fear of disapproval; if prolonged breast-feeding does occur, it is often concealed from family, friends, and health care providers. Dettwyler’s work (2004) in this area reports segments of the country where relatively large groups of women nurse longer than 3 years. These areas include Seattle, WA; Salt Lake City, UT; College Station, TX; and Wilmington, DE. Cartagena et al. (2014) support this view reporting that Hispanic mothers are more likely to practice nonexclusive breast-feeding, initiate early introduction of solid foods including ethnic foods, and perceive plumper infants as healthy infants. Cultural norms driving family influences and socioeconomic factors do play a role in the feeding practices of this population. For breast-feeding women from traditional backgrounds, it is important for nurses to be aware of factors that have been shown to affect the quality and duration of the breast-feeding experience, along with factors impacting weaning practices. Wambach and Cohen’s (2009) qualitative study examined breast-feeding experiences of urban adolescent mothers. Englishspeaking adolescent mothers, between the ages of 13 and 18, who were currently breast-feeding or had breast-fed their infants within the past 6 months, were invited from teen obstetric clinics at two urban university-affiliated medical centers. Twenty-three teens completed the study. The findings indicated that adolescent mothers chose breast-feeding mainly for infant health reasons, closeness, and bonding. Among those who weaned, problems, such as perceptions of insufficient milk supply, nipple/breast pain, time

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demands of school or work, problems with pumping, embarrassment, lack of support, and feeling overwhelmed and frustrated led to weaning. Many who weaned did not seek help and reported regret about weaning earlier than planned. Those who continued breast-feeding beyond 6 weeks reported significant emotional and informational support from family, friends, school, and their babies. The findings indicate a need for tailoring interventions based on the mother’s developmental stage in life and a need to educate and support teens to help prevent early weaning. McKee, Zayas, and Jankowski (2004) examined predictors of successful breast-feeding initiation and persistence in a sample of low-income African American and Hispanic women in the urban Northeast. The findings indicated that those women with a strong cultural identification and cultural social support tended to initiate breast-feeding and continue with breast-feeding longer than those in the groups who did not have strong cultural identification. Adolescent African American and Latina mothers in Chicago were interviewed to explore the teens’ perceptions of breast-feeding and what influenced their infantfeeding decisions and practices. Reported influences included perceptions of breast-feeding benefits (bonding, baby’s health), perceptions of the problems with breast-feeding (pain, embarrassment, no experience with the act of breastfeeding), and respected, influential people (Hannon, Willis, Bishop-Townsend, Martinez, & Scrimshaw, 2000). Researchers have studied ethnicity, cultural beliefs or practices, and social mores as a way to understand the influences on infant-feeding practices. However, one group, in particular—the Native American population—has been studied less closely. Breast-feeding among indigenous populations (e.g., Aboriginal/Alaska Native and American Indian women) declined with the advent of infant formula availability. However, there has been a push from within Native American communities to a return to infant feeding “the natural way.” There has also been research suggesting that breast-feeding may have

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a significant impact on the development of diabetes in later life. A program that targets promotion of breast-feeding among Native women as a type 2 diabetes prevention intervention promotes the use of elders and family for support (Murphy & Wilson, 2008). Banks (2003) describes how breast-feeding is being successfully promoted among the Kanesatake, a rural Mohawk community in Quebec, Canada, using culturally competent community-based interventions. The promotion strategies include educating extended family on breast-feeding benefits; teaching the nutritional merits of breast-feeding, particularly to the maternal grandmother; addressing the social, emotional, and spiritual aspects of breastfeeding; using the oral tradition as a way to share information; setting the stage for cooperative and interactive learning; and creating teaching methods that avoid conventional courses, lectures, or written materials on infant-feeding practices, as native women are not attracted to or affected by these methods. In the Kanesatake project, a respected elder volunteered to promote breast-feeding in her community. After completing a training session, she chose to use subtle teaching encounters at banks, grocery stores, and social gatherings as a way to promote breast-feeding. Support groups or “talking circles” were organized for extended family and grandmothers of pregnant women where breast-feeding issues were discussed openly and freely, led by the elder. This approach is a good example of how community strengths, incorporation of culturally specific learning styles, and cultural sensitivity can be used as the foundation for successful program development. Prior to the industrialized age, women always breast-fed or, if they were of “royal” blood or upper class, they used “wet nurses,” women who had recently had a baby themselves and breastfed other women’s babies. Midwives attended births. They had a variety of names: aunties, medicine women, midwives, doulas, or grandmothers (grannies), but whatever their names, they were women that have and still are providing the support necessary for successful birthing

and breast-feeding experiences. As immigrants continue to pour into the United States and American-born women adhering to their traditional cultural heritage attempt to make informed decisions regarding infant-feeding practices, it is imperative as nurses to examine specific cultural norms and practices that influence breast-feeding outcomes as we work to develop successful strategies.

Cultural Issues Related to Intimate Partner Violence During Pregnancy Domestic violence has emerged as one of the most significant health care threats for women and their unborn children. Numerous transcultural factors influence the prevalence of and response to domestic violence, including a history of family violence, sexual abuse experienced as a child, alcohol and drug abuse by the mother or significant other, shame associated with abuse, fear of retaliation by the abuser, or fear of financial implications if the mother leaves the abuser, to cite a few. Outcomes of abuse shared by abused women of all cultures include stress (physical and emotional), poor lifestyle health practices, delayed prenatal care, and lack of support. A study by Shadigian and Bauer (2005) identified homicide as a leading cause of pregnancyassociated death and suicide also as an important cause of death among pregnant and recently pregnant women. Health care providers must acknowledge and understand that homicide is a leading cause of pregnancy-associated death and commonly is a result of intimate partner violence (IPV). Screening for both partner violence and suicidal ideation is an essential component of comprehensive health and nursing care for women during and after pregnancy. It has been well documented (Bewley & Gibbs, 1994) that physical abuse during pregnancy is often focused on the abdomen, breasts, and/or genitals, which puts both the mother and her unborn child at risk. Physical abuse often has psychological consequences for the victim, including possible addiction to drugs and alcohol, stress,

Evidence-Based Practice 5-7

Prenatal Care Delays Related to Battering This study evaluated patterns of abuse during the pregnancies of 132 African American, 208 Hispanic, and 162 White American women from low-income clinics in large metropolitan cities in the West. The researchers found that the incidence of abuse did not vary significantly among ethnic groups and that the abused women from these groups sought prenatal care 6.5 weeks later than did the nonabused group. In this study, one in four women reported that they had been physically abused since their current pregnancy began, with African American women experiencing the most severe and most frequent abuse.

Clinical Implications: ●●

Include questions about abuse in every routine history taken during pregnancy in order to identify abused women.

and depression. These factors can also affect both the mother’s health and potentially affect the future health of the newborn and later as the child develops. Information regarding women in abusive situations is scarce, partly because of underreporting. We do know, however, that abused women are less likely to seek health care because their abuser limits access to resources and that battering occurs more frequently during pregnancy. It is estimated by the CDC (2009) that 324,000 pregnant women are victims of IPV each year. An abused pregnant woman has a greater risk of delivering an LBW infant. One of the associations between abuse and LBW is delay in obtaining prenatal care. Indeed, findings from studies conducted during the past two decades have clearly shown that physical and sexual abuse predicts poor health during pregnancy and the postpartum period (Leserman, Stewart, & Dell, 1999). Taggart’s and Mattson’s (1996) study of the relationship between battering and prenatal

●●

Offer information about abuse and available community resources. Women reporting abuse will need further screening with specific tools. Nurses should be aware of subtle signs of abuse. For example, psychosomatic complaints, injuries inconsistent with the explanation, failure to keep clinic appointments, and overprotective partners might be indications of abuse. Become familiar with community resources for referrals.

Reference: Taggart, L., & Mattson, S. (1996). Delay in prenatal care as a result of battering in pregnancy: Crosscultural implications. Health Care for Women International, 17, 25–34.

care is still pertinent for nurses who care for pregnant women. Evidence-Based Practice 5-7 discusses this study and its importance in identifying delays in obtaining prenatal care as a result of IPV. The legacy of patriarchy, which is still deeply embedded in our culture, undoubtedly contributes to violence against women as do other factors, especially alcohol and drug abuse. Kita, Yaeko, and Porter’s (2014) study of intimate partner violence (IPV) in Japan reported risk factors associated with IPV during pregnancy, which included pregnant women over 30 years old, multiparous, previous abortion experience, and having a male partner under 30 years old. This discussion focuses on three culturally different groups of women who may experience IPV during pregnancy: Hispanic, African American, and American Indian pregnant women. What links these groups of pregnant women are shared ideologies or characteristics that influence their behavior and have profound effects on their pregnancy outcomes. Ideologies 145

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of each group are examined and recommendations are identified for nurses working with pregnant women in these unique circumstances. Recommendations for health care providers will follow each discussion and will emphasize the importance of culturally competent care to these at-risk clients. Hispanic Pregnant Women Although there are many different Hispanic groups, most share some important commonalities, for example, religion, customs, and language. As with any cultural group, differences do exist among the members. The incidence of spouse abuse among pregnant Hispanic women is not clear in the literature. Access to health care for pregnant Hispanic women is problematic. Barriers to prenatal health care include lack of health care insurance, language barriers, and low levels of education, all of which may encourage the use of traditional healers and remedies and might foster mistrust of health care professionals, leading to noncompliance. Many Hispanic women tend to be in low-paying jobs whose annual earnings are considerably less than those of non-Hispanic women. They may also have less education than White women and live in large, extended households, often made up of several children and extended family members. The literature concurs, reporting the health status of Hispanic pregnant women may be affected by their economic level as economic status has been shown to limit access to care (Center for American Progress Action Fund, 2010; Suarez & Ramirez, 1999). These factors place Hispanic women at a distinct disadvantage for accessing prenatal care. Furthermore, these same factors tend to discourage the pregnant Hispanic woman from disclosing a situation of abuse and violence. Her choices are the same as other women in abusive situations: She can try to make the relationship work, or she can leave her abuser. Charles and Perreira (2007) investigated IPV during pregnancy and 1 year postpartum. Findings indicated

that Hispanic women who are no longer romantically involved with their children's fathers were likely to experience IPV during pregnancy. Less educated women, women who reported that they or their spouses used substances (i.e., alcohol or illicit drugs), and women who reported that their pregnancy was unplanned were also at high risk of IPV both during and after their pregnancy. Pregnancy outcomes included preterm birth and LBW infants. The authors of this study noted that violence during pregnancy strongly predicted violence after pregnancy. Shneyderman and Kiely (2013) added to these findings, reporting women at highest risk in their study for pregnancy risk factors, were those participating in reciprocal violence or fighting back. Providers should consider both perpetration and victimization whenever women arrive for care, noting interventions that need to be developed according to the form of IPV presenting. The Hispanic pregnant woman who chooses to leave her abuser must often face language barriers, a poor economic situation, no insurance, and perhaps leaving her traditional family support network. These same factors inhibit the seeking of information regarding resources available to abused women. Even when faced with death, some abused women find it very difficult to expose their private situation to someone outside their cultural circle. Furthermore, certain groups of Hispanic women, such as migrants, are at higher risk because they are separated from family support systems in addition to confronting barriers related to poverty and language. Nurses and other health practitioners in prenatal clinics are in an ideal position to facilitate a trusting relationship with an abused woman. Good assessment skills are crucial, because the first sign of abuse might not be an admission of abuse but physical findings of trauma. It is also helpful that the nurses have strong interpersonal skills and a genuine interest in Hispanic culture. In this situation, a Spanish-speaking health care provider might be able to form a trusting relationship more quickly, enabling the woman to share information about domestic violence.

Chapter 5 Transcultural Perspectives in Childbearing

Recommendations for providing assistance to abused pregnant Hispanic women include working with and mobilizing support, using the family and kinship structure, educating the abused woman regarding available resources for abused women, encouraging the woman’s inner strength, and assisting in the development of skills necessary to mobilize resources. African American Pregnant Women Many cultural values of African Americans emphasize the larger Black society rather than focusing on individuals, making “all” collectively responsible for one another (Hine & Thompson, 1998). Therefore, many African American women exist in a social context supported by social connectedness versus that of autonomy (see Figure 5-7).

Figure 5-7. Pregnant family (Jaimie Duplass/ Shutterstock.com).

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It is difficult to understand the specific factors related to IPV among African American women because of the lack of information. However, poor economic conditions might be a primary reason why violence occurs in African American families; domestic violence is often related to social and economic resources. The risk of wife abuse appears to increase when the woman has a higher educational status than her partner or when the man is unemployed or has trouble keeping a job—situations that are common in African American male–female relationships (Barnes, 1999). One of the most difficult barriers confronting African American abused women who attempt to get help from police or from the legal system is the stereotypical view that violence among African Americans is normal. This view could cause African American victims’ claims of abuse to be dismissed or ignored. Again, the nurse in the prenatal setting is in an ideal position to gather information and initiate a trusting relationship. The abused pregnant African American woman might not be willing to incriminate her spouse or significant other because she already sees him as a “victim of society.” The nurse might need to rely heavily on her assessment and history-taking skills, being particularly alert to instances of trauma and problems with past pregnancies. Patient education must stress that although a woman may see her man as a “victim,” that does not mean she must tolerate abuse. The nurse can identify shelter facilities in the woman’s neighborhood and other areas. If the woman feels uncomfortable going outside her neighborhood (and many do for fear they will not be understood outside their culture), the nurse can encourage her to go to members of her extended family, a situation that might be more acceptable within African American culture. What is most important is that she has a plan of what to do, where to go, and whom to call for help the next time she is afraid for her own safety. Last, the nurse must realize that in most instances, African American women believe that it is the responsibility of the woman to maintain

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the family, regardless of other factors. Therefore, African American women may be more likely to stay in an abusive relationship. American Indian Pregnant Women Violence within families has not always been part of American Indian society. Traditionally, American Indian cultures were based on harmony and respect. Many activities Western culture has ascribed to one sex were shared in American Indian society, including the roles of warrior and hunter. As Indian communities strive to maintain their cultural heritage, the concepts of spirituality (balance, harmony, oneness), passive forbearance (humility, respect, circularity, connection, honor), and behaviors that promote harmonious living are reinforced in daily living (Nichols, 2004). Historically, cruelty to women and children resulted in public humiliation and loss of honor. Cultural disintegration, poverty, isolation, racism, and alcoholism are just a few of the problems that have fostered violence in American Indian cultures. Nevertheless, cruelty to women and children continues to be viewed by American Indians as a social disgrace (Green, 1996). In a study by Bohn (2002), the complicating factor of lifetime abuse events was shown to be a significant contributor to preterm birth and LBW infants. This means that the nurse should not only assess for current abuse by the spouse or significant other but also evaluate the other types of abuse inflicted over the mother’s lifetime, such as alcohol or drug abuse. Since the 1970s, American Indian tribes have made an effort to develop programs to meet the many needs of their communities. However, violence against women has not been addressed adequately because of the male-dominated leadership, other needs of the tribes, and the shame associated with abuse (Bohn, 1993). This trend is changing gradually as Indian communities have recognized that domestic abuse is a significant social problem and are taking measures to address it (see Figure 5-8).

Figure 5-8. Native American couple (Mona Makela/ Shutterstock.com).

In interviews with American Indian women, a sense of humor is most helpful. Culturally, it is common for American Indians to use humor when they are dealing with stress, especially health-related stress, and they view someone with whom they can laugh as easy to talk to. The nurse should also learn to become comfortable with periods of silence after questions. This does not mean that clients are not listening but rather just the opposite. Culturally, American Indians think all questions are worthy of thoughtful consideration before answering. Once abuse has been identified, the extent of abuse must then be evaluated. The nurse must then intervene by providing information, discussing alternatives, and supporting the woman in her decision. Options should focus on Native American resources because such resources have

Chapter 5 Transcultural Perspectives in Childbearing

usually been designed to be culturally sensitive. If only non-Indian resources are available, the nurse should follow through within these agencies. Abuse within American Indian culture is traditionally handled within the family first. The abused woman might be reluctant to go outside of the family for help because this might cause both families (hers and her spouse’s or significant other’s) to ostracize her. It is important to know that American Indian women generally consider it a virtue to stay with your mate no matter what the circumstance, especially if the marriage was performed or “blessed” by a traditional medicine man or woman. A woman who chooses to stay with her abuser might do so out of loyalty to her culture. As with all women attempting to leave an abusive relationship, she must know that her health care provider cares about and views her safety and that of her unborn baby as the priority (Hellmuth, Gordon, Stuart, & Moore, 2013).

Summary Culture, as it relates to pregnancy and childbirth, was discussed from many vantage points. As the United States becomes home to immigrants and refugees from around the world, and as once considered traditional societal norms are changing, so too must nurses adapt their care in ways that consider and are respectful of beliefs different from their own. These cultural and biologic variations have created opportunities for health care providers to learn about and incorporate evidence and traditional beliefs into current health care practices, improving pregnancy and birth experiences for all women of differing backgrounds. Cultural beliefs and practices are continuously evolving, making it necessary for the nurse to acknowledge and explore the meaning of childbearing with each family with whom he/she has contact. It is also important to remember that behavior must be evaluated from within each person’s cultural context and based on evidence, when

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available, so that the care provided is not only evidence based but also meaningful. It is always important for the culturally competent nurse to demonstrate genuine concern, interest, and respect for the patient’s differing backgrounds. Only when these aspects are fully realized can we develop and provide culturally congruent care for childbearing women and their families.

Review Questions 1. How will the biologic variations discussed

impact the nursing care of the childbearing woman and her family? 2. Describe the special needs of lesbian couples during the childbearing process. What are common prejudgments about lesbian mothers and how can they affect care? 3. Compare traditional Western medical support for pregnant women with nontraditional support, and describe why both might be critical for successful pregnancy outcomes in women from diverse backgrounds. 4. Why is it important to understand the differences between prescriptive and restrictive beliefs of a mother’s behavior during pregnancy? 5. How can nursing interventions for the pregnant American Indian woman presenting for IPV care be made more culturally congruent?

Critical Thinking Activities 1. Critically analyze and describe the cultur-

ally competent nursing interventions for a Hispanic woman after fetal demise from a cord accident.

2. Discuss the responses the culturally compe-

tent postpartum nurse should initiate when an Asian woman refuses to get out from under her bedding.

3. Discuss and compare the cultural differences

in the expression of labor pain. Critically

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analyze how you would respond to your Hispanic labor patient’s expression of pain versus your Native American labor patient’s manifestation of pain. Why the different approaches?

4. Describe and analyze how the nurse might

alter her care approach to an Orthodox Jewish husband who has followed his cultural traditions and refuses to accept his newborn from a female nurse.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text revision). Washington, DC: Author. Amnesty International, USA. (2010). Deadly delivery: The maternal health care crises in the USA. AMR 51/007/2010. Andrews, J.M., & Hanson, P.A. (2008). Religion, culture and nursing. In M.M. Andrews, & J.S. Boyle (Eds.) Andrews, M. M., & Hanson, P. A. (2012). Religion, culture and nursing. In M. M. Andrews & J. S. Boyle (Eds.), Transcultural concepts in nursing (5th ed., pp. 351–402). Philadelphia, PA: Lippincott Williams & Wilkins. Arnold, F. 1997. Gender preferences for children. Demographic and Health Surveys Comparative Studies No. 23. Calverton, MD: Macro International Inc. Bachman, J. A. (2000). Management of discomfort. In D. L. Lowdermilk, S. E. Perry, & I. M. Bobak (Eds.), Maternity and women’s health care (7th ed., pp. 463–487). St. Louis, MO: Mosby. Banks, J. W. (2003). Ka’nistenhsera Teiakotihsnie’s: A native community rekindles the tradition of breastfeeding. AWHONN Lifelines, 7(4), 340–347. Barnes, S. Y. (1999). Theories of spouse abuse: Relevance to African Americans. Issues in Mental Health Nursing, 20, 357–371. Benza, S., & Liamputtong, P. (2014). Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery, 30(2014), 575–584. Bewley, C., & Gibbs, A. (1994). Coping with domestic violence in pregnancy. Nursing Standard, 8(50), 25–28. Bohn, D. K. (1993). Nursing care of Native American battered women. AWHONN's Clinical Issues in Perinatal and Women's Health Nursing, 4(3), 424–436. Bohn, D. K. (2002). Lifetime and current abuse, pregnancy risks, and outcomes among Native American women. Journal of Health Care for the Poor and Underserved, 13(2), 184–198. Boyle, J. S., & Mackey, M. (1999). Pica: Sorting it out. Journal of Transcultural Nursing, 10(1), 65–68. Bromwich, P., & Parsons, T. (1990). Contraception: The facts (2nd ed.). Oxford, UK: Oxford University Press. Buchholz, S. (2000). Experiences of lesbian couples during childbirth. Nursing Outlook, 48(6), 307–311. Callister, L. C., & Vega, R. (1998). Giving birth: Guatemalan women’s voices. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 289–295.

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Diabetes Monitor. (2011). Health problems in American India/Alaska native women: Diabetes. Retrieved July 6, 2014 from http://www.diabetesmonitor.com/b350.htm Eckhardt, S., & Lauderdale, J. (2013). The impact of culture on knowledge, attitude, and practice of family planning methods in rural North Kamagambo, Kenya. Unpublished study. Feng, D., Zhang, Y., & Owen, D. (2007). Health behaviors of low-income pregnant minority women. Western Journal of Nursing Research, 29, 284–300. Finer, L. B., & Zolna, M. R.(2011). Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception, 84(5), 478–485. Gordon, N. P., Walton, D., McAdam, E., Derman, J., Gallitero, G., & Garrett, L. (1999). Effects of providing hospital based doulas in health maintenance organization hospitals. Obstetrics & Gynecology, 98, 756–764. Green, K. (1996). Family violence in aboriginal communities: An aboriginal perspective. Ottawa, ON: National Clearing House on Family Violence. Gurnah, K., Khoshnood, K., Bradley, E., & Yuan, C. (2011). Lost in translation: Reproductive health care experiences of Somali Bantu women in Hartford, Connecticut. Journal of Midwifery & Women's Health, 56(4), 340–346. Hanely, J., & Brown, A. (2014). Cultural variations in interpretation of postnatal Illness: Jinn possession amongst Muslim communities. Community Mental Health Journal, 50, 348–353. Hannon, P. R., Willis, S. K., Bishop-Townsend, V., Martinez, I. M., & Scrimshaw, S. C. (2000). African-American and Latina adolescent mothers’ infant feeding decisions and breastfeeding practices: A qualitative study. Journal of Adolescent Health, 26(6), 399–407. Hellmuth, J., Gordon, K., Stuart, G., & Moore, T. (2013). Women’s intimate partner violence perpetration during pregnancy and postpartum. Maternal and Child Health Journal, 17, 1405–1413. Helsel, D., & Mochel, M. (2002). Afterbirths in the afterlife: Cultural meaning of placental disposal in a Hmong American community. Journal of Transcultural Nursing, 13(4), 282–286. Hine, D. C., & Thompson, K. (1998). A shining thread of hope. New York, NY: Broadway Books. Igarashi, Y., Horiuchi, S., & Porter, S. (2013). Immigrants' experiences of maternity care in Japan. Journal of Community Health, 38(4), 781–790. Jirapaet, V. (2001). Factors affecting maternal role attainment among low-income, Thai, HIV-positive mothers. Journal of Transcultural Nursing, 12(1), 25–33. Kita, S., Yaeko, K., & Porter, S. E. (2014). Prevalence and risk factors of intimate partner violence among pregnant women in Japan. Health Care for Women International, 35, 442–457. Kolatch, A. (2000). The second Jewish book of why. Middle Village, NY: Jonathan David. Lagana, K. (2003). Come bien, camina y no se preocupe— Eat right, walk and do not worry: Selective biculturalism

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during pregnancy in a Mexican American Community. Journal of Transcultural Nursing, 14(2), 117–124. Lee, S., Yang, S., & Yang, Y. (2013). Doing-In-Month ritual among Chinese and Chinese-American. Journal of Cultural Diversity, 20(2), 94–99. Leserman, J., Stewart, J., & Dell, D. (1999). Sexual and physical abuse predicts poor health in pregnancy and postpartum. Psychosomatic Medicine, 61, 92. Lori, J. R., & Boyle, J. S. (2011). Cultural childbirth practices, beliefs, and traditions in post-conflict Liberia. Health Care for Women International, 32(6), 1–20. Ludwig-Beymer, P. (2008). Transcultural aspects of pain. In M. M. Andrews & J. S. Boyle (Eds.), Cultural aspects of nursing care (pp. 329–354). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Martin, J.A., Hamiliton, B.E.,Suton, P.D., Ventura, S.J., Menacker, F., & Munson, M.L. (2004). Births: Final date for 2002 [Data file]. National Vital Statistics Reports, 52(10). Available from CDC website, http://www.cdc.gov. McKee, M. D., Zayas, L. H., & Jankowski, K. R. B. (2004). Breastfeeding intention and practice in an urban minority population: Relationship to maternal depressive symptoms and mother–infant closeness. Journal of Reproductive and Infant Psychology, 22(3), 167–181. McManus, A. J., Hunter, L. P., & Renn, H. (2006). Lesbian experiences and needs during childbirth: Guidance for health care providers. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(1), 13–23. Miller, M. A. (1992). Contraception outside North America: Options and popular choices. NAACOG's Clinical Issues in Perinatal and Women's Health Nursing, 3(2), 253–265. Mosher, W. D., Jones, J., & Abma, J. C.. (2012). Intended and unintended births in the United States: 1982–2010. National Health Statistics Reports: U.S. Department of Health and Human Services, 55. Murphy, S., & Wilson, C. (2008). Breastfeeding promotion: A rational and achievable target for a type 2 diabetes prevention intervention in Native American communities. Journal of Human Lactation, 24(2), 193–198. Nichols, L. A. (2004). The infant caring process among Cherokee mothers. Journal of Holistic Nursing, 22(3), 1–28. Noble, A., Rom, M., Newsome-Wicks, M., Engelhardt, K., & Woloski-Wruble, A. (2009). Jewish laws, customs, and practice in labor, delivery and postpartum care. Journal of Transcultural Nursing, 20, 323–333. Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography: Synthesizing qualitative studies. Newbury Park, CA: Sage. Overfield, T. (1985). Biologic variation in health and illness. Menlo Park, CA: Addison-Wesley. Pacquiao, D. F. (2008). People of Filipino heritage. In L. Purnell & B. Paulanka (Eds.), Transcultural health care: A culturally competent approach (3rd ed., pp. 175–195). Philadelphia, PA: F.A. Davis Co. Perry, S. E. (2000). Medical-surgical problems in pregnancy. In D. L. Lowdermilk, S. E. Perry, & I. M. Bobak (Eds.),

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Maternity and women’s health care (7th ed., pp. 887–911). St. Louis, MO: Mosby. Pettitt, D. J., Baird, H. R., Aleck, K. A., Bennett, P. H., & Knowler, W. C. (1983). New England Journal of Medicine, 308, 242–245. Pham, A., & Hardie, T. (2013). Does a first-born female child bring mood risks to new Asian American mothers? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 42, 471–476. Pritchard, C., Roberts, S., & Pritchard, C. (2013). Giving a voice to the unheard’? Is female youth (15–24 years) suicide linked to restricted access to family planning? Comparing two Catholic continents. International Social Work, 56, 798–815. Purnell, L.,& Selekman, J. (2008). People of Jewish heritage, In: L. Purnell, & B. Paulanka (Eds.) Transcultural health care: A culturally competent approach (3rd ed., pp. 278–292). Philadelphia: F.A. DavisCo. Purnell, L. (2012). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis Co. Randi, B. S. (2012). Improving prenatal care for pregnant lesbians. International Journal of Childbirth Education, 27(4), 37–40. Rocca, C., & Harper, C. (2012). Do racial and ethnic differences in contraceptive attitudes and knowledge explain disparities in method use? Perspectives on Sexual and Reproductive Health, 44(3), 150–158. Rubin, R. (1984). Maternal identity and the maternal experience. New York, NY: Springer. Sein, K. (2013). Beliefs and practices surrounding postpartum period among Myanmar women. Midwifery, 29, 1257–1263. Shadigian, E. M., & Bauer, S. T. (2005). Pregnancy-associated death: A qualitative systematic review of homicide and suicide. Obstetrical and Gynecological Survey, 60(3), 183–190. Shneyderman, Y., & Kiely, M. (2013). Intimate partner violence during pregnancy: Victim or perpetrator? Does it make a difference? BJOG, 120, 1375–1385. Sonfield, A., Kost, K., & Gold, R. B (2011). The public costs of births resulting from unintended pregnancies: National and state-level estimates. Perspectives on Sexual and Reproductive Health, 43(2), 94–102. Spector, R. (2008). Cultural diversity in health and illness (7th ed.) Upper Saddle River. NJ: Prentice Hall Health.

Spidsberg, B. D. (2007). Vulnerable and strong-lesbian women encountering maternity care. Journal of Advanced Nursing, 60(5), 478–486. Suarez, L., & Ramirez, A. G. (1999). Hispanic/Latino health and disease. In R. M. Huff & M. V. Kline (Eds.), Promoting health in multicultural populations (pp. 115–136). Thousand Oaks, CA: Sage. Taggart, L., & Mattson, S. (1996). Delay in prenatal care as a result of battering in pregnancy: Crosscultural implications. Health Care for Women International, 17, 25–34. The Pima Indians: Obesity and Diabetes. 2010. Retrieved April 25, 2010, from http://diabetes.niddk.nih.gov/dm/ pubs/pima/obesity.htm U.S. Department of Health and Human Services. 2014. Healthy People 2020 topics & objectives. HealthyPeople. gov. [Accessed June, 2014] http://www.healthypeople. gov/2020/topicsobjectives2020/objectiveslist.aspx? UNHCR Mid-Year Refugee Trends. (2013). Retrieved July 2, 2014 from http://www.unhcr.org/52af08d26.html United Nations Children’s Fund (UNICEF). (2005). Changing a harmful social convention: Female genital mutilation/ cutting. Innocenti Digest. Florence, Italy: Author. Wambach, K. A., & Cohen, S. M. (2009). Breastfeeding experiences of urban adolescent mothers. Journal of Pediatric Nursing, 24(4), 244–254. Washofsky, M. (2000). Jewish living: A guide to contemporary reform practice. New York, NY: UAHC (Union of American Hebrew Congregations) Press. World Health Organization (WHO). (2008). Eliminating female genital mutilation: An interagency statement: OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO. Geneva, Switzerland: Author. World Health Organization (WHO). (2010). Global strategy to stop health-care providers from performing female genital mutilation: UNAIDS, UNDP, UNFPA, UNICEF, UNIFEM, WHO, FIGO, ICN, IOM, WCPT, WMA, MWIA. Geneva, Switzerland: Author. World Health Organization and UNICEF. (2010). Global strategy for infant and young child feeding. Geneva, Switzerland: Switzerland World Health Organization.

Transcultural Perspectives in the Nursing Care of Children ●●Margaret M. Andrews and Barbara C. Woodring

Key Terms Bed sharing Blended family

Conjugal family Cosleeping Curandero Extended family

Infant attachment Nuclear family Parent-child relationship Premasticate

Learning Objectives 1. Understand the composition of children as a population across cultures in the United States and Canada. 2. Explore childrearing practices, both specific and universal across cultures, and their impact on the development of children. 3. Analyze the impact of selected cultural beliefs and practices on the development of children. 4. Examine the biocultural aspects of selected acute and chronic conditions affecting children. 5. Synthesize the transcultural concepts and evidence-based practices that support the delivery of culturally competent care for children and adolescents.

Children in a Culturally Diverse Society Cultural survival depends on the transmission of values and customs from one generation to the next; this process relies on the presence of children for success. This interdependent nature of

children and society reinforces the need for the greater society to nurture, care for, and socialize members of the next generation. In this chapter, the composition of children as a population, the effect of childrearing practices both specific and universal across cultures, and the cultural influences on child growth, development, health, and illness are be examined as well as an understanding 153

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Global, National, Regional, and Local Influences

Parents and Extended Family

Community and Neighborhood

Parents and Extended Family

Communication Negotiation MOTHER

FATHER JOINT

CHILDREARING DECISIONS

Figure 6-1. Model depicting the interrelation of culture, communication, and parental decisions about childrearing practices.

of how transcultural concepts and evidence-based practices support the delivery of culturally competent care for children and adolescents. Figure 6-1 provides a visual representation of the interrelationship among culture, communication, and parental decisions/actions during child rearing. This schematic representation also serves as a model for understanding culturally significant decisions that affect the care of children and, therefore, will be evident throughout this chapter. Most children are cared for by their natural or adoptive parents. In this chapter, the term parent refers to the primary care provider whether natural, adoptive, relational (grandparents, aunts, uncles, cousins), or those who are unrelated but who function as primary providers of care and/or parent surrogates for varying periods of time. In some cases, the primary provider of care looks after the infant, child, or adolescent for a brief time, perhaps for an hour or two, while the parents are unable to do so. In other cases, this person might function as a long-term or permanent parent substitute even though legal adoption has not occurred. For example, a grandparent might assume responsibility for a child in the event of parental death, illness, disability, or imprisonment. The same factors influencing the

parents’ cultural perspectives on childrearing also influence others who might assume the care of the child (Chen & Eisenberg, 2012).

Children as a Population When defining children as a population, it is important to consider various elements that shape this population as a whole, such as its racial and ethnic makeup, the impact of poverty on this population, and the health status of children and adolescents in the United States and Canada. Other important considerations when examining this population are cross-cultural differences in growth and development, infant attachment, and crying.

Racial and Ethnic Composition According to the U.S. Census Bureau (2013), there are 74.2 million people under the age of 18 who live in the United States; of these, 67.9% are White, 24.1% Hispanic (of any race), 14.2% Black, and 5.7% Asian/Pacific Islander/Native American/ Alaska Native. The number of Hispanic children has increased faster than that of any other group (U.S. Census Bureau, 2013). It is estimated that

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

by 2020, 40% of school-aged children in the United States will represent federal minority groups. More than 3.5 million children in the United States are foreign-born, and millions more are the children of recent immigrants. Many of these children constitute the more than 10.9 million school-age children who speak a language other than English at home (Ryan, 2013). Approximately two-thirds of these children come from Spanish-speaking homes, and a large percentage of the remainder speaks a variety of Asian languages. Many children of immigrants live in linguistic isolation in the 5.9% of households where no member age 14 or older speaks English “very well” (U.S. Census Bureau, 2013). Although immigrants and their children are found throughout the United States and Canada, they tend to cluster in certain geographic areas. California, New York, Texas, Florida, New Jersey, Illinois, and Massachusetts are homes for almost two-thirds of all foreign-born children. Georgia, Virginia, Washington, Arizona, and Maryland also have relatively high numbers of children whose parents recently immigrated to the United States (U.S. Census Bureau, 2013). In Canada, most immigrants reside in one of the major metropolitan areas: Toronto, Vancouver, and Montreal are home for the majority of children of recent immigrants (Statistics Canada, 2015).

Poverty The impact of poverty on children’s health is cumulative throughout the life cycle, and disease in adulthood frequently is the result of early health-related episodes that become compounded over time. For example, when poverty leads to malnutrition during critical growth periods, either prenatally or during the first 2 years of life, the consequences can be catastrophic and irreversible, resulting in damage to the neurologic and musculoskeletal systems. If the brain fails to receive sufficient nutrients during critical growth periods, the child is likely to experience diminished cognitive development, leading to poor academic performance and later poorer job

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performance, lower pay, and thus perpetuation of the cycle of poverty and poor health. Child poverty in the United States continues to grow; one in five children (16.1 million) was poor in 2012, 40% of whom lived in extreme poverty at less than half of the federal poverty level. More than two-thirds of poor children live in families with a working adult (Centers for Disease Control and Prevention, 2014a). In 2014, the Children’s Defense Fund reported that two-thirds of children in poverty lived in working family households of US citizens, and more than 7.2 million children under 19 were uninsured in 2012. A disproportionate number of children in poverty are from African American and Latino backgrounds. Children in mother-only families are nearly four times as likely to be in poverty as those in married-couple families. Research links poverty to numerous risks and disadvantages for children, including increased abuse, neglect, lower reading scores, overall less success in the classroom, failure, delinquency, malnutrition, and violence (Centers for Disease Control and Prevention, 2014a; Children's Defense Fund, 2014; Carlson, McNulty, Bellair, & Watts, 2014; Singh & Lin, 2013). One out of every ten Canadian children lives in poverty, and among children from Aboriginal heritage, a group that comprises 4% of the total Canadian population, 25% of children are poor (Statistics Canada, 2015).

Children’s Health Status Indicators of child health status include birth weight, infant mortality, and immunization rates. In general, children from diverse cultural backgrounds have less favorable indicators of health status than their white counterparts. Health status is influenced by many factors, including access to health services. There are numerous barriers to quality health care services for children, such as poverty, geography, lack of cultural competence by health care providers, racism, and other forms of prejudice. Families from diverse cultures might have trouble in their interactions with nurses and other health care providers, and these difficulties might have an adverse impact on the delivery of health care. Because ethnic minorities are

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nderrepresented among health care professionu als, parents and children often have different cultural backgrounds from their health care providers.

Growth and Development Although the growth and development of children are similar in all cultures, important racial, ethnic, and gender differences can be identified. For example, there is cross-cultural similarity in the sequence, timing, and achievement of developmental milestones such as smiling, separation anxiety, and language acquisition. However, from the moment of conception, the developmental processes of the human life cycle take place in the context of culture. Throughout life, culture exerts an all-pervasive influence on the developing infant, child, and adolescent. Developmental researchers who have worked in other cultures have become convinced that human functioning cannot be separated from the cultural and more immediate context in which children develop (Chen & Eisenberg, 2012). For example, during a study of children aged 0 to 6 years from three different Aboriginal groups in Canada, researchers discovered that although the participants’ gross motor developmental milestones were achieved earlier when compared to the general population of Canadian children, language skills were developed later (Findlay, Kohen, & Miller, 2014). Although it is difficult to separate nongenetic from genetic influences, some populations are shorter or taller than others are during various periods of growth and in adulthood. African American infants are approximately three-fourths of an inch shorter at birth than Whites. In general, African American and White children are tallest, followed by Native Americans; Asian children are the shortest. Children of higher socioeconomic status are taller in all cultures. Data on African American and White children between 1 and 6 years old show that at age 6, African Americans are taller than Whites. Around age 9 or 10 years, white boys begin to catch up in height. White girls catch up with their African American counterparts around 14 or 15 years of age. African American children have longer legs in proportion to height than

other groups (Overfield, 1995). During puberty, growth in African American children begins to slow down, and White children catch up so that the two races achieve similar heights in adulthood. The growth spurt of adolescence involves the skeletal and muscular systems, leading to significant changes in size and strength in both sexes but particularly in boys. White North American youths age 12 to 18 years are 22 to 33 pounds heavier and 6 inches taller than Filipino youths the same age. African American teenagers are somewhat taller and heavier than White teens up to age 15 years old. Japanese adolescents born in the United States or Canada are larger and taller than Japanese adolescents who are born and raised in Japan, primarily due to differences in diet, climate, and social milieu (Overfield, 1995). To provide consistent comparisons of height and weight of children, the WHO (2010) has developed universally approved benchmarks for age- appropriate height/weight measures for children up to age 5 years based on data from 11 million children in 55 different countries or ethnic groups. Based on the wide variation in head circumference data gathered in the study, no global standards were recommended in an effort to avoid misdiagnosis of microcephy or macrocephy (Natale & Rajagopalan, 2014). Certain growth patterns appear across cultural boundaries. For example, regardless of culture, neuromuscular activities evolve from general to specific, from the center of the body to the extremities (proximal-to-distal development), and from the head to the toes (cephalocaudal development). Adult head size is reached by the age of 5 years, whereas the remainder of the body continues to grow through adolescence. Physiologic maturation of organ systems, such as the renal, circulatory, and respiratory systems, occurs early, whereas maturation of the central nervous system continues beyond childhood. Tooth eruption occurs earlier in Asian and African American infants than in their White counterparts. In terms of child development, many developmental theories are based on observations of Western children and, therefore, may not have cross-cultural generalization. Investigations of the

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

universality of the stages of development proposed by Piaget, the family role relations emphasized by Freud, and patterns of mother–infant interaction suggested by Bowlby to indicate security of attachment have resulted in modifications of the theories to reflect newer cross-cultural data. Other growth and development patterns seem to be specific to cultural groups. For example, in some cultures, the standard Western mobility pattern of sitting—creeping—crawling—standing— walking—squatting is not followed. The Balinese infant goes from sitting to squatting to standing. Hopi (Native American) children begin walking 1 to 2 months later than Anglo-American children.

Infant Attachment Cross-cultural differences are apparent when examining infant attachment, the relationship that exists between a child and their primary caregiver, which provides “a secure base from which to explore and, when necessary, as a haven of safety and a source of comfort” (Benoit, 2004, p. 1). Researchers have discovered that German and Anglo-American mothers expect early auto nomy in the child and have fewer physical interventions as the child plays, thus encouraging exploration and independence (Dewar, 2014). Japanese children are seldom separated from their mother, and there is close physical interaction with the child (Dewar, 2014). Similarly, Puerto Rican and Dominican mothers display close mother–child relationships with more verbal and physical expression of affection than European American parents. Anglo-American mothers tend to give greater emphasis to qualities associated with individualism such as autonomy, selfcontrol, and activity (Dewar, 2014). Puerto Rican mothers describe children in terms congruent with Puerto Rican culture: emphasis is placed on relatedness (e.g., affection, dignity, respectfulness, responsiveness to mother) and proximity seeking (Dewar, 2014). The development of African children is strongly related to the nutritional status of the child: those who tend to be malnourished have lessened attachment (Dewar, 2014).

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Studies suggest that differences in infant attachment are linked to cultural variations in parenting behavior and life experiences. Parental socialization, values, beliefs, goals, and behaviors are determined in large measure by how a culture defines good parenting and preferred child behaviors for each gender. Other factors include the move from rural to urban residences and the associated social, economic, and lifestyle changes that shift children to more independent and autonomous behaviors. Some researchers argue that contemporary urbanization has created complex and highly technological societies that simultaneously foster children’s autonomous, cooperative, and prosocial behavior (Chen & Eisenberg, 2012; Keller, 2013).

Crying Cultural differences exist in the way mothers perceive, react, and behave in response to their infants’ cues, behaviors, and demands. Knowledge of cultural differences in parental responses to crying is relevant for nurses because assessment of the severity of an infant’s distress is often based on the parent’s interpretation of the crying. The seriousness of a problem may be overestimated or underestimated because of cultural variations in perception of the infant’s distress. The degree of parental concern toward an infant may be misinterpreted if one’s cultural beliefs and practices differ from those of the parent (Dewar, 2013). For example, in Asian and Latino cultures, the male child is expected to maintain strong control over his emotions, and not cry in the presence of others; therefore, a child crying in pain may be interpreted one way by a nurse and dismissed as inappropriate gender-related behavior by a parent.

Culture-Universal and CultureSpecific Child Rearing The values, attitudes, beliefs, and practices of one’s culture affect the way parents and other providers of care relate to a child during various

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evelopmental stages. In all cultures, infants and d children are valued and nurtured because they represent the promise of future generations. Figure 6-2 presents a model summarizing the cultural factors that influence parental beliefs and practices related to child rearing. Influences on the parents include cultural and socioeconomic factors, educational background, political and legal considerations, religious and philosophical beliefs, environmental factors, contemporary technologies, personal attributes, and individual preferences. These influences, in turn, shape and form parental beliefs about normal growth and development; nutrition and diet; sleep; toilet training; communication patterns; and parent–child interactions and relationships, including beliefs and practices concerning

parental authority. Beliefs and practices also influence discipline and culturally appropriate relationships with siblings, extended family members, nurses, physicians, teachers, law enforcement and other authority figures, and peers. Similarly parental cultural beliefs and practices influence behaviors and interventions that promote the child’s health (immunizations, foods, exercise/activity) and the manner in which he/she is cared for during illness, how parents know when their child is sick or injured, the perceived seriousness of the illness or injury (and the need for primary, secondary, or tertiary care), type(s) of healers and interventions used to cure or heal the child. Lastly, factors inherent in the child, such as genetic and acquired conditions, gender, age, and related characteristics.

Parental Beliefs and Practices

Influences on Parents Socioeconomic factors Educational background Politics and law Religion Technology Environment Culture Personal attributes and preferences

Influences on Child

Normal Growth and Development Nutrition Sleep Elimination Discipline Relationship with Parents Siblings Extended family Authority figures Peers Health/illness Preventive health care Immunization

CHILD Genetic Factors Figure 6-2. Model depicting cultural perspectives of childrearing.

Influence of Folk and Biomedical Health Care Systems Primary, Secondary and Tertiary Health Care.

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

Throughout infancy, childhood, and adolescence, girls and boys undergo a process of socialization aimed at preparing them to assume adult roles in the larger society into which they have been born or to which they have migrated. As children grow and develop, their communications and interactions occur within a cultural context. That which is considered acceptable is strongly influenced by parental education, social expectation, religious background, and cultural ties. However, all parents want their children to treat them respectfully and to show respect toward others, thus becoming a source of pride and honor to their family and cultural heritage. There are many universal childrearing practices, but most research has focused on specific cultural differences rather than on similarities. It is important to distinguish between cultural practices and those that reflect the economic well-being of the family, for example, the stereotypes that suggest that teenage pregnancy is more common and more acceptable among African Americans than among counterparts in other cultures. When socioeconomic factors are considered, the myth is shattered. Although African American adolescents from the lower socioeconomic groups have higher rates of teen pregnancy, this is not true for middleand upper-income African Americans (Aruda, 2011; Bresnahan, et al., 2014; Carlson et al., 2014). Although not an exhaustive review of childrearing customs, the following discussion focuses on clinically significant childrearing behaviors among families from diverse cultures. These include nutrition, sleep, elimination, menstruation, parent– child relationships and discipline, and child abuse. Cross-cultural differences concerning gender are also discussed in this section.

Nutrition: Feeding and Eating Behaviors In many cultures, breast-feeding is traditionally practiced for varying lengths of time ranging from several weeks to several years. The growing availability and convenience of extensively marketed prepared formula have resulted in a decrease in

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the number of women who attempt to breast-feed, especially among recent migrants to the United States who may culturally find it inappropriate to breast-feed in public. Many nursing mothers immigrating to the United States or Canada may be separated from female family members who could assist them with successful breast-feeding, and lack of an interpreter during prenatal and postnatal visits with health professionals can become a barrier to breast-feeding (Schmied et al., 2012). Some cultural feeding practices might result in threats to the infant’s health. The practice of propping a bottle filled with milk, juice, or carbonated beverages to quiet a child or lull them to sleep is known in many cultures and can result in dental caries; this practice should be discouraged. In some cultures, mothers premasticate, or chew, food for young children in the belief that this will facilitate digestion. This practice, most frequently reported among Black and Hispanic mothers, is of questionable benefit and may transmit infection from the mother’s mouth to the baby (Centers for Disease Control and Prevention, 2014b; Rakhmanina et al., 2011). Health status is dependent in part on nutritional intake, thus integrally linking the child’s nutritional status and wellness. Although the United States is the world’s greatest food-producing nation, nutritional status has not been a priority for many people in this country. An estimated 1% of children in the United States are malnourished (John Hopkins Children's Center, 2015). Malnutrition is described as undernutrition (not enough essential nutrients or nutrients excreted too rapidly) or overnutrition (eating too much of the wrong food or not excreting enough food) (WHO, 2010). Malnutrition may be serious enough to interfere with neuro- and musculoskeletal development. Malnutrition is not exclusive to children from poor, lower socioeconomic groups. By definition, many middle- and upper-income families have obese children who are also malnourished. Obesity frequently begins during infancy, when some mothers succumb to cultural pressures to overfeed (Moreno, Johnson-Shelton, & Boles, 2013). For example, among many who identify

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themselves as Filipino, Vietnamese, Somali, His panic American, and Mexican, to name a few cultures, fat babies generally are considered healthy babies (Bresnahan, Zhuang, & Park, 2014; Cachelin & Thompson, 2014; Cartagena et al., 2014; Centers for Disease Control and Prevention, 2014b). Among some African tribes, such as the Igbo and Yoruba in Nigeria, overweight babies are considered healthy, and mild to moderate obesity in children is considered a sign of affluence. Similar beliefs have been identified among Somali and Berber women (Liamputtong, 2011) as well as some Hispanic mothers who subscribe to a long-standing cultural belief that “a chubby baby is a healthy baby” (Children's Defense Fund, 2014). Evidence-Based Practice 6-1 describes racial and ethnic differences in childhood obesity. The popularity of fast-food restaurants and “junk” foods has resulted in a high-calorie, highfat, high-cholesterol, and high-carbohydrate diet for many children. Parents and children are frequently involved in numerous activities outside the house and have less time for traditional tasks such as cooking or seating the family together for a meal. Because fast foods have some intrinsic nutritional value, their benefit should be evaluated based on age-specific requirements. Poverty forces some parents to provide inexpensive substitutes for the expensive, often unavailable, essential nutrients. These lower nutrients, high-fat, highcalorie foods are referred to as “empty calories” and have led to the epidemic of childhood obesity. The prevalence of childhood obesity among various cultural and ethnic groups within the United States was described by Ogden, Carroll, Kit, and Flegal (2014). The reported weight-for-age imbalance among preschool, school-age, and adolescent African American and Hispanic children was especially disturbing and purports serious complications of hypertension, diabetes, and cardiovascular disease for young Black and Hispanic adults (see Figure 6-3). The extent to which families retain their cultural practices at mealtime varies widely. However, when a child is hospitalized, their recovery might be enhanced by familiar foods, and nurses should

assess the influence of culture on eating habits. For example, most Asian parents believe that children should be fed separately from adults and that they should acquire “good table manners” by the time they are 5 years old; these practices can be supported during hospitalization. For hospitalized children, nurses can foster an environment that closely simulates the home (e.g., use of chopsticks rather than silverware). Family members can be encouraged to visit during mealtime to encourage the child to eat. As the child’s condition allows, food may be brought from home, and/or the family can be encouraged to eat with the child if this is appropriate. In many cultures, illness is viewed as a punishment for an evil act, and fasting (abstaining from solid food and sometimes liquids) is viewed as penance for evil. A situation may become dangerous, and even deadly, should a parent view the child’s illness as an “evil” event and consequently withhold food and/or water. Dehydration occurs rapidly and malnutrition may quickly follow. These dangerous issues may require legal intervention to protect the child and may produce difficult, culturally insensitive outcomes. Nurses must be vigilant to support cultural eating habits and be prepared to educate parents and children about the prevention of and intervention for malnutrition and dehydration. Safe drinking water is not always available in many regions of the world. Contaminated water is found in all countries at some time and in some countries at all times. Children die daily from waterborne diseases that could be prevented with a few drops of bleach or a safe water supply. Weather-related disasters, earthquakes, famine, and war typically escalate the water crises. In cases of vomiting, diarrhea, and dehydration, contaminated water supplies should always be investigated as a possible source.

Sleep Although the amount of sleep required at various ages is similar across cultures, differences in sleep patterns and bedtime rituals exist. The sleep

Evidence-Based Practice 6-1

Racial and Ethnic Differences in Childhood Obesity The World Health Organization warns that the increasing prevalence of obesity in children during the past 30 years has reached epidemic levels. A global problem affecting many low- and middleincome countries, obesity affected more than 42 million children under the age of 5 in 2013. Nearly 31 million of these children live in urban parts of developing countries and are at risk for remaining obese into adulthood, at which time they are more likely to develop diabetes and cardiovascular diseases (World Health Organization, 2014). Children at highest risk for obesity live in the United States, United Kingdom, and Mexico.

Measuring Overweight and Obesity in Children It is difficult to develop one simple index for the measurement of overweight and obesity in children and adolescents because their bodies undergo a number of physiologic changes as they grow. Measurement is further compounded by the child’s race; African Black children carry less body fat than White counterparts, and Hispanic and Asian children typically have a higher percentage of body fat. Given the wide variation in the level and distribution of body fat between different racial and ethnic groups, different benchmarks for defining overweight and obesity are used in different countries. Cowie (2014) reports on various tools and strategies used to measure and assess overweight and obesity in children and identifies what is currently considered to be the most reliable and effective. Different methods to measure a body’s healthy weight, depending on the age, are available from the World Health Organization. In the United States, the Centers for Disease Control’s reference data are based on a sample of boys and girls aged 2 to 20 years (CDC, 2010).

Factors Contributing to Obesity in Early Childhood Weden, Brownell, and Rendall (2012) studied diffe rences in the likelihood of early childhood obesity between Black and White US children using data

from the Early Childhood Longitudinal Study directed by the National Center for Education Statistics. The sample consisted of a nationally representative cohort with n = 1,515 children and their mothers (age 14 to 21 years) who were assessed in waves at 9 months, 2 years, 4 years, and upon entry into kindergarten using computer-assisted, inhome interviews with children, mothers, fathers, or guardians. The investigators examined differences in Black and White children’s prevalence of socioeconomic, prenatal, perinatal, and early life risk and protective factors relative to their likelihood of obesity in early childhood. Black children’s mothers were only one-third as likely as White children’s mothers to have completed high school, a strong indicator of socioeconomic disadvantage. Black children were 3 to 3.5 times as likely as White children to live in a family or household whose annual income was below $25,000, and their mothers were three to four times as likely to be unmarried. In analyzing prenatal and perinatal risk factors, almost half of Black children’s mothers, compared to one-third of White children’s mothers, were overweight or obese before pregnancy. Prepregnant obesity was the strongest risk factor for early childhood obesity, with Black children’s mothers being more likely to be obese than White counterparts, thus perpetuating “a troubling cycle of intergenerational transmission of racial disparities in body mass index” (Weden et al., 2012, p. 2062). The investigators also studied racial differences in protective factors that would decrease the likelihood of early childhood obesity, for example, long-duration breast-feeding (>8 months), frequency and quality of meals, children’s television viewing, and exercise/physical activity care (Bresnahan, et al., 2014; Cachelin & Thompson, 2014; Kirby, Liang, Hsin-Jen, & Wang etal., 2012; Moreno et al., 2013).

Protective Factors Contributing to Prevention of Obesity in Early Childhood Among early life protective factors to reduce the likelihood of obesity, Black children were less (continued )

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Racial and Ethnic Differences in Childhood Obesity (continued) likely than White children to be breast-fed for 1 to 7 months and only one-third as likely to be breastfed for 8 months or longer. Black children were also less likely than White children to have daily family meals. Twice as many Black children as White children watched television for 4 or more hours per day during the daytime at 4 years of age. Black children’s mothers were more likely to be employed full time than White children’s. Black children also were more likely to be cared for by relatives or in a day care center and less likely to be cared for by a nonrelative or exclusively by their parents. In the statistical analyses, it was revealed that younger children’s television watching was not correlated with obesity, as has been reported elsewhere in the literature, perhaps because television-related sedentary behavior is a more critical determinant in obesity at older ages.

Clinical Implications The study findings provide insights into potentially modifiable determinants of racial disparities in early childhood obesity among Black and White preschool-aged children. Disparities among Black children are concerning because early childhood obesity often develops into adult obesity, which, in turn, has implications for adult cardiovascular disease and diabetes, the leading causes of premature death in African Americans. Eliminating Black–White differences in early childhood obesity provides an opportunity to reduce racial disparities in the overall health and longevity of both Black and White populations.

practices in a family household reflect some of the deepest moral ideals of a cultural community. Nurses working with families of young children in both community and inpatient settings frequently encounter cultural differences in family sleeping behaviors. Community health, psychiatric, and pediatric nurses who work with young children and their families often assess the family’s sleep and rest 162

The study findings also have implications for nurse midwives, obstetric nurses, obstetricians, doulas, and others who assist with deliveries and engage in parent education programs about the benefits of breast-feeding, proper nutrition, and exercise/activity; for employers who establish workplace policies related to breast-feeding; for teachers responsible for exercise and activity programs in preschools and kindergartens; for dieticians who are responsible for nutrition and diet education programs for the parents and other care givers for preschool-aged children; and for federal, state, foundation, and corporate funding for the prevention of childhood obesity. References Cowie, J. (2014). Measurement of obesity in children. Primary Health Care, 24(7), 18–23 Kirby, J. B., Liang, L., Hsin-Jen, C., & Wang, Y. (2012). Race, place, and obesity: The complex relationships among community racial/ethnic composition, individual race/ethnicity, and obesity in the United States. American Journal of Public Health, 102(8), 1572–1578 Moreno, G., Johnson-Shelton, D., & Boles, S. (2013). Pre valence and prediction of overweight and obesity among elementary school children. Journal of School Health, 83(1), 157–163 Weden, M. M., Brownell, P., & Rendall, M. S. (2012). Prenatal, perinatal, early life, and sociodemographic factors underlying high body mass index in early childhood. American Journal of Public Health, 102(11), 2057–2065 World Health Organization. (2014). Global strategy on diet, physical activity: Childhood overweight and obesity. Retrieved on 11-5-14 at http://www.who.int/dietphysicalactivity/childhood/en/

patterns. Bed sharing is the practice of a child sleeping with another person on the same sleeping surface for all or part of the night. Although bed sharing may be born out of financial necessity, it is a cultural phenomenon in many societies that emphasize closeness, togetherness, and interdependence (Jain, Romack, & Jain, 2011). Globally, bed sharing prevalence ranges widely, from 6% to 70%; an estimated 15% of US children

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Figure 6-3. Childhood obesity is often initiated or reinforced through diets of “fast foods.”

bed share. Among children in households with an annual income less than $20,000/year, bed sharing is 1.5 times more likely than those with incomes greater than $20,000/year. On the issue of family cosleeping, nurses traditionally have taken a rigid approach that excludes this common cultural practice. Although some degree of cosleeping—the practice of parents and children sleeping together in the same bed for all or part of the night—is common in families with young children, there are marked cultural differences in the proportion that regularly implement this practice (Barajas, Martin, Brooks-Gunn, & Hale, 2011; Jain et al., 2011; Lujik, Mileva-Seitz, Jansen et al., 2013; Salm Ward, 2014). Research has found that the majority of parents bring their children into bed with them at some time. Parents bring their children into bed with them to facilitate breast-feeding, to comfort the child, to improve the child’s sleep or parent’s sleep, to monitor the child, to improve bonding or attachment, and for other reasons; the constellation of reasons for bed sharing depends largely on the culture of the family (Huang et al., 2013; Salm Ward, 2014).

Cosleeping is more common and occurs most frequently among African American families (Luijk, Mileva-Seitz, Jansen, et al., 2013). Most White middle-class North American and Euro pean families believe that infants and children should sleep alone. There are no negative associations between cosleeping during the toddler years and behavior and cognition at 5 years of age (Barajas et al., 2011). The type of bed in which a child sleeps might vary considerably. In a traditional American Samoan home, infants sleep on a pandanus mat covered with a blanket, and sometimes, a pillow is used. The cradleboard is used by several Native American nations. Constructed by a family member, a cradleboard is made of wood and might be decorated in various ways depending on the affluence of the family and tribal customs (see Figure 6-4). The cradleboard helps the infant feel secure and is easily moved while the family engages in work, travel, or other activities. Although cradleboards have been blamed for exacerbating hip dysplasia in Native American infants, diapering counterbalances this by causing a slight abduction of the hips (Kliegman, Stanton, Saint Geme, Schor, & Behrman, 2011).

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Figure 6-4. The cradleboard, created many centuries before the car seat, helps to promote infant mobility and safety and its use is still prevalent among some Native Americans.

In the United States and Canada, the common developmental milestone of sleeping for 8 uninterrupted hours by age 4 to 5 months is regarded as a sign of neurologic maturity. In many other cultures, however, the infant sleeps with the mother and is allowed to breast-feed on demand with minimal disturbance of adult sleep. In such an arrangement, there is less parental motivation to enforce “sleeping through the night,” and infants continue to wake up every 4 hours during the night to be fed (Huang et al., 2013). Thus, it appears that this developmental milestone, in addition to its biologic basis, is a function of context. A common transition from sleeping in a crib to a bed without side rails is a developmental marker

that is important to the child. This transition usually occurs during preschool years, depending upon the physical space in the home, the parental attitude toward the child’s independence, and the child’s neuromuscular development/coordination. For the hospitalized child, caregivers need to identify the child’s usual bedtime routines. For example, once children have gained the independence of leaving a crib, it may be emotionally traumatic for them to be placed into a hospital bed with side rails of any kind. Health care providers need to be sensitive to this situation and reassure both child and parent that any regressive behavior that occurs as a result of reverting to a bed with side rails will be shortlived. Bedtime routines and preparation for sleep might include a snack, prayers, and/or a favorite toy or story. Common bedtime routines should be continued in the hospital as much as possible. Homelessness presents many problems, one of which is the lack of a consistent place for a child to sleep. Although nomadic tribes have for centuries moved their habitat on a daily basis, even they generally had a consistent tent or covering. Today, approximately 1.6 million of children experience homelessness each year and daily face the issues of not having a permanent, safe, or secure place in which to lay their head (The National Center on Family Homelessness, 2015). Whether because of poverty, disease, war, or disaster, children with or without families nightly wander without a safe place to sleep. The toll of the massive number of homeless children that are the result of recent natural disasters, war, and famine has yet to be estimated. Lack of a safe place to sleep is only one of many issues to be considered (see Figure 6-5).

Elimination Elimination refers to ridding the body of wastes. It is a function that is accomplished by the combined work of the gastrointestinal, genitourinary, respiratory, and integumentary systems of the body. Of primary concern to parents of toddlers and preschoolers is bowel and bladder control. Toileting or toilet training is a major developmental milestone and is taught through a variety of cultural patterns.

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Figure 6-5. A Haitian child stands amidst earthquake rubble without clean water, food, or a place to sleep.

Most children are capable of achieving dryness by 2½ to 3 years of age. Bowel training is more easily accomplished than bladder training. Daytime (diurnal) dryness is more easily attained than nighttime (nocturnal) dryness. Some cultures start toilet training a child before his or her first birthday and consider the child a “failure” if dryness is not achieved by 18 months. Often, there is significant shaming, blaming, and embarrassment of the child who has not achieved dryness by the culturally acceptable timetable. The nurse should remember that due to spinal cord/nerve development, maintenance of dryness is not physiologically possible until the child is able to walk without assistance. In some cultures, children are not expected to be dry until 5 years of age. Generally speaking, “Girls typically acquire bladder control before boys, and bowel control typically is achieved before bladder control” (Kliegman et al., 2011, p. 71). Constipation in a child is a persistent concern among parents who expect a ritualistic daily pattern of bowel movements. In some cultures, infants are given herbs aimed at purging them when they are a few days, weeks, or months old to remove evil spirits from the body.

Parents should be advised against using purgatives in infants because fluid and electrolyte imbalance occurs, and dehydration can ensue rapidly. The role of the nurse is to acknowledge that toilet training can be taught through a variety of cultural patterns but that physical and psychosocial health are promoted by accepting, flexible approaches. A previously toilet-trained child might become incontinent as a result of the stress of hospitalization, but will generally regain control quickly when returned to the familiar home environment. Parents should be reassured that regression of bowel and bladder control frequently occurs when a child is hospitalized; this is normal and is expected to be a short-term occurrence.

Menstruation Ethnicity is the strongest determinant of the duration and character of menstrual flow, although diet, exercise, and stress are also known to influence menstruation in women of all ages. In most cultures globally, menarche signals that a girl’s body is physiologically becoming ready for motherhood.

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The age at which it is culturally appropriate for a young woman to bear children is highly variable (Davis, Farage, & Miller, 2011). As indicated in Figure 6-6, in some cultures, motherhood occurs in the early teens, which results in children parenting children, often with encouragement and support from an extended family, including other wives in polygamous cultures. In other cultures, adolescent pregnancy is discouraged. Attitudes toward menstruation are often culturally based, and the adolescent girl might be taught many folk beliefs. For example, in traditional Mexican American families, girls and women are not permitted to walk barefooted, wash their hair, or take showers or baths during menses. In encouraging hygienic practices, respect

Figure 6-6. Menarche sets the developmental stage for girls to become mothers: children parenting children (Giancana/Shutterstock.com).

cultural directives by encouraging sponge bathing, frequent changing of sanitary pads or tampons, and other interventions that promote cleanliness (Davis et al., 2011). Some Mexican Americans believe that sour or iced foods cause the menstrual flow to thicken, and some Puerto Rican teenagers have been taught that drinking lemon or pineapple juice will increase menstrual cramping. The nurse should be aware of these beliefs and should respect personal preferences concerning beverages. The teenager might have been taught the folk practices by her mother or by another woman in her family who might be watchful during the girl’s menstrual periods. If menstruation coincides with hospitalization, nurses should respect the teenager’s preferences and reassure the mother or significant other that cultural practices will be respected. Many cultural groups treat menstrual cramping with herbs and a variety of home remedies. Health care providers should ask the adolescent whether she takes anything special during menstruation or in the absence of menstrual flow. Verify the amount and type of home remedies used to determine possible interactive effect with prescribed medications. Adolescent girls of Islamic religious backgrounds have cultural and/or religious prohibitions and duties during and after menstruation. In Islamic law, blood is considered unclean. The blood of menstruation, as well as blood lost during childbirth, is believed to render the female impure. Because one must be in a pure state to pray, menstruating girls and women are forbidden to perform certain acts of worship, such as touching the Koran, entering a mosque, praying, and participating in the feast of Ramadan. During the menstrual period, sexual intercourse is forbidden for both men and women. When the menstrual flow stops, the girl or woman performs a special washing to purify herself. In Islam, sexual pollution applies equally to men and women. For men, sexual intercourse and the discharge of semen is an act that renders a man impure and requires a ritual washing before being able to perform the prayer. Buddhist and Hindu women do not enter the kitchen and may sleep in separate/special rooms during menses (Davis et al., 2011).

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

Parent–Child Relationships and Discipline In some cultures, both parents assume responsibility for the care of children, whereas in other cultures, the relationship with the mother is primary and the father remains somewhat distant. With the approach of adolescence, the gender-related aspects of the parent–child relationship might be modified to conform to cultural expectations. Some cultures encourage children to partici pate in family decision making and to discuss or even argue points with their parents. Some African American families, for example, encourage children to express opinions verbally and to take an active role in all family activities. Many Asian parents value respectful, deferential behavior toward adults, who are considered experienced and wise; therefore, children are discouraged from making decisions independently. The witty, fast reply that is viewed in some US, Canadian, European, and Australian cultures as a sign of intelligence and cleverness might be punished in some non-Western circles as a sign of rudeness and disrespect. The use of physical acts, such as spanking or various restraining actions, is connected with discipline in many groups, but can sometimes be interpreted by those outside the culture as inappropriate and/or unacceptable. Physical punishment of Native North American children is rare. Instead of using loud scolding and reprimands, Native North American parents generally discipline with a quiet voice, telling the child what is expected. During breast-feeding and toilet training, or toilet learning, Native North American children are typically permitted to set their own pace, and parents tend to be permissive and nondemanding. Some African American parents tend to point out negative behaviors of a child and may use spanking and physical punishment as a strategy to quickly gain the child’s attention and rapidly get him or her to behave, especially in public (Whaley, 2013). With the approach of adolescence, parental relationships and discipline generally change.

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Teens are usually given increasing amounts of freedom and are encouraged to try out adult roles in a supervised way that enables parents to retain considerable control. In many cultures, adolescent boys are permitted more freedom than girls of the same age. Among some religious groups, such as the American Amish, adolescents are given a period of time (a month to a year) of a more independent lifestyle prior to commitment to specific religious life rules.

Child Abuse Child abuse and neglect have been documented throughout human history and are evident across cultures. International attention to child maltreatment emerged in the late 1970s, and the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) held an international congress to explore physical abuse and neglect, molestation, child prostitution, nutritional deprivation, and emotional maltreatment from a cross-national perspective. This congress led to the formation of a multicountry study of child maltreatment/abuse and the United Nations–WHO joint publication “Enhancing the Rights of Adolescent Girls” (WHO, 2010). Cross-cultural variability in childrearing beliefs and practices has created a dilemma that makes the establishment of a universal standard for optimal child care, as well as definitions of child abuse and neglect, extremely difficult. In defining child maltreatment across cultures, the WHO and UNICEF have included Korbin’s (1991) classic three characteristics: (1) cultural differences in childrearing practices and beliefs, (2) departure from one’s culturally acceptable behavior, and (3) harm to children. Practices that are acceptable in the culture in which they occur may be considered abusive or neglectful by outsiders; some examples follow. In many Middle Eastern cultures, despite warm temperatures, infants are covered with multiple layers of clothing and might be observed to sweat profusely because parents believe that young children become chilled easily and die of exposure to

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the cold. Many African nations continue to practice rites of initiation for boys and girls, usually at the time of puberty. In some cases, ritual circumcision—of both boys and girls—is performed without anesthesia, and the ability to endure the associated pain is considered to be a manifestation of the maturity expected of an adult. In the United States and Canada, some Southeast Asian folk healing practices such as coining, cupping, and burning that produce marks on the body are used for treatment of upper respiratory illnesses, pain relief, and various other illnesses. In some Middle Eastern and Mexican societies, fondling of the genitals of infants and young children is used to soothe them or encourage sleep; however, such fondling of older children or for the sexual gratification of adults falls outside of acceptable cultural behaviors. Although African American children are three times more likely than White children to die of child abuse (Lanier, Maguire, Tova, Drake, & Hubel, 2014), there is considerable disagreement about whether race differences exist in the prevalence of child abuse independent from socioeconomic factors such as income, education, and employment status. Health care providers need to become knowledgeable about folk beliefs, childrearing practices, and cultural variability in defining child maltreatment.

Gender Differences From the moment of birth, differentiation bet ween the sexes is recognized. Physical differences between boys and girls appear early in life and form the basis for adult roles within a culture. Normal newborn boys are larger, more active, and have more muscle development than newborn girls. Normal newborn girls react more positively to comforting than do newborn boys. Physiologically, adult men differ from adult women in both primary and secondary sex characteristics. On average, men have a higher oxygen-carrying capacity in the blood, a higher muscle-to-fat ratio, more body hair, a larger skeleton, and greater height.

Behaviorally, there are also differences between the two sexes, especially in the division of labor. The early differentiation of gender roles is manifested in gender-specific tasks, play, and dress. For children, gender differences can be identified cross-culturally in six classes of behavior: nurturance, responsibility, obedience, self-reliance, achievement, and independence (Barry, Bacon, & Child, 1967). Variability in gender role behavior is common. Most people in a society adopt common behaviors defined as appropriate to their biologic sex, but there are many exceptions. Gender roles are themselves highly variable by age, social class, religious orientation, and sexual preference. The stringency of expectations also varies: girls and women in the United States, Canada, Australia, Israel, and many parts of Europe can violate gender role norms with fewer explicit sanctions than their counterparts in other regions of the world.

Health and Health Promotion The concept of health varies widely across cultures. Regardless of culture, most parents desire health for their children and engage in activities that they believe to be health promoting. Because health-related beliefs and practices are such an integral part of culture, parents might persist with culturally based beliefs and practices even when scientific evidence refutes them, or they might modify them to be more congruent with contemporary knowledge of health and illness.

Illness The family is the primary health care provider for infants, children, and adolescents. It is the family that determines when a child is ill and when to seek help in managing an illness. The family also determines the acceptability of illness and sick-role behaviors for children and adolescents. Societal and economic trends influence the cultural beliefs that are passed from generation to generation. Health, illness, and treatment (care/ cure) are part of every child’s cultural h eritage.

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

Every society has an organized response to defined health problems. Certain people are designated as being responsible for deciding who is sick, what kind of sickness the person has, and what kind of treatment is required to restore the person to health. Research has consistently demonstrated that African American and Hispanic children are less likely to have seen a physician than are Whites. They also have a lower average number of ambulatory visits than their White counterparts. Even when children are hospitalized, minorities receive fewer services than do Whites (Federal Interagency Forum on Child and Family Statistics, 2006; Statistics Canada, 2009; Children’s Defense Organization, 2009).

Health Belief Systems and Children Among many cultural groups, traditional health beliefs coexist with Western medical beliefs. Members of a cultural group choose the components of traditional (Western) medicine, Eastern medicine, or folk beliefs that seem appropriate to them. A Mexican American family, for example, might take a child to a physician and/or a traditional healer (curandero). After visiting the physician and the curandero, the mother might consult with her own mother and then give her sick child the antibiotics prescribed by the physician and the herbal tea prescribed by the traditional healer. If the problem is viral in origin, the child will recover because of his or her own innate immunologic defenses, independent of either treatment. Thus, both the herbal tea of the curandero and the penicillin prescribed by the physician might be viewed as folk remedies; neither intervention is responsible for the child’s recovery. Belief systems about specific symptoms are culturally unique. These are referred to as cultural illnesses. In Hispanic culture, susto is caused by a frightening experience and is recognized by nervousness, loss of appetite, and loss of sleep. Mexican American babies must be protected from these experiences. Pujos (grunting) is an illness manifested by grunting sounds and protrusion of

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the umbilicus. It is believed to be caused by contact with a woman who is menstruating or by the infant’s own mother if she menstruated sooner than 60 days after delivery. The evil eye, mal ojo, is an affliction feared throughout much of the world. The condition is said to be caused by an individual who voluntarily or involuntarily injures a child by looking at or admiring him or her. The individual has a desire to hold the child, but the wish is frustrated, either by the parent of the infant or by the reserve of the individual. Several hours later, the child might become listless, cry, experience fever, vomiting, and/or diarrhea. The most serious threat to the infant with mal ojo is dehydration; the nurse encountering this problem in the community setting needs to assess the severity of the dehydration and plan for immediate fluid and electrolyte replacement. Parents should be taught the warning signs and the potential seriousness of dehydration. A simple explanation of the causes and treatment of dehydration should be provided. If the parents adhere strongly to traditional beliefs, respect their desire for the curandera to participate in the care. Parents or grandparents might wish to place an amulet, talisman, or religious object such as a crucifix or rosary on the child or near the bed. For the Mexican American family, caida de la mollera, or fallen fontanel, can be attributed to a number of causes such as failure of the midwife to press preventively on the palate after delivery, falling on the head, abruptly removing the nipple from the infant’s mouth, and failing to place a cap on the infant’s head. The signs of this condition include crying, fever, vomiting, and diarrhea. Given that health care providers frequently note the correspondence of these symptoms with those of dehydration, many parents see deshidratacion (dehydration) or carencia de agua (lack of water) as synonymous with caida de la mollera. Although regional differences exist, parental treatment usually is directed at rehydration, thus raising the fontanel. Empacho is a digestive condition believed by Mexicans to be caused by the adherence of

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ndigested food to some part of the gastrointestiu nal tract. This condition causes an “internal fever,” which cannot be observed but which betrays its presence by excessive thirst and abdominal swelling believed to be caused by drinking water to quench the thirst. Children who are prone to swallowing chewing gum are believed to experience empacho, but it can affect persons of any age. Among some Hindus from northern India, there is a strong belief in ghost illness and ghost possession. These culture-bound syndromes, or folk illnesses, are based on the belief that a ghost enters its victim and tries to seize the soul. If the ghost is successful, it causes death. Illness and the supernatural world are linked by the concepts of fever and the ghost, which is a supernatural being discussed in Hindu sacred scriptures. One sign of ghost illness is a voice speaking through a delirious victim; this may occur in children and adults. Other signs are convulsions and body movements, indicating pain and discomfort, and choking or difficulty breathing. In the case of an infant, incessant crying is a sign. The psychological state of the parents is often involved in the diagnosis, and some believe that ghosts might be cultural scapegoats for the illness and death of children. When an infant or small child becomes ill and dies, a mother or father might be relieved of psychic tension from feelings of personal guilt by transferring the blame for the death to a ghost.

Biocultural Influences on Childhood Disorders Children may be born with genetic traits inherited from their biologic parents, who have inherited their own genetic compositions. The child’s genetic makeup affects his or her likelihood of both contracting and inheriting specific conditions. In both children and adults, genetic composition has been demonstrated to affect the individual’s susceptibility to specific diseases and disorders. It is often difficult to separate genetic influences from socioeconomic factors such as poverty, lack of proper nutrition, poor hygiene, and environmental conditions such as lack of ventilation, sanitary

facilities, and heat during cold weather, and clothing that is insufficient to provide protection during the various seasons. Other factors responsible for differing susceptibilities to specific conditions are variations in natural and acquired immunity, intermarriage, geographic and climatic conditions, ethnic background, race, and religious practices. Some studies have attempted to explain differences in susceptibility solely on the basis of cultural heritage, but they have not succeeded in doing so. This section examines some common conditions in which genetic constitution seems to be a factor influencing child health. Immunity Perhaps one of the most frequently cited examples of the connection between immunity and race is that of malaria and the sickle cell trait in Africans. Black Africans possessing the sickle cell trait are known to have increased immunity to malaria, a serious endemic disease found in warm, moist climates. Thus, blacks with the sickle cell trait survived malarial attacks and reproduced offspring who also possessed the sickle cell trait. The transfer of immunity to many contagious diseases via injection/ingestion of live or attenuated viruses has been a major factor in decreasing childhood deaths. However, there is no evidence of culture-bound positive or negative effects where vaccines are available. Some religious groups refuse immunizations and often experience outbreaks of preventable communicable diseases within their community. Other parents refuse immunizations based on the belief of a connection between childhood autism and vaccines, which has not been supported by clinical research to date. Intermarriage Intermarriage among certain cultural groups has led to a wide variety of childhood disorders. For example, there is an increased incidence of ventricular septal defects (VSDs) among the Amish, amyloidosis among Indiana/Swiss and Maryland/ German families, and intellectual disability in several other groups (Kliegman et al., 2011).

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

Ethnicity Although the role of socioeconomic factors in tuberculosis—such as overcrowding and poor nutrition—cannot be disregarded, ethnicity also appears to be a factor in this disease. Groups with a relatively high incidence of tuberculosis are Native North Americans living in the Southwest United States and in northern and prairie regions of Canada, Mexican Americans, and Africans and refugees from third world countries. Ethnicity is also linked to several noncommunicable conditions such as Tay–Sachs disease, a neurologic condition affecting Ashkenazi Jews of Northeastern European descent, and phenylketonuria (PKU), a metabolic disorder primarily affecting Scandinavians (Kliegman et al., 2011). Race Race has been linked to the incidence of a variety of disorders of childhood. For example, the endocrine disorder cystic fibrosis primarily affects White children, and sickle cell anemia has its primary influence among Blacks and those of Mediterranean descent. Black children are known to be at risk for inherited blood disorders, such as thalassemia, G-6-PD deficiency, and hemoglobin C disease. In addition, an estimated 70% to 90% of black children have an enzyme deficiency that results in difficulty with the digestion and metabolism of milk (Coutts, 2013).

Beliefs Regarding the Cause of Chronic Illnesses and Disabilities Chronic illnesses and disabilities in children and adults have become the dominant health care problem in North America and are the leading causes of morbidity and mortality (Agency for Healthcare Research, and Quality, 2014; Centers for Disease Control and Prevention, 2014). Illness is viewed by many cultures as a form of punishment. The child and/or family with a chronic illness or disability might be perceived to be cursed by a supreme being, to have sinned, or to have violated a taboo. In some cultural groups, the

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affected child is seen as tangible evidence of divine displeasure, and its arrival is accompanied throughout the community by prolonged private and public discussions about what wrongs the family might have committed. Inherited disorders and illnesses are frequently envisioned as being caused by a family curse that is passed along from one generation to the next through blood. Within such families, the nurse’s desire to determine who is the carrier for a particular gene might be interpreted as an attempt to discover who is at fault and might be met with family resistance. Folk beliefs mingled with eugenics have resulted in the realization that many chronic conditions, particularly intellectual disability, are the products of intermarriage among close relatives (Agency for Healthcare Research and Quality, 2014; Centers for Disease Control and Prevention, 2014b). The belief that a chronically ill or disabled child might be the product of an incestuous relationship can further complicate attempts to encourage parents to seek assistance. Among those who believe that chronic illness and disability are caused by an imbalance of hot and cold (as in Latino cultures) or yin and yang (as in Southeast Asian cultures), the cause and potential cure lie within the individual. He or she must try to reestablish equilibrium through regaining balance. Unfortunately for those with permanent disabilities who cannot be fully healed, their community might perceive them as living in a continually impure or diseased state. Traditional beliefs can be tenacious and tend to remain even after genetic inheritance or physiologic patterns of chronic disease progression are explained to the family. However, new information is quickly integrated into the traditional system of folk beliefs more often, as is evidenced by the addition of currently prescribed medications to the hot/cold classification system embraced by many Hispanic families. An explanation of the genetic transmission of disease might be given to a family, but this does not guarantee that the older, traditional belief in a curse or “bad blood” will disappear.

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When disability is seen as a divine punishment, an inherited evil, or the result of a personal state of impurity, the very presence of a child with a disability might be something about which the family is deeply ashamed or with which they are unable to cope. In addition to suffering from public disgrace, some parents or families, especially immigrant groups from Eastern Europe and Southeast Asia, also fear that disabled children will be taken away and institutionalized against their will. Some cultural explanations of the cause of chronic disease or disability are quite positive. For example, some Mexican American parents of chronically ill children believed that a certain number of ill and disabled children would always be born into the world. Many Mexican American parents who embrace Roman Catholicism believe that God has singled them out for the role because of their past kindnesses to a relative or neighbor who was disabled and view the birth of the disabled infant as God’s will. The number of chronically ill children in industrialized nations has increased markedly over the past decade, particularly those from minority and low-income households who are at high risk for health disparities (Agency for Healthcare Research

and Quality, 2014; Centers for Disease Control and Prevention, 2014a; Schreirer & Chen, 2013). This increase is primarily due to dramatic changes in obesity, environmental pollutants responsible for asthma and other respiratory illnesses, accidents, and injuries. Adolescent pregnancy among lowincome populations is often accompanied by poor nutrition before and during pregnancy, failure to seek prenatal care (or waiting until the third trimester to do so), and low-birth-weight infants who are at high risk for respiratory illnesses and failure to thrive (Kliegman et al., 2011; Upadhya & Ellen, 2011). In the United States, extensive medical resources are used to save the lives of very low-birth-weight infants; however, the lifesaving efforts often leave a child with multiple chronic illnesses; in countries with fewer medical resources, such as Uganda and Haiti, these same very-low-birth-weight babies will not survive infancy (see Figure 6-7).

Special Health Care Needs of Adolescents There are approximately 23 million adolescents in the United States and Canada (Laughlin, 2014; Statistics Canada, 2015; U.S. Census Bureau, 2014).

Figure 6-7. Many low-birth-weight infants are “saved” by the availability of hi-tech health care, only to experience multiple chronic illnesses later in life.

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

Teenagers are in a process of evolving from childhood to adulthood, and they belong not only to the cultural groups that have formed the basis for their values, attitudes, and beliefs but also to the subculture of adolescents. This subculture links the adolescent with other adolescents through a system of socially transmitted behaviors and belongings, such as brand-named clothing, music, and status symbols. The adolescent subculture has its own set of values, beliefs, and practices that may or may not be in harmony with those of the cultural group that previously guided their behaviors. The adolescent subculture is vaguely structured and lacks formal written rules or codes. Conformity with the peer group behavior is expected. One of the most outstanding characteristics of the adolescent subculture is preoccupation with clothing, hairstyles, and grooming. Clothing mirrors the personal feelings of the adolescent and facilitates identity with the peer group. Some young men and women prefer to dress in traditional clothing. In the hospital setting, gowns might stifle the individual’s sense of identity, so the adolescent should be permitted to wear familiar clothing whenever the style does not interfere with safety, comfort, or hygiene. In a clinical setting, there is no harm in allowing a reasonable amount of makeup, jewelry, or other items of apparel that might be important to the adolescent. Body piercing, prominent in some culture for years, has become widely accepted to the adolescent subculture worldwide. The nurse must assess the placement of the piercing to determine whether it may safely remain in place or must be removed. Piercing of the tongue may prove a hygienic issue and must be discussed with the teen before requiring removal. There is a relationship between some diseases and socioeconomic status; consequently, low-income teenagers may have a wide range of diagnosed and undiagnosed diseases. During the transition from dependent children to independent adults, some disorders might interfere with the adolescent’s development of a positive body image, sexual and personal identity, and value system. The entrance of HIV/AIDS as a

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global health issue has caused adolescents and adults worldwide to seriously evaluate their sexual behavior. The U.S. Agency for International Development, in collaboration with the World Bank, has completed a 13-nation study of adolescent health in Asia and the Near East in which the key educational tool for adolescents was teaching the ABCs of sex: Abstinence, Be Faithful, and use Condoms. However, condoms are not always used, and unplanned pregnancies and/or unwanted diseases such as HIV, AIDS, pelvic inflammatory disease, chlamydia, and others often follow in adolescents globally (Centers for Disease Control and Prevention, 2014; U.S. Agency for International Development, 2012). Evidence-Based Practice 6-2 identifies effective ways to assist Latina adolescents prevent rapid repeat births.

Culturally Competent Nursing Care for Children and Adolescents A few principles of care for specific cultural groups have been provided to illustrate the practical ways in which culturally competent nursing care should be provided. The examples are intended to be illustrative, not exhaustive.

Nursing Assessment of the Family When assessing the family of a child or adolescent in a clinical setting, nurses should consider the cultural background of the family, the belief systems of the family, as well as the relationship between the child and their family. Each of these components plays a vital role in the cultural assessment of the family and their ability to provide culturally competent care. Cultural Background Culture, like language, is acquired early in life, and cultural understanding is typically established by age 5. Every interaction, sound, touch, odor, and experience has a cultural component

Evidence-Based Practice 6-2

Preventing Rapid Repeat Births Among Latina Adolescents: The Role of Parents Nationally, an estimated 20% of adolescent mothers become pregnant again within 24 months of a previous birth; this is known as a rapid repeat birth. Latina adolescents have the highest rate of rapid repeat births in the United States. Although not all adolescent births have adverse outcomes for the Latina mother, they have been associated with an increased rate of sexually transmitted infections and HIV, reduced educational attainment, and decreased financial independence. Adolescent childbearing can also influence future generations. Children born to adolescent mothers have lower levels of cognitive development in childhood, experience less academic achievement, and face a statistically higher probability of becoming adolescent parents themselves, thereby perpetuating a cycle of rapid repeat births among the Latino community. Several effective pregnancy prevention and parent-based interventions to prevent rapid repeat births among Latino youths from engaging in risky sexual behavior have been developed: ●● ●● ●● ●● ●● ●●

National Campaign to Prevent Teen and Unplanned Pregnancy National Council of La Raza Families Talking Together Familias Unidas (Families United) Cuidalos (Take Care of Them) Rompe el Silencio (Break the Silence)

peers. Among pregnant and parenting Latina adolescents, parents are often the primary source of social, emotional, and financial support, and most adolescent parents live at home after giving birth to a child. Research reveals that parents can influence a range of significant behaviors and outcomes among pregnant and parenting teens, including participation in prevention programs, encouragement to pursue higher education, improved contraception knowledge and use, and reduced likelihood of future pregnancies.

Clinical Implications: ●●

●● ●●

●●

Latina adolescent parents are an underserved population with complex reproductive and sexual health needs. Nurses should recognize the importance of the Latino family in guiding adolescent sexual behavior. Parent-based interventions should take into account that adolescents have already engaged in sexual activity and are likely to do so again. Interventions should examine the pregnancy intentions of pregnant and parenting Latina adolescents, specific issues in having a partner who is older, various forms of effective contraceptive use, integration of secondary prevention with sexually transmitted infections and HIV prevention, and support for further education and/or pursuit of a career or technical training that will enable the adolescent to be financially self-sufficient.

In a national random-digit dial telephone survey of greater than 1,000 adolescents age 12 to 19 years, investigators found that the majority of Latino youths (55%) identified their parents as the greatest influence on their sexual decision making, a proportion significantly greater than reported by their White (42%) and African American (50%)

Reference: Bouris, A., Guiliamo-Ramos, V., Cherry, K., Dittus, P, Michael, S., & Gloppen, K. (2012). Preventing rapid repeat births among Latina adolescents. American Journal of Public Health, 102(10), 1842–1847.

that is absorbed by the child even when it is not taught directly. Lessons learned at such early ages become an integral part of thinking and behavior. Table manners, the proper behavior when

interacting with adults, sick role behaviors, and the rules of acceptable emotional response are anchored in culture. Many beliefs and behaviors learned at an early age persist into adulthood.

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Over time, culture has influenced family functioning in many ways, including marriage forms and ceremonies; choice of mates; postmarital residence; family kinship system; rules governing inheritance, household, and family structure; family obligations; family–community dynamics; and alternative family formations. These traditions have given families a sense of stability and support from which members draw comfort, guidance, and a means of coping with the problems of life, including physical and mental illness, handicaps, disabilities, dying, and death. Each family modifies the culture of the larger group in ways that are uniquely its own. Some beliefs, practices, and customs are maintained, whereas others are altered or abandoned. Although it is helpful for you to have a basic knowledge of children’s cultural backgrounds, it is also necessary to view each family on an individual basis. Assumptions or biased expectations cannot be allowed to replace accurate assessment. It is essential for the nurse to remember that not all members of a cultural group behave in the same fashion. For example, although many Chinese North American children behave in a manner congruent with the stereotype—showing respect for authority, polite social behavior, and a moderate-to-soft voice—some are disrespectful, impolite, and boisterous, and illness only exaggerates the differences. Individual differences, changing norms over time, the degree of acculturation, the length of time the family has lived in a country, and other factors account for variations from the stereotype. Family Belief Systems The behavior of children and adolescents is influenced by childrearing practices, parental beliefs about involvement with children, and the type and frequency of disciplinary measures. Although both parents exert an influence on the child’s orientation to health, research indicates that a wide cultural variability exists, with the mother being the most influential parent in many cultural groups; this is easily verified in

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most single-parent households and also very visible in matriarchal societies of African and African American families. Identifying the attitudes, values, and beliefs about health and illness held by the parents and other providers of child care is an important part of the cultural assessment of the family. Mothers’ attitudes toward health and illnesses are related to their educational level. Mothers with little formal education tend to be more fatalistic about illness and less concerned with detecting clinical manifestations of disease in their children than are well-educated mothers. The former are also less likely to follow up on precautionary measures suggested by health care providers. A mother who believes that people have no control over whether they become sick is more likely to seek care in an emergency facility and less likely to have a preventive approach to health. She is also less likely to seek preventative education and might not comply with recommended immunization schedules. Nursing interventions with a mother who believes that there is much a person can do to keep from becoming ill will be different with regard to the nature of health education and counseling provided. Assessment data related to the belief system(s) of the family provide the nurse with facts from which to choose approaches and priorities. For a mother who is not oriented to prevention of illness or maintenance of health, focusing energies on teaching might not be productive; it might be more useful to spend time designing family follow-up care or establishing an interpersonal relationship that invites the parent to follow recommended immunization schedules, well-child care, and other aspects of health promotion. Family Structures Families have become increasingly diverse and complex in recent decades, and there are many ways that social scientists have classified them. One out of every five children in the United States lives with at least one foreign-born parent, and the population is projected to become even more

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ethnically diverse in the future (Laughlin, 2014; U.S. Census Bureau, 2014). The number of children under age 18 living in nuclear or conjugal families, those with two married biologic parents and one or more children, is 46.7 million or 63% of all children (Laughlin, 2014; U.S. Census Bureau, 2014). Among families worldwide, the nuclear family is a rarity. In only 6% of the world’s societies are families as isolated and nuclear as in the United States and Canada. Approximately 18 million children, or 24% of all US children, live in a single-parent family, most of whom live with a single female parent. An additional 3.8 million children, or 5% of children, live with two unmarried parents. 3.3 million children (5% of children) do not live with either parent; rather, they reside with a guardian, such as another relative or nonrelative acting as a guardian for the child in the absence of a parent. Fifty-five percent of children (1.83 million) who do not live with a parent live with a grandparent or other extended family member. If children coreside with members of their mother’s family, this is referred to as a matrifocal family constellation; if the children coreside with members of their father’s family, it is called a patrifocal family constellation. Blended families include children from a previous marriage of the wife, husband, or both parents, or families formed outside of marriage. Lastly, there are extended families in which parents and children coreside with other members of one parent’s family. The extended family is far more universally the norm. Kin residence sharing, for example, has long been acknowledged as characteristic of many African American, Chinese American, Mexican American, Amish, and other groups (Laughlin, 2014; U.S. Census Bureau, 2014). Early in the nurse–parent relationship, it is necessary to identify members of the family who play a significant role in the care of the child. In societies where the extended family is the norm, parents—particularly those who married at a young age—might be considered too

inexperienced to make major decisions on behalf of their child. In these groups, key decisions are frequently made in consultation with more mature relatives such as grandparents, uncles, aunts, cousins, or other kin. Sometimes, nonkin is considered to be part of the extended family. In many religions, the members of one’s church, synagogue, temple, or mosque are viewed as extended family members who might be relied on for various types of support, including child care. Not coincidentally, members of some congregations refer to one another as brothers and sisters. The Amish family pattern is referred to as friendscraft, or three-generational family structure. Amish parents know that they can rely on the support of their entire church community. For example, a young Amish couple might turn to that community for assistance with decision making, finances, and emotional and spiritual support when a child is ill. The nurse should ask the parents if anyone else will be participating in the decision making that affects their child. Once that information is known, the person(s) identified by the parents should be included in the child’s plan of care. The influence of the extended family or the social support network on the child’s development becomes particularly important when the number of single-parent families in some culturally diverse groups is considered. The nuclear family is the unit for which most health care programs are designed. Consider the implicit message about the family when two or three chairs for visitors are placed in hospital rooms, physician or nurse practitioner offices, and other health care settings, for example. Although a handful of rural hospitals make special accommodations for the extended and church family of clients, few provide a place for the Amish to hitch their horses and buggies adjacent to the facility. With the advent of Family-Centered Care in the United States, all children’s hospitals provide more flexible visiting hours and extend visiting privileges to include siblings, extended family, and friends (see Evidence-Based Practice 6-3).

Evidence-Based Practice 6-3

When Health Care Provider Decisions Clash with Parental Preference Each year, health care research unravels the mystery of previously unknown diseases and conditions; recently, expanded knowledge about Proteus syndrome has been revealed. This rare congenital and progressive disorder causes soft tissue overgrowth (nonmalignant tumors), resulting in swelling that compresses nerves, vessels, and organs. Asymmetrical growth of skeletal and soft tissue also produces spinal deformities and respiratory compromise. It was a 12-year-old with Proteus syndrome who attracted the attention of the health care team. Turner (2010) provides unique insight into 2 years in the life of this child. These 2 years reflected a situation in which the care perceived necessary for the longevity of the child was in direct conflict with the traditional cultural beliefs of a Chinese family who immigrated to the United States. Over several years, the child deteriorated from attending school regularly to a nonverbal, agitated child exhibiting self-injurious behavior (head banging, scratching, and banging of extremities); she was hospitalized seven times. The mother had difficulty physically managing the child; the family had limited financial resources, lived in a small apartment that could not accommodate needed care equipment, was unable to communicate in English, and had no extended family available; the parents voluntarily placed the child in medical foster care. Over nearly 2 years in foster care, the child improved significantly. Consistent pain management helped to eliminate the self-injurious behavior; mobility improved; she demonstrated the understanding of simple words and began smiling. Since the course/progression of Proteus syndrome is unknown and hospitalizations were becoming

more frequent, the primary medical team requested a palliative care consultation. To determine the outcome of the ethical dilemma, the health care team utilized a four-quadrant ethical decision-making tool taking into consideration medical indications (principles of beneficence and nonmalfeasance), patient preference (respect for autonomy), quality of life (principles of beneficence, nonmalfeasance, and autonomy), and contextual features (loyalty and fairness). When the decisions were made and presented to the parents, they determined it was their familial duty to take the child out of foster care and back to their home to provide a dignified death. The health care team was severely divided about this decision: Some felt, for the child’s well-being, she should return to the foster care home where she was showing emotional improvement, and others believed it was a parental decision related to the care of a minor child. This dilemma was taken to the hospital ethics committee for decision. The committee determined that the rights of the parents superseded the other factors and the child was discharged to the parental home with a home care and pain management plan. This was clearly a difficult decision; however, the solution has ended being a correct one. Once again in her home environment, the child began to thrive, smile, make eye contact with her family, and even walk as few feet. She has been at home for 2 years and her parents seemed quite comfortable with the results: Supported by strong cultural ties, her mother never stops smiling.

Nursing Interventions

and hair care, apply to children of all racial and ethnic backgrounds, but the specific manner in which care is given might vary widely. Despite its importance, hair care is sometimes omitted for

Care of the hospitalized child’s body is the primary domain of the nurse. Principles related to personal hygiene, including bathing, shaving,

Reference: Turner, H. N. (2010). Parental preference or child well-being: An ethical dilemma. Journal of Pediatric Nursing, 25(1), 58–63.

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Black children because White, Hispanic, Asian, and Native American nurses might be unfamiliar with proper care. The hair of black children varies widely in texture and is usually fragile. Hair might be long and straight or short, thick, and kinky. The hair and scalp have a natural tendency to be dry and to require daily combing, gentle brushing, and application to the scalp of a light oil such as Vaseline or mineral oil. The hair might be rolled on curlers, braided, or left loose, according to personal preference. Bobby pins or combs might be used to keep the hair in place. If an individual has cornrow braids or shaved, sculptured hair, the scalp might be massaged, oiled, and shampooed without unbraiding the hair. Some blacks prefer straightened hair, which might be obtained chemically or thermally. Hair that has been straightened with a pressing comb will return to its naturally kinky state when exposed to moisture or humidity or when hair growth occurs. Children of Asian descent tend to have straight hair that does not require the same amount of care as the hair of most African Americans or Whites. Textural variations also are found in the facial hair of culturally diverse boys and men during adolescence and adulthood. Many Asian teenage boys have light facial hair and require infrequent shaving, whereas African American boys and men tend to have a heavy growth of facial hair requiring regular attention. Some black teenage boys have tightly curled facial hair, which, when shaved, curls back upon itself and penetrates the skin. This may result in a local foreign-body reaction on the face that can lead to the formation of papules, pustules, and multiple small keloids. Some African American teens and men might prefer to grow beards rather than shave, particularly when they are ill. Before shaving a teen, determine his usual method of facial grooming and attempt to shave or apply depilatories (agents that remove hair) in a similar manner. When using depilatories, protect the skin from irritation by keeping the chemical from contacting the client’s nose,

mouth, eyes, and ears. Straight and safety razors are contraindicated when depilatories are used because they can cause local irritation to the skin. Nurses should ask the child’s parent or exten ded family member how personal hygiene is carried out at home if in doubt. Children might feel more secure if a parent or close family member actually provides the care. If you determine that the child would benefit from care by a familiar caregiver from home, the rationale for requesting family intervention should be explained. Comments that the nursing staff is too busy or uninterested in providing personal hygiene or hair care should be avoided; rather, the benefit to the child’s security and sense of well-being should be emphasized. When bathing a client, remember that the washcloth removes some parts of the outermost skin layer. Such sloughed skin, which will be evident on the washcloth and in the bathwater, will vary in color depending on the ethnic group of the person being bathed. The sloughed skin of a darkly pigmented child, for example, will be a brownish black color. This does not mean that the child was dirty; the normal sloughing of skin is simply more evident in darkly pigmented people when compared with lightly pigmented groups. The more melanin that is present, the darker the skin color will be. Because dryness is more evident on darkly pigmented skin, Vaseline, baby oil, lanolin cream, and lotions can be applied after the bath to give the skin a shiny, healthy appearance. Communicating with the Hospitalized Child and Family Communicating with the child and the family is a key component in a successful hospitalization and recovery. Verbal communication is especially difficult when the child–family–health care provider do not speak the same language. The nurses may obtain the services of an interpreter, although they should be aware of gender- and age-related customs before doing so. For instance,

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

an a dolescent girl might be uncomfortable with an older male interpreter, and an older boy might prefer a friend to translate rather than an interpreter connected to the health agency. Attention should also be paid to the correct national origin of the child before seeking an interpreter; for example, an individual from Southeast Asia may speak Vietnamese, Cambodian, or Laotian— vastly different languages. Approximately 15% of migrant/immigrant families speak English in the home; this factor should be included in the nursing assessment. Most children and adolescents involved in the American school system learn English quickly and may serve as interpreters for family members. Even in families who have mastered English as a second language, the stress of illness and hospitalization may cause them to have difficulty communicating with English. Therefore, using a formal or informal interpreter is recommended. Nonverbal expressions can be powerful communication tools. Nurses should take their cues from observing the family interactions. Some Italian parents/families are very demonstrative with facial expressions and arm/hand gestures while the children may remain quiet. On the other hand, Asian parents and children both remain quiet and often wear “masked faces” showing very little emotional expression. Nurses must be aware of their own nonverbal expressions or actions, as they are often interpreted as disrespect or dislike of the individual rather than a situation. Evaluation of the Nursing Care Plan Obtaining a thorough cultural assessment, including use of folk remedies, during the initial encounter with the child/adolescent and parents is essential. It is upon this basis that the plan of care is developed, negotiated, and evaluated. To evaluate the effectiveness of the nursing care plan in providing culturally competent care, first ask a few probing questions to determine whether the plan was successful in achieving the desired outcomes, including the

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mutual goals established with the child and parents. Second, if the goals were not met, ask a few probing questions to determine the reasons for failure. Were the child and parents included in the planning and implementation of the nursing care? Were extended family members included in the plan? Did the true decision maker in the family participate in the care plan? Third, if the goals were met, the reasons for their success should be evaluated and communicated to other members of the health care team for future reference.

Application of Cultural Concepts to Nursing Care Two case studies are presented here to demonstrate the application of transcultural nursing concepts, theories, and research findings to clinical nursing practice. The first, Case Study 6-1, focuses on a very young child from an American Amish family and the second, Case Study 6-2, on a dying child from a Buddhist family. Each case exemplifies the need for involvement of extended families of varying types. Each also reflects how the response of the nursing team affected the end result of the child’s care. In addition, a specific, individualized plan of care for the Amish family is presented. As shown, the nursing issues in each case are complex and multifaceted. The interconnectedness of the various components of the child’s situation with the larger system is often minimized or disregarded. The values and beliefs of both the nurses within the health care delivery system and the family’s extended social network must be considered. For the purpose of analysis, some fundamental conflicts in values and beliefs have been identified. Similarities and differences also have been indicated in the nursing plan of care. In the case involving the Amish child, the young nurse was clearly advocating for a patient, in a situation requiring change in hospital practice, if not policy. It is assumed that this facility

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A rural Amish community is located about 50 miles from an urban medical center, the only facility available for care of an acutely ill child. An enthusiastic new RN emphatically presents her case to allow the presence of family/extended family of a 6-month-old Amish child who has been admitted for the repair of a cardiac VSD. The nurse is passionate about the issue, rational in her approach, and assured that she can prevail to change existing visitation policies. The problem of overnight accommodation for the extended community family has become a topic of debate among the nursing staff. Sensitive to the cultural practices and beliefs of the Amish child and his family, the new RN begins stating her position on behalf of the family’s right to adhere to Amish cultural practices to her supervisor. The supervisor listens impatiently and quickly interrupts with her decision. “These people are such a nuisance. The child wouldn’t even have the VSD if they didn’t insist on intermarriage within their own community. Then they come here in droves and think we have to give them a place to sleep. This isn’t a hotel. They can just go back to their horses and buggies and old-fashioned ways. The answer is NO! The natural, biologic mother and father may spend the night. Everyone else is to go home. And that’s final.”

The nurse leaves the discussion with her supervisor feeling dejected; however, she completes her data collection. Using Leininger’s transcultural model (1991), she examines the underlying attitudes, values, and beliefs among the Amish parents and those of the health care providers and then develops an individualized, culturally congruent, plan of care. Prior to discharge, the nurse, in collaboration with the parents and other significant members of the extended family, evaluates the effectiveness of the nursing care from a transcultural nursing perspective. The young nurse must also review the process in which change can be accomplished within the agency. She needs to determine what parts of the system can/should be manipulated to bring about desired change and who are the formal and informal leaders who can effect change. Outcome: There are no definitive solutions or answers for this dilemma. The case study is intended to demonstrate the complexity of the cross-cultural issues and to emphasize the necessity for thoughtful analysis of various facets of the problem. The ability to synthesize information from previous learning—psychology, anthropology, religion and theology, history, economics, sociology, principles of leadership, and others—to the nursing care of children from culturally diverse backgrounds is invaluable. The cultural assessment is the foundation of excellent transcultural care and cannot be overlooked even in the face of major obstacles of attitudes of others or limited time. A cultural assessment must become an integral part of the admission assessment of all children and adolescents, thus enabling excellent, individualized, family-centered care.

had not yet implemented principles of familycentered care, which are common practice in most agencies that care for children. Given the negative response of the nursing supervisor, it would seem the nurse needs to reassess her approach to the problem. She would be wise to first gather data from her colleagues to help her understand the immediate, inflexible response of the supervisor, and then determine whether there are possible compromises that would be

a cceptable to both family and supervisor. She will need to present the risk versus benefits of having the extended family remain with the child: Consider factors from agency perspective, the legal perspective, perspective of other patients, and the child/family perspective (see Box 6-1). A review of the literature will reveal significant data that support involvement of extended family in hastening recovery of the child by supporting the entire family.

Case Study 6-1 Presence of Immediate and Extended Family

Case Study 6-2 End-of-Life Care for a Buddhist Adolescent

Ving, 16 years of age, was born in Vietnam and immigrated to Australia with her family 15 years ago. She is a devout Buddhist. Ving was born hepatitis B positive, which is now complicated by advanced liver cancer. Over the past few weeks, Ving’s pain has become unmanageable at home, and her family has her admitted to the hospital for better pain management. Her family is concerned that appropriate preparations be made for her death. In collaboration with Buddhists monks, the nurses of the inpatient unit agree that Ving would be cared for through the final hours of her life with

minimal noise and minimal activity in her room; this was to ensure that her soul was as untroubled as possible. Her family remained with Ving around the clock and agreed to notify the nurses when she died; the health care team agreed not to touch the body until the family agreed it was appropriate. Outcome: On the day of her death, family, close friends, and spiritual advisors were present to oversee the process. Eight hours after her death, it was determined that Ving’s consciousness had departed; she was then examined by the health care team, and the time of death was documented. Adapted with permission from The Royal Australian College of General Practitioners from Clark, K., & Phillips, J. End of life care—The importance of culture and ethnicity. (2010). Australian Family Physician, 39(4), 210 -213. Available at www. racgp.org.au/afp/2010/april/end-of-life-care-%E2%80% 93-the-importance-of-culture-and-ethnicity

Box 6-1 Nursing Plan of Care: Hospitalization of an Amish Child: Conflicting Cultural Values Goal: Child’s recovery and ultimate discharge from the hospital (return to parents) in an optimal state of health. This is a mutual goal of the Amish child’s parents and of the health care providers within the health care system. In order to plan care for this child, the nurse needs to examine the underlying attitudes, values, and beliefs of the two groups that are in conflict. Points on which there is agreement must be identified as well. Amish–Rural, Agricultural Lifestyle Family Large families, extended sociocultural– religious network of community members who assist the natural parents Cooperation and support among extended family, especially in stressful “crisis” times such as hospitalization of a child Child generally not left alone when away from community; someone from the community visits or stays in absence of parents. Concept of family includes “nonblood relatives.” Parental Obligations Children are a part of a larger cultural group; adult members of the larger community have various relationships and obligations to the children and parents even though they are not biologically related.

Urban Health Care Providers Small family units, urban lifestyle, nuclear family

Individual responsibility by members of a nuclear family; mother and father primarily responsible Visiting by grandparents and siblings accepted but only two at any given time and only parents can remain over night. Concept of family includes only biologically related persons. Mother and father are responsible for children; only they may stay with the child overnight. Physical size of hospital facilities does not allow for a large number of visitors, who clutter rooms, violate fire safety rules by blocking doorways, and hinder delivery of care. Responding to requests for information from every visitor is time consuming and violates HIPAA policies. (continued)

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Economic Considerations Communal sharing of resources; hospital bill is paid from a common fund; entire bill is paid in cash upon discharge.

Rely on private or state subsidized health insurance coverage for payment of all costs related to patient care; sense of anonymity and impersonal involvement

Traditional and Religious Values Religious values permeate all aspects of daily living; time set aside daily for prayer and reading of scripture.

Religion is important and adherence to practices often vary based on severity of illness; worship usually limited to a single day of the week, such as Saturday or Sunday.

Belief that illness afflicts both the “just” and the less righteous and is to be endured with patience and faith

Illness is part of a cause–effect relationship; science and technology will one day conquer illness.

Protestant work ethic (in an agricultural, rural sense)

Protestant work ethic (in an urban sense)

Dress is according to 19th-century traditions; specific colors and styles indicate marital status.

Fashions occur in trends; wide range of “acceptable” dress.

Married men wear beards; single men are clean-shaven.

Whether a man shaves is a matter of personal preference.

Simple, rural lifestyle; family-oriented living. For religious reasons, avoid “modern” conven iences such as electricity; use candles/ kerosene lights, outdoor sanitary facilities.

Use hi-tech electronic equipment, electricity, and nuclear energy. Indoor plumbing is the norm; autoflush toilets and water that runs with the wave of a hand are “ordinary.”

Summary Culture exerts an all-pervasive influence on infants, children, and adolescents and determines the nursing interventions appropriate for the individual child, parents, and extended family members. Knowledge of the cultural background of the child and family is necessary for the provision of excellent transcultural nursing care. Cross-cultural communication must convey genuine interest and allow for expression of expectations, concerns, and questions. Culture influences the child’s physical and psychosocial growth and development. Basic physiologic needs such as nutrition, sleep, and elimination have aspects that are culturally determined. Parent–child relationships vary significantly among families of different cultures, and individual differences among those with the same background add to the complexity. Cultural beliefs and values related to health and illness influence

health-seeking behaviors by parents and determine the nature of care and cure expected. Regardless of the cultural background of an adolescent, the transition from childhood to adulthood must be accomplished. This can be complicated when the adolescent’s values, beliefs, and practices conflict with traditional cultural values or with those of the dominant culture in which the teenager lives. Acculturation of an adolescent presents multiple issues for the family as well as for the teen.

Review Questions 1. Compare and contrast the childrearing practices

of three cultural groups. For each of the three groups, also discuss the role of extended family members in raising children, and describe the ways in which extended family members can assist parents during a child’s illness.

Chapter 6 Transcultural Perspectives in the Nursing Care of Children

2. Critically examine the perceived causes of

chronic illness and disability in children from diverse cultures. Describe how the parental philosophic and religious beliefs affect their reaction to and explanations for the child’s chronic illness and/or disability. 3. Describe the symptoms associated with the following Hispanic cultural illnesses affecting children:

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2. When caring for a child from a cultural back-

ground different from your own, spend time talking with the child’s parents or primary provider of care, and discuss the childrearing beliefs and practices specifically related to the child’s nutrition, sleep, elimination, parent–child relationship, discipline, growth, and development. Compare and contrast the parental responses with your own beliefs and practices.

a. Pujos (grunting) b. Mal ojo (evil eye) c. Caida de la mollera (fallen fontanel) d. Empacho (a digestive disorder)

3. When assigned to the pediatric unit, observe

Critical Thinking Activities

4. When caring for a child from a cultural back-

1. Arrange for an observational experience in

a culturally diverse classroom. Compare and contrast the behaviors observed. Does the student–teacher interaction vary according to cultural background? What culturally based attitudes, values, and beliefs are reflected in the children’s behaviors? The teacher’s attitude? Ask the teacher(s) to describe the cultural similarities and differences in the classroom.

the number and relationship of visitors for children from various cultures. Who visits the child? If nonrelated visitors come, how do they interact with the child? With the parent(s)?

ground different from your own, ask the parent(s) or primary provider(s) of care to tell you what they believe causes the child to be healthy and unhealthy. To what cause(s) do they attribute the current illness or hospitalization? What interventions do they believe will help the child to recover? Are there any healers outside of the professional health care system (e.g., folk, indigenous, or traditional healers) whom they believe could help the child return to health?

References Aruda, M. M. (2011). Predictors of unprotected intercourse for female adolescents measured at their request for a pregnancy test. Journal of Pediatric Nursing, 26(3), 216–223. doi: 10.1016/j.pedn.2010.02.005 Agency for Healthcare Research and Quality. (2014). 2013 National Healthcare Disparities Report. U.S. Department of Health and Human Services (AHRQ Publication No. 14–0006. Rockville, MD: Author. Barajas, R. G., Martin, A., Brooks-Gunn, J., & Hale, L. (2011). Mother-child bed-sharing in toddlerhood and cognitive and behavioral outcomes. Pediatrics, 128(2), e339–e347. doi: 10.1542/peds.2010-3300. Barry, H., Bacon, M. K., & Child, I. L. (1967). Definitions, ratings, and bibliographic sources of child-training practices of 110 cultures. In C. S. Ford (Ed.). Cross-cultural approaches (pp. 293–331). New Haven, CT: HRAF Press. Benoit, D. (2004). Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatrics & Child Health, 9(8), 541–545.

Bresnahan, M., Zhuang, J., & Park, S. (2014). Cultural differences in the perception of health and cuteness of fat babies. The International Journal of Communication and Health (4), 52–58. Cachelin, F. M., & Thompson, D. (2014). Impact of Asian American mothers’ feeding beliefs and practices on child obesity in a diverse community sample. Asian American Journal of Psycology, 5(3), 223–229. Carlson, D. L., McNulty, T. L., Bellair, P. E., & Watts, S. (2014). Neighborhoods and racial/ethnic disparities in adolescent sexual risk behavior. Journal of Youth and Adolescence, 43(9), 1536. doi: 10.1007/s10964-013-0052-0 Cartagena, D. C., Ameringer, S. W., McGrath, J., Jallo, N., Masho, S. W., & Myers, B. J. (2014). Factors contributing to infant overfeeding with Hispanic mothers. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 43(2), 139. doi: 10.1111/1552-6909.12279. Centers for Disease Control and Prevention. (2014a). Strategies for reducing health disparities: Selected

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Kirby, J. B., Liang, L., Hsin-Jen, C., & Wang, Y. (2012). Race, place, and obesity: The complex relationships among community racial/ethnic composition, individual race/ethnicity, and obesity in the United States. American Journal of Public Health, 102(8), 1572–1578. Kliegman, R. M., Stanton, B. F., Saint Geme, J. W., Schor, N. F., & Behrman, R. E. (2011). Nelson textbook of pediatrics (19th ed.). Philadelphia, PA: Elsevier Saunders. Korbin, J. E. (1991). Cross-cultural perspectives and research directions for the 21st century. Child Abuse and Neglect, 15(Suppl. 1), 67–77. Lanier, P., Maguire, K., Tova, J., Drake, B., & Hubel, G. (2014). Race and ethnic differences in early childhood maltreatment in the United States. Journal of Developmental and Behavioral Pediatrics, 35(7), 419–430. Laughlin, L. (2014). A child’s day: Living arrangements, nativity, and family transitions: 2011 (selected indicators of child well-being), Current Population Reports, P70-139. Washington, DC: U.S. Census Bureau. Leininger, M. M. (1991). Culture care delivery and universality: A theory of nursing. New York, NY: National League for Nursing Press. Liamputtong, P. (2011). Infant feeding practices: A crosscultural perspective. New York, NY: Springer Science + Business Media. Luijk, M. P., Mileva-Seitz, V. R., Jansen, P. W., van IJzendoorn, M. H., Jaddoe, V. W., Raat, H., et al. (2013). Ethnic differences in prevalence and determinants of mother-child bedsharing in early childhood. Sleep Medicine, 14, 1092–1099. Moreno, G., Johnson-Shelton, D., & Boles, S. (2013). Prevalence and prediction of overweight and obesity among elementary school children. Journal of School Health, 83(1), 157–163. Natale, V., & Rajagopalan, A. (2014). Worldwide variation in human growth and the World Health Organization growth standards: A systematic review. British Medical Journal Open, 8(1), e003735. Retrieved at http://www. pubfacts.com/detail/24401723/Worldwide-variation-inhuman-growth-and-the-World-Health-Organizationgrowth-standards:-a-systematic The National Center on Family Homelessness. (2015). “Children.” Retrieved January 11, 2015 from http://www. familyhomelessness.org/children.php?p=ts Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA, 311(8), 806. Overfield, T. (1995). Biologic variation in health and illness: Race, age and sex differences (2nd ed.). New York, NY: CRC Press. Rakhmanina, N., Hader, S., Denson, A., Gaur, A., Mitchell, C., Henderson, S., Paul, M., Barton, T., Herbert-Grant, M., Perez, E., Malachowski, J., Dominguez, K, Danner, S., & Nesheim, S. (2011). Premastication of food by caregivers of HIV-exposed children—Nine US sites, 2009–2010. Morbidity and Mortality Weekly Report, 60(9), 273–275.

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Transcultural Perspectives in the Nursing Care of Adults ●●Joyceen S. Boyle

Key Terms Adulthood Caregiving Developmental crises Developmental tasks Generativity Health/illness situational crises

Health/illness situational transitions “High blood” HIV/AIDS Middle adulthood Midlife crisis “Nerves” Physiologic development

Psychosocial development Sandwich generation Social age Social roles Stroke belt Transitions of adulthood Young adulthood

Learning Objectives 1. Evaluate how culture influences adult development. 2. Explore how health-related situational crises or transitions might influence adult development. 3. Analyze the influences of culture on caregiving in the African American culture. 4. Analyze the influences of culture on women’s development in the African American family. 5. Evaluate cultural influences in adulthood that assist individuals and families to manage during health-related situational crises or transitions. 6. Explain how gender and specific religious beliefs and practices might influence an adult’s health and/or illness during situational crises or transitions.

This chapter discusses transcultural perspectives of health and nursing care associated with developmental events in the adult years. The focus is primarily on young and middle adulthood. The 186

first section of this chapter presents an overview of cultural influences on adulthood, with an emphasis on how health/illness situational crises or transitions might be influenced by

Chapter 7 Transcultural Perspectives in the Nursing Care of Adults

c ultural variations. The second section provides the context for and gives an example of a healthrelated situational crisis. The influences of culture on individual and family responses to health problems, caregiving, and health/illness transitions and crises are discussed. Health/illness transitions have been referred to in the past as developmental tasks, those transitions that occur in a normal successful adulthood. A health/illness situational crisis refers to changes or turmoil as individuals struggle to cope with a sudden life-threatening illness. Erikson (1963), who studied adult development, used the term “developmental tasks” or “developmental crises” to describe those times in an individual’s life when changes occur, such as marriage or the birth of a child. Meleis, Sawyer, Im, Hilfinger Messias and Schumacher (2000) chose the term “transitions” as they believe that term more adequately describes life changes and is a conceptually more appropriate term for nursing theory. Nomenclature or terminology about changes and experiences in adulthood can be confusing as the terms are changing. In this chapter, transitions refer to those health or illness events that occur within adulthood and require an individual to make modifications in his/her lifestyle. Transitions can occur gradually over a period of time or they may be preceded by a situational crisis. A situational crisis includes more turmoil and anxiety and is more threatening to an individual and family. An example of a health/illness situational crisis might be a sudden myocardial infarction experienced by a 48-year-old man. Until his condition is stabilized, both he and his family will be in a crisis situation, worried and very anxious about his life. When his condition stabilizes and is no longer life threatening, both he and his family members will experience a more gradual health/ illness transition. This transition will include changes in his behavior such as appropriate exercises, changes in diet that might include weight reduction, and the addition of daily medications. Whether the client experiences a crisis or a transition, he or she will need culturally competent and contextually meaningful nursing care.

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Overview of Cultural Influences on Adulthood Health/illness crises and/or transitions during adulthood are of interest to nursing because they include responses to health and illness. In addition, health/illness transitions influence how individuals respond to health promotion and wellness by shaping individual lifestyles including eating habits, exercise, work, and leisure activities. Consider, for example, how pregnancy (a transition into motherhood) influences many young adult women to improve their diet, begin moderate exercises, abstain from alcohol, and, in general, take better care of themselves so their baby will be healthy. The adult years are a time when gradual physical and psychosocial changes occur. These changes are usually gradual and reflect the normal processes of aging. These physical changes, or physiologic development, are evident in the hormonal changes that take place in adulthood in both men and women. Psychosocial development, or the development of personality, may be more subtle but is equally important. Both physiologic development and psychosocial development are influenced by cultural values and norms, and they occur throughout a lifetime.

Physiologic Development During Adulthood Women undergo menopause, one of the more profound physiologic changes that results in a gradual decrease in ovarian function with subsequent depletion of progesterone and estrogen. While these physiologic changes occur, self-image and self-concept (psychosocial terms) change also. The influence of culture is relevant because women learn to respond to menopause within the context of their families and culture. The perception of menopause and aspects of the experience of menopausal symptoms appear to vary across cultures. It has sometimes been assumed that non-Western women do not experience the

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menopausal problems seen in Western society because their status increases as they age; however, this assumption has been challenged. In Western cultures, such as Canada and the United States, youth and beauty are valued and aging is viewed with trepidation. Western medicine has tended to treat the symptoms of menopause with hormone replacement therapy, surgical interventions, and/or pharmaceutical products. Although there are not many studies on the perimenopausal transition across cultural groups, there seem to be cultural differences in the reporting of symptoms associated with treatments for menopausal symptoms. One recent study has shown that such factors as length of time spent in the United States and social–economic status were significant predictors of number and severity of menopausal symptoms among immigrant women (Im, Lee, & Chee, 2010). This reinforces an earlier statement that women (as well as others) learn to respond to menopause and aging within the context of their families and culture. Men also have physical and emotional changes from the decreased levels of hormones. Loss of muscle mass and strength and a possible loss of sexual potency occur slowly. However, developmental differences among both adult men and women have not been extensively examined cross-culturally, and most existing theoretical and conceptual models of adult health do not provide insight into cultural variations. The cultural belief that aging, however gradual, is a normal process and not a cause for medical and/or surgical intervention may be more apparent in diverse cultural groups.

Psychosocial Development During Adulthood Adulthood was termed the “empty middle” by Bronfenbrenner (1977). A noted developmental psychologist, his use of this term was an indication of Western culture’s lack of interest in the adult years. Traditionally, these years were viewed as one long plateau that separates childhood from old age. It was assumed that decisions

affecting marriage and career were made in the late teens and that drastic changes in developmental processes seldom occurred afterward. For many years, most developmental theorists saw adulthood as a period to adapt to and come to terms with aging and one’s own mortality. Western thinking has changed considerably since Bronfenbrenner’s observations. Psychosocial development in middle age is now viewed as a vigorous and changing stage of life involving many challenges and transformations. Sociocultural factors in Western society have precipitated tremendous changes, producing crises, change, and other unanticipated events in adult lives. Divorce, remarriage, career changes, and increased mobility, as well as other societal changes (the sexual revolution, the women’s movement), have had a profound impact on the adult years. Many middle-aged adults may be caught in the sandwich generation—still concerned with older children (and sometimes grandchildren) while also increasingly concerned with the care of aging parents. Middle life can be a time of reassessment, turmoil, and change. Society acknowledges this with common terms such as midlife crisis or even empty nest syndrome, along with other terms that imply stress, dissatisfaction, and unrest. However, adulthood is not always a tumultuous, crisis-oriented state; many middleaged persons welcome the space, time, and independence that middle age often brings. Midlife can be a time of challenge, enjoyment, and satisfaction for many persons. We now tend to view a “midlife crises” as a time of transition that can be a positive experience, including the mastery of new skills and behaviors that helps an individual to change and grow in response to a new environment (Meleis et al., 2000).

Chronologic Standards for Appropriate Adult Behavior Much of the work on adult development was done in the 1960s and 1970s by developmental psychologists such as Bronfenbrenner (1977); Havighurst (1974); and Neugarten (1968), all of who proposed

Chapter 7 Transcultural Perspectives in the Nursing Care of Adults

different theories about adult development. We still rely on some of this early work as we attempt to understand the complexities of adult development. Neugarten (1968) observed that each culture has specific chronologic standards for appropriate adult behavior and that these cultural standards prescribe the ideal ages at which to leave the protection of one’s parents, choose a vocation, marry, have children, and, in general, get on with life. The events associated with these standards do not necessarily precipitate crises, but they do bring about change. What is more important is the timing of these events. As a result of each culture’s sense of social time, individuals tend to measure their accomplishments and adjust their behavior according to a kind of social clock. Awareness of the social timetable is frequently reinforced by the judgments and urging of friends and family, who say, “It’s time for you to …” or “You are getting too old to …” or “Act your age.” Problems often arise when social timetables change for unpredictable reasons. An example is the recent trend of adult children, frequently divorced, unemployed, or both, returning to live with their parents, often bringing along their own children. Grandparents caring for grandchildren is now a common phenomenon in Western society. Being widowed in young adulthood or losing one’s job at age 50 due to an economic downturn are examples of events in adulthood that are likely to cause stress and conflict because they occur outside of the acceptable social timetable. Culture exerts important influences on human development in that it provides a means for recognizing stages in the continuum of individual development throughout the lifespan. It is culture that defines social age, or what is considered an appropriate behavior in each stage of the life cycle. In nearly all societies, adult role expectations are placed on young people when they reach a certain age. Several cultures have defined rites of passage that mark the line between youth and adulthood; in the United States, markers of beginning adulthood include reaching the legal age to obtain a driver’s license, to drink alcohol, or to join the military forces.

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Menarche is a milestone in a young girl’s physiologic development and a psychologically significant event that provides a rather dramatic demarcation between girlhood and womanhood. However, this is not an event that is celebrated openly in Western culture; most girls are too embarrassed to talk openly about it with anyone but their mothers or close friends. There are no definitive boundaries that mark adulthood for either young girls or young boys, although legal sanctions confer some rights and responsibilities at the ages of 18 and 21 years. There is no single criterion for the determination of when young adulthood begins, given that different individuals experience and cope with growth and development differently and at different chronologic ages. A young boy who joins the military forces at age 18 and serves in Iraq or Afghanistan may “grow up” more quickly than the 18-year-old who lives with his parents, has a part-time job, and attends a local community college. Adulthood is usually divided into young adulthood (late teens, 20s, and 30s) and middle adulthood (40s and 50s), but the age lines can be fuzzy. Generally, a young adult in his or her late teens and early 20s struggles with independence and issues related to intimacy and relationships outside the family. Role changes occur when the young adult is pursuing an education, experiencing marriage, starting a family, and establishing a career. A middle adult most often concentrates on career and family matters. However, as previously mentioned, adulthood is not necessarily an orderly or predictable plateau. Experiences at work have a direct bearing on the middle-aged adult’s development through exposure to jobrelated stress, levels of physical and intellectual activity, and social relations formed with coworkers. “Recareering” or changing careers during middle adulthood is also becoming more common. At home, family life can be chaotic, with role changes and other developmental transitions occurring with dizzying frequency. Often, adults are faced with the realization that they are getting older and feel like they have made the wrong choices or have left many things still undone.

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Some life changes can lead to developmental crises. According to Erikson (1963), a developmental crisis occurs when an individual experiences normal and expected challenges that are age appropriate. For example, a young adult may have difficulties separating from his or her parents and establishing independence. This is usually resolved as “homesickness” and dissipates as the young adult gains the ability to adjust to a new lifestyle such as college, the military, or employment away from home. A health/illness situational crisis is often focused and specific and can occur at any time. Sometimes, a situational crisis can be precipitated by an illness, such as a diagnosis of type 2 diabetes or the death of an infant. A situational health/illness crisis usually is time limited, although additional transitions may occur. How well individuals cope with and manage the challenges of health/illness crises and transitions in adulthood is influenced by cultural values, traditions, and backgrounds. Developmental Tasks Throughout life, each individual is confronted with developmental tasks (Erikson, 1963), those responses to life situations encountered by all persons experiencing physiologic, psychological, spiritual, and sociologic changes. Although the developmental tasks of childhood are widely known and have long been studied, the developmental tasks of adulthood are less familiar to most nurses. Several theorists have studied and defined the developmental or midlife tasks of adulthood. Many personality theorists—for example, Freud, Erikson, and Fromm—cite maturity as the major criterion or task of adulthood. These various theories have implications for how we define “development,” “maturity,” and “wisdom.” According to Erikson (1963), the major developmental task of middle adulthood is the resolution of generativity versus stagnation. Resolution of the “crises” or conflict between these two conflicting forces results in attainment of the first attribute, in this case generativity. Generativity is accomplished through parenting, working in one’s career,

articipating in community activities, or working p cooperatively with peers, spouse, family members, and others to reach mutually determined goals. Mature adults have a well-developed philosophy of life that serves as a basis for stability in their lives. Individuals in adulthood assume numerous social roles, such as spouse, parent, child of aging parent, worker, friend, organization member, and citizen. Each of these social roles involves expected behaviors established by the values and norms of society. Through the process of socialization, the individual is expected to learn the behaviors appropriate to the new role. It is important to note that many developmental theories have connotations of stability and blandness associated with adulthood, although this probably is not the case. The constellation of characteristics enumerated by Erikson and other theorists has been attributed to predominantly White Anglo-Saxon Protestant (WASP) views and behaviors. For many cultural groups in Western society, the mastery of Erikson’s developmental tasks is not easily managed and is not always applicable, and in some cases, it may even be undesirable. For some groups, developmental tasks may be accomplished through culturally defined patterns that are different from or outside of the norm of what is expected in the dominant culture. Evidence-Based Practice 7-1 discusses how an observant Jewish woman and her family, in labor, delivery, and postpartum, should have nursing care that allows her to abide by Jewish laws, customs, and practices that influence everyday life as well as those that pertain to childbearing. Childbearing is a special time for most cultures, and there are cultural prescriptions to ensure the well-being of both the mother and the child. Childbearing that occurs in young and middle adulthood is a prime example of the interface between culture, religion, childbearing practices, and transcultural nursing care. Studies focusing on the developmental experiences of women have led several authors (Belenky, McVicker, Clinchy, Goldberger, & Tarule, 1997) to suggest that developmental stages and the

Evidence-Based Practice 7-1

Jewish Laws, Customs, and Practice in Labor, Delivery, andPostpartum Care This article provides a comprehensive and thorough guide to specific laws, customs, and practices of traditionally, religious observant Jews that assist the transcultural nurse or midwife to provide culturally congruent and sensitive care during labor, delivery, and the postpartum period. Providing culturally congruent care includes cultural knowledge, in this case, the nurse or midwife needs to understand the Jewish laws, customs, and practices that guide everyday life, as well as those that pertain to childbearing. These cultural issues include adherence to the laws that influence intimacy issues between husband and wife, or niddah; dietary laws, or kashrut; and observance of the Sabbath. Detailed tables are provided that list the following: (1) observant Jewish customs, laws, and practices during labor, delivery, and postpartum; (2) annual Jewish holidays and fast days; (3) a cultural assessment for Jewish clients in labor, delivery, and postpartum. Case studies are presented that describe cultural competence challenges for nurses who want to learn about the Jewish culture and how to provide culturally competent care to Jewish women during childbirth.

associated developmental tasks of adulthood have been derived primarily from studies of men. These authors suggest that women experience adult development differently. Women’s traditional location of responsibility was in the home, nurturing children and husbands as well as parents. Belenky et al. point out that this view is changing, prompted by societal changes and informed by scholars who are addressing women’s psychosocial development in new ways. Culture and Adult Transitions More recent theories of adulthood (Demick & Andreoletti, 2003; McCrae & Costa, 2003) suggest that development is an evolutionary expanse

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Recognize that observant Jewish couples are committed to maintaining their religious laws, customs, and practices as much as possible throughout the labor, delivery, and postpartum experiences. Understand that childbirth is a time that is highly influenced by cultural values and beliefs. The religious laws, customs, and practices that will be most apparent during labor, delivery, and postpartum will pertain to prayer, communication between husband and wife, dietary laws, the Sabbath, modesty issues, and labor and birth customs. The culturally competent nurse follows the cues of the religious family, tailoring his or her health and nursing care in a manner that allows the family to practice their traditions in their specific designed manner while employing professionalism and creativity in providing quality patient care.

Reference: Noble, A., Rom, M., Newsome-Wicks, M., Englehardt, K., & Woloski-Wruble, A. (2009). Jewish laws, customs, and practice in labor, delivery and postpartum care. Journal of Transcultural Nursing, 20, 323–333.

involving different eras and transitions. These life transitions have triumphs, costs, and disruptions. Within nursing, Meleis et al. (2000) proposed a framework to study life transitions. They focus on transitions that are developmental and situational, including those brought about by an illness. The next section discusses several important adult life transitions and examines how culture and life events influence adult growth and change during these transitions. The successful progression through developmental tasks and/or life transitions may occur slowly over many years and are important in terms of quality of life and life satisfaction. Culture influences these transitions, and it is important that nurses be able to 191

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evaluate their adult clients and help them adjust and change in culturally appropriate ways. These adult life transitions are often based on what we could call “middle-class, White American culture.” Diverse cultures may experience different life transitions or experience life transitions in different ways depending on the cultural group (Baird, 2012; Baird & Boyle, 2012). The following section focuses on various cultural groups and how they might experience adult life transitions. The terms “transitions” and “developmental tasks or goals” are used interchangeably and refer to selected activities at a certain period in life that are directed toward a goal. Unsuccessful achievement of this goal is thought to lead to inability to perform tasks associated with the next period or stage in life. Developmental Transitions: Achieving Career Success

Many persons in traditional Western culture define career success in financial terms, while others may see it as providing service or making a contribution to the lives of their fellow citizens. Achieving success in one’s career—and that includes adequate financial renumeration as well as satisfaction and enjoyment—is considered an important developmental task or goal in adulthood. However, there are many groups who struggle to attain this goal. Immigrants to the United States, Canada, or Europe may find it is very difficult to find employment that pays an adequate salary or offers opportunities for advancement or job satisfaction. North America and Europe, as well as other parts of the world, have experienced a tremendous influx of immigrants and refugees from Southeast Asia, Latin America, Eastern Europe, the Middle East, Africa, and other geographical areas. Although immigrants and refugees may aspire to career success or to earn a higher salary, those may be difficult goals to attain. They may have difficulty with the language, with the skills and educational level required, as well as other factors necessary for holding a good job in their new country. Other factors, such as gender, also influence the attainment of satisfaction in career choices.

More women are working outside of the home, and there may be a different division of time and energy for both spouses that pose challenges. Women’s presence in the work force has increased dramatically, from 30.3 million in 1970 to 72.7 million during 2006 to 2010, and this has had a significant impact on childcare and family finances. Although women have made significant gains in certain occupations, many women continue to be employed in low-paying jobs with little chance for advancement. Many are employed in occupations that have been traditionally oriented toward women (Huffington Post, April 12, 2014), and the salaries are less than men earn in similar positions. Working in a low-paying job that does not offer opportunities for advancement or intellectual challenges does not lead to career success or recognition from one’s peers. Many immigrant and refugee families experience role conflict and stress as gender roles begin to change during contact with Western culture. For example, sometimes, the male head of household who has immigrated is unable to find employment; if he was a professional in his former country, he may be reluctant to accept the menial jobs that are traditionally filled by immigrants or refugees when they first migrate to another country. Frequently, low-status jobs are more available to immigrant women, yet their traditional roles are closely tied to the home and family. When an immigrant or refugee woman begins to work outside of the home, her role changes and those changes alter the traditional power structure and the roles within the family. The lack of adequate social supports, such as affordable daycare for children and adequate compensation for work, and the additional physical and emotional stress result in an unacknowledged toll on immigrant and refugee families. Box 7-1 lists some characteristics of immigrant and refugee families. At present, to expect members of certain groups, such as poor or ethnic minorities, newly arrived immigrants or refugees, the homeless, the mentally ill, or the unemployed, to achieve satisfaction from jobs that interest them or from status derived from succeeding in a career is unrealistic

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Box 7-1 Some Characteristics of Immigrant and Refugee Families 1. Traditional family values are evident; for example, roles of men and women are differentiated. Women’s role is in the home, with the family. Men are heads of the household and family providers. 2. Families tend to be extended; if members do not actually live in the same household, they visit and contact each other frequently. New immigrants and refugees tend to keep in fairly close contact with family members in the home country. 3. Many immigrants come to the United States because they already have family members here. 4. Most immigrants and refugees are poor and struggle to earn an adequate income. Often, men in refugee communities have been professionals in their home country but are unable to be employed in the same capacity in their new host country. Women are often more easily employed outside of the home,

and indicates a lack of sensitivity to the problems faced by these groups. Thus, although the work role is valued in American society, the attainment of a successful career that includes financial success and personal fulfillment may not be realistic for some minority groups, immigrants, or even certain individuals within the majority culture, some of whom are returning to school in the hope of preparing for a second career. Developmental Transition: Achieving Social and Civic Responsibility

Social and civic responsibilities are in part culturally defined. Generally speaking, American and Canadian cultures value the voluntary contributions of their citizens in various agencies and organizations that contribute services to the community or society in general. For this discussion, achieving social and civic responsibilities can be viewed as participation in those activities in adulthood that contribute to the “good of society.”

and they often find employment as domestic or service workers. For many refugee or immigrant women, working outside of the home is a new experience for them. To earn a salary and provide for their families can be very empowering for these women. 5. Refugees may be fleeing war and political persecution. Many may experience symptoms of posttraumatic stress syndrome. 6. Traditional health and illness beliefs may influence behavior. Immigrant and refugee families may combine traditional health practices with modern Western health care. The use of traditional practices is fairly common in some groups. 7. Language is a significant barrier for the first few years that immigrants and refugees live in the United States and Canada. Children tend to learn English and become acculturated faster than their parents.

Usually, this means activities and c ommitments outside of the immediate family. It can vary considerably, from serving as a board member for a community agency, such as a homeless shelter, to volunteering to teach in a literacy program or donating blood at the local blood bank. Not all members of dominant Western cultures value achieving an elected office in, for example, the local Parent–Teacher Association (PTA) or Rotary Club; other cultures may find these goals baffling and, instead, emphasize activities and contributions within the cultural group. For example, in some groups, religious obligations are given priority over civic responsibilities. Usually, traditional religious groups have not encouraged the emergence of women in leadership roles within the church structure or the wider society, although this is now being challenged by women within several religious groups. Sometimes within traditional cultures, women who seek roles outside the family are criticized

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because recognition and acknowledgment outside the family group may conflict with the traditional role of women. Some religious and ethnic or cultural groups believe that a woman’s place is in the home, and women who attempt to succeed in a career or participate in activities outside the home or group are frowned on by other members of the group. Civic responsibilities that relate to children or domestic matters may be viewed as more appropriate for women to assume, whereas other civic activities may be viewed as more within the province of men. Middle Eastern and Southeast Asian cultures emphasize and value responsibilities and contributions to the extended family or clan rather than to the wider society. Numerous researchers (Baird, 2012; Baird & Boyle, 2012) have reported that refugee women in the United States continue to socialize almost exclusively with other refugee women, often extended family/clan or tribe members. They are more comfortable with others who not only share their traditional culture and language and life events, but who are also going through similar situational transitions (the immigrant experience). Many refugee women are single or widowed with children. Women whose husbands have been killed or have stayed behind to fight in various conflicts are often forced to flee with children and/or elderly family members. Women refugees carry a substantial burden during the migration process and are essential in helping the family members settle into a new country. Coping with life in a new country becomes the focus of their daily lives. Finding a job, getting children into school, learning English, and other resettlement activities become challenging transitions for them. Many refugee women are justifiably very proud of their accomplishments. They learn new job skills, a new language, how to drive a car, all accomplishments that are not always recognized by members of their new society. For the refugee women and her family, these are significant achievements; however, they can be quite stressful. Often, informal social networks, such as having family members and friends nearby, are very helpful and supportive. The social and

civic responsibilities that we have associated with adulthood in Western cultures may not be appropriate for many other cultural groups. Concepts such as social connectedness and integration, resilience, and strength (described by Baird, 2012 and Baird & Boyle, 2012) might help us better understand adult development and transitions in refugee and immigrant families. Developmental Transition: Marriage and Raising Children to Adulthood

Marriage and raising children usually take place in early to middle adulthood. The age at which young persons marry and become independent varies by custom or cultural norm, as well as by socioeconomic status. Generally speaking, in Western culture, young adults of lower socioeconomic status leave school, begin work, marry, and become parents and grandparents at earlier ages than middle-class or upper-class young adults. Indeed, many North American families encourage early independence by urging their children to attend college or to find employment away from home. Other cultural groups, such as those from the Middle East and Latin America, place more emphasis on maintaining the extended family. Even after marriage, a son and his new wife may choose to live very close to both families and to visit relatives several times each day. Families from some cultural groups, such as Hispanics, or traditional religious groups, such as the Hutterites or the Amish, may be reluctant to allow their young daughters to leave home until they marry. In many Muslim families, girls do not leave home until they are married. Increased mobility in American and Canadian societies has impacted family life as many young families now live far away from grandparents, and the traditional influences of grandparents on young grandchildren are decreasing. Sometimes because of geographical distance, grandparents barely know their grandchildren, although digital photos via home computers, cell phones, Skype, and other technological devices are helping to keep grandparents up to date with the growth and activities of their grandchildren.

Chapter 7 Transcultural Perspectives in the Nursing Care of Adults

Changes in terms of women’s participation in the workforce began in the 1970s when a singleincome household could no longer support a comfortable, middle-class lifestyle (Huffington Post, April 9, 2014). In addition, many young women attend college or universities and want to become established in their careers before they marry or have children. With both mothers and fathers working, children are often placed in childcare facilities. These factors have had a tremendous impact on men and women’s roles and responsibilities within the marriage and on how children are raised. Developmental Transition: Changing Roles and Relationships

Relationships between marriage partners, between and among genders, within social networks of family and friends, and between parents and children and the roles men and women play within these relationships are all influenced by cultural norms and traditions. In Western culture, the relationship between a wife and husband is often enhanced in middle adulthood, although divorce at this time is not infrequent in the United States. The frequent need for both spouses to work may conflict with traditional roles and cause feelings of guilt on the part of both the husband and wife. Some women continue to assume all responsibility for domestic chores while working outside the home, and they experience considerable stress and fatigue as a result of multiple role demands. If either or both spouses are working in low-paying jobs and still struggling to make ends meet, or if the jobholder is laid off or loses his or her job, adulthood may not be a time of enjoyment and leisure activities. Some adults may experience what is known as a “midlife jolt,” a particularly dramatic life event such as an accident, divorce, death of a spouse, or other life-changing event. The struggle to adjust to such an event and make meaning out of it often inspires profound and lasting personal growth and change. Of course, not everyone experiences transformative growth after a traumatic event; for some individuals, such an event might trigger depression,

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a sense of despair, and a downward trajectory in terms of quality of life. The relationship between married adults can vary considerably by culture. For example, not all cultures emphasize an emotionally close interpersonal relationship between spouses. In some Hispanic cultures, women develop more intense relationships or affective bonds with their children or relatives than with their husbands. Latin men, in turn, may form close bonds with siblings or friends—ties that meet the needs for companionship, emotional support, and caring that in other cultures might be expected from their wives. Gender roles and how men and women go about establishing personal ties with either sex are heavily influenced by culture. Touch between men (walking arm in arm) and between women is acceptable in many societies. In contemporary American society, women are more likely to have intimate, self-disclosing friendships with other women than men have with other men; a man’s male friends are likely to be working, drinking, or playing “buddies.” In Southern Europe and the Middle East, men are allowed to express their friendship with each other with words and embraces; expressions of affection between men are less common in American culture or might be attributed to homosexuality. Affiliation and friendship needs in adulthood and the satisfaction of these needs are facilitated or hindered by cultural expectations. Social support, family ties, and friendship needs can be met through the extended family and kinship system or through other culturally prescribed groups such as churches, singles bars, work, and civic associations. Social networking websites are an increasingly popular way to connect with friends and family as well. An individual’s health may be affected by these social ties: persons who have a reliable set of close friends and an extensive network of acquaintances are usually healthier—emotionally and physically—than persons without supportive networks and close friends. Facebook, LinkedIn, and other Internet sites might meet social needs of younger persons, or even older adults.

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Roles and relationships change between adult children and their parents as both become older. Caring for and launching their own children and caring for their own aging parents place some middle-age adults between the demands of caregiving from parents and those from children. Primarily, caregivers have been women, and the stress resulting from the demands of caregiving places them at increased risk of health problems (National Alliance for Caregiving & AARP, 2009). In traditional cultures that value and maintain extended family networks, the responsibilities of caring for both children and older parents can be shared with other family members (see Figure 7-1). This decreases the responsibilities being placed on any one family member. Adjusting to the aging of parents and the associated responsibilities, as well as finding appropriate solutions to problems created by aging parents, is a challenge created by situational, developmental, and even health–illness transitions. Placing an aged mother or father in a nursing home or extended care facility may be a decision made with reluctance and only when all other alternatives

have been exhausted. Such actions may be totally unacceptable to some members of other cultural groups, in which family and community networks would facilitate the complex care required by an aged ill person. Such cultural norms would exert a great deal of social pressure on an adult son, or especially a daughter, who failed in this obligation. Cultural values also influence professional health care roles and relationships. How individuals are approached and greeted as well as the kind and type of relationship established may be closely tied to cultural expectations and norms. A casual, first-name basis has become the norm in many health care situations, with medical receptionists (and often other health professionals as well) calling patients by their first names. While this may be appropriate at the check-in desk because of HIPPA regulations, it can be inappropriate in other instances. Health care professionals should always inquire about the appropriate manner to use in approaching clients and their family members. Table 7-1 provides some suggestions and guidelines to use in approaching clients and using their names in professional relationships.

Figure 7-1. The extended family of Teresa and Neil Cooper of Carlsbad, California. This family is multiethnic in each generation, yet maintaining close family ties is a priority that has continued through three generations.

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Table 7-1: Guidelines for Names Culture

Guidelines

Arab

Both male and female children are given a first name. The father’s first name is used as the middle name; the last name is the family name. Usually, a person is called formally by the first name, such as Mr. Mohammed or Dr. Anwar.

Chinese

The family name is stated or written first followed by the given name (the opposite of European and North American tradition). Only very close friends use the given name. Politeness and formality are stressed; always use the whole name or family name. Use only the family name to address men, for example, if the family name is Chin and the man’s given name is Wei-jing, address the man as Chin. Women in China do not use their husband’s name after marriage. Many Chinese take an English name that they use in their North American host country. Use the title Mr. or Mrs. preceding the English name; using only the first name is considered rude.

Latin American

The use of surnames may differ by country. Many Latin Americans use two surnames, representing the mother’s and father’s sides of the family. “Maria Cordoba Lopez” indicates that her father’s name is Cordoba and her mother’s surname is Lopez. When Maria marries, she will retain her father’s name and add the last name of her husband, becoming Maria Cordoba de Recinos. Many Latin American immigrants drop their mother’s surnames after they immigrate to the United States because having two last names can be inconvenient. In approaching clients of traditional Latin cultures, it is appropriate to use the Spanish terms señor or señora, followed by the primary surname (the husband’s), if the nurse is comfortable with those terms.

Native North Native North American names differ by tribal affiliation. Many tend to follow the dominant cultural American norms. In the Navajo culture, a health care provider may call an older Navajo client “grandfather” or “grandmother” as a sign of respect. In the past, some tribes have tended to convert traditional names into English surnames, for example, Joe Calf Looking and Phyllis Greywolf. The above-mentioned examples are very general. If in doubt, always ask: it can be embarrassing for both the nurse and the client if the nurse uses a name in an inappropriate manner. Generally speaking, it is always best and most appropriate to be formal and to use the surname with the appropriate title of Mr. or Mrs. (or other culturally appropriate titles) preceding the name, unless the client has indicated that he/she prefers to be called by his/her first name. Adapted from Purnell, L. D., (2014). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis.

Health-Related Situational Crises and Transitions Situational transitions often occur when a serious illness is diagnosed or other traumatic events occur to individuals and their families. Some developmental theorists refer to the initial period as a “situational crisis” when a serious illness is diagnosed or traumatic event occurs. Such a diagnosis or event often leads to fear and anxiety in the client and family members. As clients and family members learn more about the precipitating condition, they realize that many of their fears are unfounded as they gain more confidence in managing the illness condition. The “crisis” dissipates but still the illness remains and must be managed appropriately. The client and family must “transition” to

l iving with a chronic illness. It is not uncommon for a situational transition, precipitated by an illness event, to occur in middle age or late adulthood. The leading causes of death in the United States are heart disease, cancer, cerebrovascular disease, respiratory disease, accidents, and diabetes, and they are usually diagnosed in adults (Centers for Disease Control and Prevention [CDC], National Center for Health Statistics, 2010). These conditions affect individuals, but they also occur within a family system and affect children, spouses, aging parents, and other close relatives. Because middleaged adults may be caring for aging parents, adult children, and even grandchildren, the illness of any one individual must be evaluated carefully for the myriad of ways in which it affects all members of the family. Evidence-Based Practice 7-2 describes the experiences of Latina wives as their husbands

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Purposeful Normalization When Caring for Husbands Recovering from Prostate Surgery This study describes the experiences of Latina women as their husbands recovered from radical proctectomies. Purposeful normalization can be viewed as a situational transition. The women’s lives changed dramatically when their husbands were diagnosed with cancer. Cultural beliefs related to gender roles and sexual functioning are some of the strongest values and traditions within a cultural system. The husbands’ depression, irritability, and erectile dysfunction posed special challenges to the Latina women in this study. Prostrate cancer is the most frequently diagnosed noncutaneous cancer in men in the United States. Despite high incidence rates, overall survival rates are very high and increasing all of the time. Issues such as postsurgical incontinence and erectile dysfunction, along with the fact that many prostrate survivors are married men, have prompted many to describe prostate cancer as a couple’s disease. Partnered men have significantly better mental health, lower symptom distress, and less urinary problems than unpartnered men. Still, many wives experience significant distress when faced with their partner’s diagnosis and treatment. This study interviewed 28 partners of Latino men who had a radical prostatectomy. The primary aim was to describe the experiences of low-income Latinas as their husbands recovered from radical prostatectomies. The overarching process was identified as normalization with some themes working against normality while others worked toward it. Working Against Normality: Threats to normality of the women’s lives began immediately when their husbands were diagnosed with cancer. Some concerns diminished with time, such as the initial shock and fear and dealing with the side effects. They feared losing their husband. Dealing with the symptoms and the side effects caused the women to feel anxious and frustrated. The husbands’ depression and irritability, as well as erectile dysfunction, posed special challenges. Working Toward Normality: The Latina women described many themes that kept them feeling a

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sense of “normal.” They worked hard to conceal their own emotions and to show their husbands that they had everything under control. They tried to move forward, putting changes brought about by their husband’s illness behind them. They tried to make dietary changes that they believed were helpful—such as eating more vegetables and fruits and cutting down on sugar. Their families were supportive with the grown children visiting and making frequent phone calls. Grandchildren visited and were a source of joy and comfort. Women found great support in their religious faith that helped them make changes in a positive way.

Clinical Implications ●●

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Understand that caregiving can be extremely stressful and that caregivers need support, understanding, and help in this role. Simply acknowledging the emotional impact of both the illness itself and of caring for the patient can be helpful. Talk to wives/caregivers about actively shaping the emotional responses they feel and how they can help their husbands deal with the changes they are is experiencing. Encourage caregivers to contribute to recovery by empowering them to make healthy changes in their lifestyle, such as eating healthy food, getting appropriate amounts of sleep, and perhaps simple exercise such as walking short distances together with their husband. Become comfortable when discussing symptoms such as erectile dysfunction and helping clients and their partners consider alternative forms of intimacy. Actively encourage family members to visit and to telephone frequently. Help clients plan for grandchildren to spend the night.

Reference: Williams, K. C., Hicks, E. M., Chang, N., Connor, S. E., & Maliski, S. L. (2014). Purposeful normalization when caring for husbands recovering from prostate surgery cancer. Qualitative Health Research 24(3), 306–316.

Chapter 7 Transcultural Perspectives in the Nursing Care of Adults

recovered from radical proctectomies. The shock of the cancer diagnoses and the long-term effects of the surgery precipitated a situational transition that affected both husbands and wives. Cultural beliefs and values influence health promotion, disease prevention, and the treatment of illness. Families influence the health-related behavior of their members because definitions of health and illness, and reactions to them, form during childhood within the family context. When an illness has social and/or cultural connotations, or involves sexual issues, shame, and/or stigma, the response from the client and the family may be more pronounced. Sexual education has sometimes been a “flash point” in numerous communities, and many parents have objected to such programs in the school setting. Shambley-Ebron (2009) conducted

Case Study 7-1 Mrs. Ernestine Pollard, a 57-year-old African American woman, lives in a small town in rural Georgia. Mrs. Pollard cares for her older sister, Ethel, who is now 65 years old. Mrs. Pollard explains that her sister “can’t talk, and her mind’s not good.” Mrs. Pollard says that even as a little girl, she knew that Ethel would be her special responsibility, and when she (Mrs. Pollard) married, Ethel came to live with her and her new husband. Mr. Pollard died a few years ago following a stroke. Recently, Ethel’s health has been deteriorating because of a series of what Mrs. Pollard calls “little strokes.” Additionally, just a few months ago, Mrs. Pollard’s 26-year-old daughter, Tywanda, returned home to live with her. Tywanda was living and working in New Jersey, where she had become ill. She was taken by friends to the emergency department and admitted to a local hospital. During this hospitalization, she tested positive for HIV. Tywanda has been a great worry to her mother for a number of years; Mrs. Pollard has suspected that Tywanda was occasionally using drugs. Although Mrs. Pollard welcomed Tywanda home again, she worried about her past high-risk behaviors and hoped

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a study with preadolescent African American girls and included their mothers. A targeted 8-week educational program tapped into the cultural and gender beliefs and practices to educate girls about HIV/AIDS prevention. Input for educational intervention was solicited from women in the community, including the mothers of the young girls. The findings from this study indicate that culture and gender influences play a critical role in how young African American girls develop culturally appropriate strategies to deal with sexuality and healthy womanhood. This study is also an example of how education about sensitive topics such as HIV/AIDS prevention can be conducted. The content in this section provides the context for and gives an example of a health-related situational crisis (which is detailed in Case Study7-1). they would not continue. When Tywanda told her mother about her HIV status, Mrs. Pollard was very upset and worried. Mrs. Pollard explains that sometimes with the stress of caregiving for Ethel and worrying about Tywanda, her “pressure goes sky high.” She tells the nurse that she has had “high blood” for several years. Her physician prescribed medication for her blood pressure, and she tries to take it on a regular basis, but sometimes, she forgets. Other times, she decides that she just does not have the money for medication. Lately, Tywanda has been staying away from home and acting secretively, so Mrs. Pollard is not sleeping well and she is worried that Tywanda may be taking drugs again. She told her doctor that she has bad “nerves” and explained that she is unable to sleep at night. The physician prescribed sleeping pills for her, but Mrs. Pollard is unwilling to take them because she fears that she will not hear Ethel if she gets up during the night. Ethel seems to be getting more confused and disoriented, especially at night. Mrs. Pollard’s other grown children, two daughters, live in Atlanta, several hours’ drive from the small town where Mrs. Pollard lives. Mrs. Pollard is experiencing a health/illness situational crisis resulting from the stress of caregiving, the challenges of managing ongoing chronic diseases, and anxiety about her young adult daughter who is HIV positive and engages in risky behaviors.

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The influences of culture on individual and family responses to health problems, caregiving, and health/illness transitions and crises are discussed.

Caregiving Caregiving occurs when an unpaid person, usually a family member, helps another family member who has a chronic illness or disease. Many caregivers are women who are caring for their aged and ill parents or husbands. Assuming the role of caregiver often predisposes women to interrupted employment and limited access to health care insurance and pension and retirement plans. Caregiving, as used in this chapter, implies the provision of long-term help to an impaired family member or close friend. Caregiving is usually labor intensive, time consuming, and stressful; the exact effects on the physical and emotional health of caregivers are still being documented. Although positive outcomes, such as feelings of reward and satisfaction, do occur for caregivers, caregivers still experience negative psychological, emotional, social, and physical outcomes (Family Caregiver Alliance, 2006). When caregiving for other family members takes place during middle adulthood, the roles for both the caregiver and the recipient may change as new challenges emerge. The caregiver may be forced to quit his or her job as caregiving responsibilities increase when the person being cared for becomes more infirm or ill and the need for assistance in tasks of daily living increases. Culture fundamentally shapes how individuals make meaning out of illness, suffering, and dying. Cultural beliefs about illness and aging influence the interpretation and management of caring for the ill and aged, as well as the management of the trajectory of caregiving. Family members provide care for the vast majority of those in need of assistance. The demands of caregiving can result in negative emotional and physical consequences for caregivers. How they cope with stress, social isolation, anxiety, feelings of burden, and the challenges of caregiving will all be influenced by cultural values and traditions.

Shambley-Ebron and Boyle (2006a, 2006b) have documented that these general problems and characteristics of caregivers are compounded for African American women by the special circumstances of their lives and the lives of the men and children for whom they care. In the case of African American caregivers, prejudice, discrimination, health disparities, and poverty often all interact to increase stress and pose challenges that frequently result in poor health. Like other caregivers, African American caregivers are mostly female; most recipients of care from African American caregivers are females as well (e.g., daughters caring for their mothers) (National Alliance for Caregiving & AARP, 2009). Culture and ethnicity can influence beliefs, attitudes, and perceptions related to caregiving, including how often individuals engage in selfcare versus seeking formal health services, how many medications they take, how often they rest and exercise, and what types of foods they consume when ill. Ethnic and/or cultural differences have rarely been analyzed in caregiver research; only recently have nurse researchers and others focused on specific cultural groups to study caregiving (Family Caregiver Alliance, 2006) and the ethnocultural factors that are so important in planning support for caregivers (Crist, Kim, Pasvogel, & Velazquez, 2009). Studies of African American caregivers have found that they tend to use religious beliefs and/ or spirituality to help them cope with the stress of caregiving; Giger, Appel, Davidhizar, and Davis (2008) found that a major source of support for Black caregivers was their personal relationships with “Jesus,” “God,” or “the Lord.” These authors suggest that spirituality is both personal and empowering for some African Americans and is related to the deepest motivations in life. Spirituality is often expressed in the context of the daily life of Black caregivers, not necessarily by formal attendance at religious events. Numerous researchers have noted that the specific nature of the religion–health connection among African Americans is of great interest to health professionals as it holds promise for integrating church-based health interventions.

Chapter 7 Transcultural Perspectives in the Nursing Care of Adults

The Context of HIV/AIDS and the African American Community HIV/AIDS disproportionately affects African Americans and has had a devastating effect on African American communities. According to CDC data, at every stage—from HIV diagnosis through the death of persons with AIDS—the hardest-hit racial or ethnic group is African Americans. Even though African Americans make up only approximately 13% of the US population, 44% of the estimated new cases of HIV/AIDS diagnoses in the United States in 2010 were in African Americans (CDC, HIV among African Americans Fact Sheet, 2014; CDC, HIV/AIDS Surveillance report, 2008). In 2014, women accounted for about one in four new HIV/AIDS cases in the United States. Of these newly infected women, about two in three are African American. Most of these women contracted HIV from having unprotected sex with a man. The rate of AIDS diagnosis for African American women was 20 times the rate of White women by the end of 2006 (National Alliance of State and Territorial AIDS Directors [NASTAD], 2008). AIDS was the fifth leading cause of death for African American females, ages 25 to 34, in 2010 (CDC, 2010. Mortality Tables, National Center for Health Statistics, Leading Causes of Death by Age Group, Black Females, United States). Prevention Challenges From a public health standpoint, preventive education about HIV/AIDS has been hindered by an unwillingness to talk frankly about behaviors surrounding sex and drug use, and this has been a substantial barrier in effective HIV preventive programs. In essence, the AIDS epidemic has forced society to examine and attempt to alter cultural behaviors and values that were largely ignored in the past. And, as a society, we have not always been comfortable with this frankness. Over the past three decades in the United States, the practice of high-risk HIV behaviors has changed from selected populations of White homosexual men with no history of drug use

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to heterosexuals having multiple sex partners and/or using drugs. HIV/AIDS disproportionately affects selected groups, especially Blacks and Hispanics, and risk patterns are different for men and women. African American women (adolescents and adults) are especially at risk. The CDC points out that the African American community faces numerous barriers that impact HIV prevention efforts. Among these factors are biological vulnerabilities as well as the unique characteristics and nuances of heterosexual relationships in African American culture. Also contributing to increased HIV transmission in African American communities are poverty, unemployment, substandard education, and incarceration (CDC, HIV among African Americans Fact Sheet, 2014; Womenshealth.gov, 2011). Implementing intervention programs has proven extremely difficult. Evidence-Based Practice 7-3 describes a study with African American mothers to understand how they talked to their young daughters about sexual health. This knowledge is helpful when developing culturally relevant prevention programs for sexual health, including the prevention of HIV/AIDS. Influential Factors Numerous explanations have been offered about the factors that influence the high rate of HIV/ AIDS in African American communities. Poverty is a major factor. Denial, drug use, and homophobia and concealment of homosexual behavior also influence HIV/AIDS rates. Poverty

The poverty rate is higher among African Americans than other racial/ethnic groups as African Americans, generally speaking, have lower incomes than other Americans. The poverty rate for all African Americans in 2012 was 28.1%, an increase from 25.5% in 2005. Black families with children under 18 headed by a single mother have the highest rate of poverty, at 47.5%, compared to only 8.4% of married-couple Black families (BlackDemographics.com. (n.d.)). The socioeconomic issues associated with poverty—including

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Cultural Preparation for Womanhood in Urban African American Girls: Growing Strong Women Poor sexual health is a significant contributor to morbidity in young African American women. Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and other sexually transmitted infections (STIs) are tragic and costly in all populations; however, African Americans bear an excess burden of poor health due to these conditions. Understanding how knowledge about sexual health is transmitted to African American girls is needed to develop effective and culturally relevant preventive interventions. This study explored the ways that African American mothers transmitted sexual values and information to their daughters. The author interviewed 14 m others who had young daughters, 8 to 16 years of age. The data were qualitatively analyzed, and three major themes about Growing Strong Black women were identified: truth-telling, building strength through selfesteem, and spirituality as helper. Helping their daughters grow into strong, successful, and healthy women was viewed by the mothers as a task that was primarily their responsibility. This responsibility was enacted through an ongoing process of providing truthful answers and open communication, helping their daughters develop a healthy self-esteem that would promote independence, and providing a foundation of spirituality and religious beliefs to enable their daughters to deal with the societal issues that face young African American girls and women. Mothers were honest with their daughters with regard to sexuality, their changing bodies, and relationships with men. Sometimes, mothers told their daughters painful stories of their own experiences. Other times, they sought out literature to explain how their bodies worked or how STIs occurred. Mothers reinforced their daughters’ self-esteem and helped them develop confidence in their own abilities to

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be successful in life. They encouraged them to become active in church and school activities, to develop a faith and belief in God, and to participate in religious practices such as prayer and attendance at religious services.

Clinical Implications ●●

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Supportive networks for young African American girls can be broadened and strengthened by involving teachers, nurses, and women from their church groups as support persons to help them achieve their goals relative to age-appropriate relationships and sexual behaviors. African American mothers (indeed, all mothers) of teenage girls need accurate information about sexual health and STIs. Nurses can work with churches and various community groups to provide information and support to parents. Culture and gender are unique and distinct aspects of the lives of young African American girls and must be taken into account when planning preventive interventions for health and well-being. Nursing interventions that focus on building selfesteem and supporting the future aspirations of young African American girls can be useful to reinforce parental teachings and help young girls move into adulthood successfully. The use of spirituality and religiosity appears consistently in the literature as ways to help young African American girls deal appropriately with life experiences.

Reference: Shambley-Ebron, D., Dole, D., & Karikari, A. (2014). Cultural preparation for womanhood in urban African American girls: Growing strong women. Journal of Transcultural Nursing. Online 6 May 2014. doi: 10:1177/1043659614531792

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limited access to high-quality health care, h ousing, and HIV prevention education—directly and indirectly increase the risk for HIV infection. The CDC (HIV among African Americans Fact Sheet, 2014) suggests that these factors may explain why African Americans have worse outcomes on the HIV continuum of care, including lower rates of linkage to care, retention in care, prescription HIV treatment, and viral suppression. CDC data from 2010 indicate that 75% of HIV-infected African Americans aged 13 or older are linked to care, 48% are retained in care, 46% are prescribed antiretroviral therapy, and only 35% are virally suppressed (CDC, HIV among African Americans Fact Sheet, 2014). Accessing health care services is a problem if an individual does not have health insurance, and not all health departments offer high-quality care and follow-up for clients. In addition, for many African Americans, dayto-day living activities (long working hours, low pay, family responsibilities) often take precedence over whether an individual has the time and energy to access educational information about HIV and AIDS. Poverty or lack of money, stigma, and lack of access to high-quality health care influence access to HIV testing and state-of-the-art treatment if an individual is diagnosed with HIV. Often, stigma, racism, and fear are associated with poverty, and they too play a part in delaying appropriate upto-date treatment, complying with medication regimens and other appropriate care. Delay in diagnosis late in the course of HIV infection is too common for African Americans, and this delay results in missed opportunities for early medical intervention and prevention of transmission to others (CDC, HIV among African Americans Fact Sheet, 2014; Black Womens Health Imperative, n.d.).

about HIV/AIDS may be met with d isapproval as some African Americans may feel that it is not an appropriate subject for discussion. Talking frankly about sexual behavior with new partners and insisting on the use of condoms may be very difficult for African American women. They may be afraid to ask a male partner about his sexual history or his use of or experience with drugs for fear of abruptly ending their relationship. The nuances of African American male–female relationships are rarely understood by health care providers. ShambleyEbron and Boyle (2006a, 2006b) suggest that problematic relationships between Black males and females are complex in nature and are reflections of institutional racism, political and economic oppression, and internalization of negative stereotypes on the parts of both men and women. These disabling relationships often lead to denial about HIV; this may be why many African Americans who are HIV infected do not seek early testing and do not know they are HIV positive. Persons who do not know that they are HIV infected are more likely than those with a diagnosis to engage in risky behavior and to unintentionally transmit HIV to others (CDC, A Heightened National Response to the HIV/AIDS Crises among African Americans, 2007). The denial of risks of HIV/AIDS can affect HIV rates. Approximately one in five adults and adolescents in the United States living with HIV do not know their HIV status. This translates to about 116,750 African Americans. Late diagnosis of HIV infection is common; this creates missed opportunities to obtain early medical care and prevent transmission to others. The sooner an individual is diagnosed and linked to appropriate care, the better the outcome (Womenshealth.gov, 2011).

Denial

Most new HIV infections among African American women (87% or 5,300) are attributed to heterosexual contact (CDC, HIV among African Americans Fact Sheet, 2014). Injecting drugs is the second leading cause of HIV infection for African American women and the third leading cause of HIV infection for African American men. In addition to the danger from contaminated needles, syringes, and other drug p araphernalia, persons who use drugs

Denial and lack of awareness of HIV/AIDS have frequently led to late diagnoses and treatment for many rural African Americans. They know that HIV/AIDS is a problem in Atlanta or New York City, or even in Florida, but they find it hard to believe that HIV/AIDS is a problem in rural Georgia or Alabama. This lack of awareness of HIV presence can affect HIV rates within communities. Talking

Drug Use

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are more likely to take other risks, such as unprotected sex, while under the influence of drugs (CDC, HIV among African Americans Fact Sheet, 2014). An early study of HIV-infected women found that women who used drugs, compared with women who did not, were also less likely to take their antiretroviral medicines exactly as prescribed or to attend clinic appointments on a regular basis (Sharpe, Lee, Nakashima, Elam-Evans, & Fleming, 2004). Homophobia and Concealment of Homosexual Behavior

Homophobia and stigma can cause some homosexual African American men to identify themselves as heterosexual or to not disclose their sexual orientation, presenting challenges to prevention programs (Millett, Peterson, Wolitski, & Stall, 2006). The CDC indicated that in 2010, African American gay, bisexual, and other men who have sex with men represented an estimated 72% of new infections among all African American men and 36% of an estimated 29,800 new HIV infections among all gay and bisexual men (CDC, HIV Among African Americans Fact Sheet, 2014). It is extremely important to involve African American community stakeholders in developing and implementing programs to address sensitive topics and behaviors associated with homosexual sex. Confronting homophobia is necessary to achieve significant reductions in HIV/AIDS and ultimately to end this epidemic among African Americans. Involving community stakeholders will mobilize African American communities to become more aware of the need to develop strategies that address broader social and cultural factors such as homophobia, drug use, stigma, and denial (CDC, HIV among African Americans Fact Sheet, 2014).

Adult Development in an African American Family: The Convergence of Developmental and Health Illness Situational Transitions Case Study 7-1 provides an example of a middleaged African American woman who provides care to her developmentally delayed sister and

to her 26-year-old daughter, who has HIV/AIDS. This case study points out the complex situation of three adult women, each facing significant life changes brought about by health/illness situational crises. Issues related to caregiving, aging, chronic diseases, drug use, and HIV are described. Each woman faces difficult issues that require different kinds of responses to stabilize and improve their health as they are experiencing myriad transitions that are significantly influencing their lives. Culturally appropriate ways in which the nurse might implement nursing care are suggested. Health Promotion Interventions for Health/ Illness Situational Crises African American women are at high risk for cardiovascular diseases, particularly hypertension and stroke. Mrs. Pollard lives in that area of the South known as the stroke belt because morbidity and mortality from cardiovascular diseases (especially among African Americans) are quite high in this region (Mortality Tables, 2010). The nursing management priorities for Mrs. Pollard will be to support her caregiving role and provide health promotion strategies to control her blood pressure and help reduce the stress she is currently experiencing. In terms of blood pressure management, a nurse might advise Mrs. Pollard to lose weight by incorporating changes in eating habits and regular exercise into her lifestyle. However, social and cultural factors, as well as the caregiving situation, may compromise these health goals. Nurses can become more sensitive to cultural norms and values of clients like Mrs. Pollard by listening carefully, being empathetic, recognizing the client’s self-interest and needs of her family members, being flexible, having a sense of timing, appropriately using the client’s and family’s resources, and giving relevant information at the appropriate time. Although Mrs. Pollard does have a private physician and tries to seek care when appropriate, she considers Ethel’s and Tywanda’s needs before her own. Mrs. Pollard does not have health

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insurance and therefore access to quality care is compromised. Tywanda attends an infectious disease clinic about 50 miles from where her mother lives. Her medications are provided through the Ryan White HIV/AIDS Program, a federal program focused exclusively on HIV/AIDS care. The program is for those who do not have sufficient health care coverage or financial resources for coping with HIV disease (U.S. Department of Health and Human Services, HIV/AIDS Bureau, n.d.). Mrs. Pollard does not accompany Tywanda when she visits the clinic because Tywanda acts as if she does not want her mother to go with her and Mrs. Pollard does not wish to leave her sister alone. The nurses at the clinic wonder if anyone in Tywanda’s family really cares about her because she always comes alone to the clinic appointments. However, Tywanda does not always attend the clinic, nor does she tell her mother when she misses an appointment. Mrs. Pollard does not know about the medications that Tywanda takes for HIV/AIDS. Tywanda does not readily disclose information, and Mrs. Pollard tries to be sensitive to her daughter’s wishes. Mrs. Pollard is concerned about Ethel’s appetite because she believes that the proper food will promote and enhance her health. Like many other adults, Mrs. Pollard has fairly definite preferences about food and the way it is prepared and served. The Pollard family frequently eats foods that are high in fat; for example, they enjoy servings of bacon or fatback for breakfast once or twice during the week. Breakfast is an important meal for them. They prefer their vegetables cooked with bacon, fatback, or ham for flavoring. Symbolism is attached to food in every culture, and Mrs. Pollard believes that both Ethel and Tywanda’s health will improve by eating what Mrs. Pollard considers “healthy” foods. With her concern for Tywanda and the time she spends with her sister, Mrs. Pollard neglects her own diet or eats whatever is convenient, often “fast foods” or those high in fat, cholesterol, and sodium. Mrs. Pollard needs to be gently reminded by the nurse that it is important for her to pay attention to her own nutrition also. The nurse could

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initiate a discussion about the kinds of nutritious foods that would be appropriate for the three of them and the different ways of preparing food. For example, vegetables can be cooked without the addition of fatback. Young-Mason (2009) suggested that understanding the art and culture of food of those we seek to help is paramount to being and becoming an astute and learned nurse. Campinha-Bacote (2013) observed that food can have many roles, in addition to providing physical nourishment. For example, food can serve as a means of enhancing interpersonal relationships or communicating love and caring. Historically, African American rites revolve around food. Being able to prepare food that her daughter and sister will eat and enjoy is a source of satisfaction for Mrs. Pollard and a reinforcement of her successful role as caregiver. It is an act of caring and love for her to prepare a meal for her family. At the same time, she must maintain her own health to continue to provide care for Tywanda and her sister. Nurses providing care to clients like Mrs. Pollard will need to consider other cultural factors that ultimately influence the nursing goals. Rural African Americans often have cultural ways to view health and illness; these patterns of beliefs and behaviors can be viewed as culturebound syndromes. Many of these patterns are indigenously considered to be “illnesses” or at least afflictions and most have local names. “High blood” is an illness condition or affliction that is associated with African American culture in the rural South. Many health care professionals make the wrong assumption that “high blood” is the same as high blood pressure, and although there are similarities, the cultural explanation of “high blood” is different from the biomedical explanation of high blood pressure. “High blood” is conceptualized in terms of blood volume, blood thickness, or even elevations of the blood in the body (e.g., “blood rushes to your head”). “High blood” is believed to be caused primarily by factors that “run blood up,” such as salt, fat, meats, and sweets. This condition can result in an increased “pressure” or high blood pressure.

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Sometimes, “high blood” leads to a feeling of faintness that may cause the afflicted person to “fall out” or faint. Other causal factors that result in “high blood” are emotional upsets, troubling experiences, or prolonged stress. Sometimes, it is thought to be caused by a falling out with God or by eternal forces such as enemies putting a “hex” on someone. Many older African American clients believe that eating slightly acidic foods, such as collard greens with vinegar or dill pickles, will lower “high blood.” Thus, although there are similarities between “high blood” and high blood pressure, the explanations and treatments are not always the same in the cultural prescriptions as in the biomedical model. Mrs. Pollard tries to be conscientious about taking her blood pressure medication, but she sometimes forgets to take it and sometimes does not get around to promptly renewing the prescription, so she might go without her medication for several days or a couple of weeks. The nurse should acknowledge Mrs. Pollard’s active involvement in her own health promotion, encourage her to take her blood pressure medication as prescribed, and remind her to renew it promptly before she is completely out of medication. The nurse can also discuss “high blood” with Mrs. Pollard, and if there are no contraindications, she can encourage her to eat collard greens with vinegar or dill pickles. She can listen carefully to Mrs. Pollard’s explanation of “high blood,” and if Mrs. Pollard believes she has somehow offended God, the nurse should encourage her to talk with her church pastor. “Nerves” or even “bad nerves,” while not unique to the rural South, are commonly described by many Southerners. “Bad nerves” are often equated with anxiety and worry but may refer to something as serious as a “mental breakdown” or severe emotional disorder. Mrs. Pollard uses the term to refer to her worry, concern, and anxiety about Tywanda and Ethel. Sometimes, she has “crying spells” that she describes as “just crying and crying, and not being able to stop.” She gets up several times at night to answer her sister’s call or to check on Tywanda and make

certain that they are sleeping well. Lack of sleep and continued worry and anxiety accelerate her psychological distress. Again, recognition and acknowledgment from the nurse that she is providing excellent care for her sister and her daughter will be reassuring for her. She should be encouraged to rest and should be assured that crying and feeling sad are normal reactions to her sister’s deteriorating condition and Tywanda’s HIV/AIDS. Because of a lack of economic resources, African American midlife women are likely to be subjected to many stressful life events, such as job and marital instability, lack of male companions as heads of households, erratic income, and frequent changes and relocations (Hine, 1998). Because she has worked in small local businesses (dry cleaners, restaurants) most of her life, Mrs. Pollard lacks health insurance. She has experienced many life stresses related to the lack of economic resources. Mrs. Pollard was working as a clerk in a local dry cleaning establishment when Tywanda returned home and told her mother that she had HIV/AIDS. However, as Ethel’s health deteriorated and Tywanda’s risky behaviors became more obvious and problematic, Mrs. Pollard decided to stop working for a while, thinking that if she stayed home, she could provide closer supervision and care to Ethel and be available to Tywanda when she needed her mother. Mrs. Pollard faces numerous situational crises: Tywanda’s illness and high-risk behaviors, the poor health and aging of her sister, and economic hardship because she is the family provider and is not working at the present time. Her own health is also a concern. Stress and anxiety are normal reactions in the lives of middle-aged adults like Mrs. Pollard. However, limited resources and lack of access to high-quality health care compound the stress and complicate a situational crisis. Mrs. Pollard’s physician prescribed sleeping medication for her, assuming that would take care of her inability to sleep. The nurse can reinforce Mrs. Pollard’s decision not to take this medication and explore with her how to set aside time during the day when she

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might be able to take a nap. Mrs. Pollard’s anxiety and inability to sleep well are directly related to the stress of caregiving. Some ways to support and help Mrs. Pollard deal with stress and anxiety may be family support and participation in religious activities. The nurse might suggest that Mrs. Pollard set aside some time during the day to quietly read the Bible or other appropriate reading material and listen to religious music. Mrs. Pollard told the nurse that she used to enjoy crocheting; she could be encouraged to try crocheting again. Close family and spiritual ties within the African American family and community support the caregiving role. Extended and nuclear family members willingly care for sick persons and assume these roles without hesitation. Mrs. Pollard’s two daughters try to help their mother and Tywanda as much as possible, but they live several hours’ drive away. They try to visit one weekend each month and bring their children with them. Tywanda enjoys the company of her sisters, and Mrs. Pollard notices that on weekends when one of the sisters is expected, Tywanda’s mood seems improved as she obviously looks forward to the visit. Ethel is always excited to see her nieces and looks forward to their visits. While Mrs. Pollard’s daughters know that Tywanda has been diagnosed with HIV/AIDS, they are reluctant to disclose the diagnosis to others outside the family because the stigma of disclosure in a small community can affect all members of the family. Mrs. Pollard’s minister is aware of Tywanda’s condition, as are a few members of Mrs. Pollard’s “church family.” One of the primary stressors of women during the midlife years is the loss of relationships and friendship networks, often because of competing demands on time. Caregivers, like Mrs. Pollard, have very little time for their own needs. It is extremely important for Mrs. Pollard’s health and coping abilities that she continue to participate in church activities as much as possible and to maintain those friendships and networks. Spiritual beliefs form a foundation for Mrs. Pollard’s daily life. Like other African Americans who live in the same rural community, Mrs. Pollard attends a small Protestant church whose

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embership is exclusively African American. m Many, but not all, African Americans strongly believe in the use of prayer for all situations they may encounter. They use prayer and reading the Bible as a means of dealing with everyday problems and concerns. Mrs. Pollard relies a great deal on prayer, and her religious beliefs and practices provide her with support and strength in her caregiving role. Encouraging Mrs. Pollard to take even 15 minutes each day to read familiar biblical verses or listen to religious music might be one of the most helpful interventions the nurse could suggest. Mrs. Pollard has a lifetime of experience with her church; the church has been the center of activities for African Americans for decades (Campinha-Bacote, 2013). Mrs. Pollard’s religious beliefs are integrated into her daily life as a caregiver, and her belief in God enhances her ability to care for Ethel and Tywanda. She, like many other African Americans, has a personal relationship with God and is able to share her worries and concerns through prayer. Her traditional spirituality and church support provide a foundation for an active approach to coping with problems. Adult Health Transitions and Nursing Interventions Mrs. Pollard is distressed about the deterioration of her sister’s physical condition and Tywanda’s diagnosis of HIV/AIDS and drug use. In addition, Mrs. Pollard is dealing with several health problems of her own. While there are certain “crisis dimensions” to this situation, the conditions are not life threatening. Overtime, the crises lessen and the situation slowly develops a transitory nature. The health/illness transitions occur over a longer period of time. They can best be dealt with by the provision of culturally relevant health promotion and risk reduction strategies. The health teaching and nursing interventions provided to the Pollard family should focus on wellness and health promotion. In addition to the nursing interventions that are important for health promotion, there are several interventions that will

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help Mrs. Pollard navigate the transitions and changes of caregiving. An important priority of nursing care for Mrs. Pollard and her family is to help them understand and adjust to the impact of HIV disease. This includes urging Tywanda to seek help for her drug use. The nurse can refer Mrs. Pollard to the social services available for patients who have HIV/AIDS and their family members. Mrs. Pollard may want to talk to a mental health counselor about the fears and concerns she has about Tywanda and drug use. In addition, the nurse can encourage Tywanda to keep clinic appointments and to seek appropriate counseling and follow-up, not only for her HIV status but also for the use of illicit drugs. While the nurse is not a trained mental health counselor, she or he can recommend that Tywanda seek mental health services, and the nurse can be supportive and encourage healthseeking behaviors. Medications now available for treating HIV can lower viral counts and transmission of the virus to others; helping Tywanda find appropriate services and follow-through treatment is a priority in providing nursing care for this family. Of particular concern is the timing of Tywanda’s illness. A serious health condition in a young, previously healthy adult child will cause unique trauma and conflict because of society’s expectations that young adults will outlive their older parents. In addition, as a person diagnosed with HIV/AIDS, Tywanda has a condition that often generates shame and stigma. It is important that these issues be acknowledged by both Mrs. Pollard and Tywanda. Achieving career success is one of the developmental transitions that Western culture emphasizes. Mrs. Pollard has worked successfully outside the home most of her adult life; because rural African American culture does not place the same kind of value on work and career as does the larger culture, career “success” is not necessarily viewed as an important accomplishment. Family ties and providing for her family are highly valued in African American culture and are emphasized over women’s successful careers outside the home. Mrs. Pollard’s ties of love and

affection to Tywanda and to her sister, Ethel, are reinforced by African American cultural values. In a historical study of African American women in America, Hine and Thompson (1998) suggested that Black women have always been the financial providers in Black families and that women’s work roles have been culturally viewed as an inherent part of Black motherhood, not as individual careers. Mrs. Pollard has always been proud that she was able to take care of her family and that she could “make do” with very little. These values are important to family integrity and they can be positively reinforced by the nurse. Many African American women of Mrs. Pollard’s generation obtain meaning in their lives by caring for family members. Their feelings, behaviors, and attitudes go beyond a simple sentiment of affection or of family ties. In explaining why she cares for her older developmentally challenged sister, Mrs. Pollard says, “We were little girls together. I always knew that I was going to take care of her.” In many societies, women disproportionally provide caregiving services and social policies and home-based programs are organized around the assumption of women’s availability and willingness to provide care. At the same time, it is important to understand that Mrs. Pollard values the traditional caregiving role, and she needs support and assistance in providing the care she believes her family members need. It is important for the nurse to acknowledge that Mrs. Pollard is valued, recognized, and respected for her competence and expertise as a caregiver and as a caring and generous sister. The nurse could begin by including Mrs. Pollard, Tywanda, and her sisters in developing mutual goals for Tywanda’s progress and care. At the same time, they can discuss Ethel’s deteriorating condition and the realistic expectations for her future. Mrs. Pollard should be encouraged in her role of providing help and care to family members and in promoting the health of her daughter and sister. It is also important that her attention be directed toward her own needs on occasion, considering that she tends to focus on meeting the needs of Tywanda and Ethel before her own.

Chapter 7 Transcultural Perspectives in the Nursing Care of Adults

Social and civic responsibilities among rural, older African Americans in the South are met almost entirely at the level of the extended family and the African American church. These ties and associations are very strong, are often complex, and are not readily understood by outsiders. African American pastors are key players in the lives of their congregants and in their communities. Mrs. Pollard should be encouraged to attend church services and to seek the help and support available to her through this important cultural resource. Mrs. Pollard sings in the church choir and tries to attend choir practice every Wednesday evening. Tywanda has agreed to stay home with her Aunt Ethel on Wednesday evenings while Mrs. Pollard is away for the evening. This should be positively reinforced by the nurse. The Black church has been a traditional source of support, and congregations are frequently made up of middle-aged or older adults. Coping strategies such as prayer, singing, or reading the Bible and resources such as family and church support may help mediate Mrs. Pollard’s reaction to stressful situations. A culturally competent nurse understands that spirituality is a traditional cultural value that can be supportive during a health crisis. Mrs. Pollard’s life revolves around her family and church. The nurse must acknowledge and support cultural ties with kin and others. It is not uncommon for adult African Americans to cope with little social support from others, relying instead on internal spiritual resources. However, the support provided by close personal relationships is crucial when health conditions deteriorate or an illness develops and is necessary for successful health promotion and maintenance in caregiving activities. Mrs. Pollard’s Atlantabased daughters are crucial for support and assistance during this stressful time. The nurse should actively seek to meet them and acknowledge and encourage their contributions. They should be encouraged to participate in mutual goal setting with the members of the Pollard family. The nurse can continue to encourage Mrs. Pollard to attend church services because her social life is derived from her participation in the activities

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of her church. Providing positive reinforcement for Tywanda’s decision to stay with her aunt Ethel while Mrs. Pollard attends church services and choir practice would be appropriate. It is the church family who will be instrumental in providing emotional support and help as Ethel’s condition continues to decline, as well as the opportunity for Mrs. Pollard to find meaning and to cope with her loss and grief if Ethel predeceases her. If Tywanda continues risky drug and sexual behavior, Mrs. Pollard will need continued support and counseling from health care professionals to continue her caregiving role. Nursing interventions at the individual and family level are extremely important in maintaining and extending quality of life.

Summary All individuals are confronted with life transitions, crises, and/or changes. All cultures have acceptable and defined ways of responding to these life situations. Adulthood is a busy and productive time and should no longer be considered a stable “slide” toward old age. A situational health transition was presented: an African American woman, Mrs. Pollard, who cared for her developmentally delayed sister, Ethel, and her 26-year-old daughter who has HIV/AIDS. Ethel’s health was deteriorating and Mrs. Pollard was fearful that her daughter was using illicit drugs. Mrs. Pollard’s own health problems were exacerbated by this situational transition, and her normal development through adulthood was disrupted. How nurses can understand such situations and provide culturally appropriate care was described.

Review Questions 1. Describe examples of health transitions in

your family members and friends. Which types of transitions can you identify in your clients/patients? Do you think it is helpful to think of “transitions” as opposed to “developmental tasks or stages?” Why?

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2. How does culture influence transitions of adult-

hood? For example, explain how a woman from a traditional culture such as those in the Middle East might experience adulthood differently. 3. Discuss how gender might influence adult development in a White, middle-class family. 4. Describe how social factors such as mobility, increased education, and changes in the economy have influenced adult development in American and Canadian cultures. 5. How might caregiving for a family member bring about a situational transition for a middle-aged adult? Would this differ in cultural groups such as Chinese Americans or Mexican Americans? How? 6. Describe how culture influences the role of the caregiver in some African American cultures. What can you find in the literature about caregiving in other cultural groups?

Critical Thinking Activities 1. Interview a middle-aged colleague, a client,

or a person from another cultural group. Ask about adult roles within the family and how they are depicted. How are these role descriptions typical of traditional roles that are described in the literature? If not, how are they different? What are some of the reasons why they have changed?

2. Interview a middle-aged client from another

cultural group. Ask about the client’s experiences within the health care system. What were the differences the client noted in health beliefs and practices? Ask the client about his or her health needs during middle age.

3. Using

the Andrews/Boyle Transcultural Nursing Guide for Individuals and Families provided in Appendix A, conduct a cultural assessment of a middle-aged client of another cultural group. Critically analyze how the client’s culture affects the client’s role within the family and the timing of developmental transitions. How might the assessment data differ if the client were older? Younger?

4. Review the literature on Mexican American

culture. Describe the traditional Mexican American family. What are the cultural characteristics of Mexican Americans to consider in assessing the developmental transitions of adulthood in this group?

5. You are assigned a new patient, a 24-year-old

man from El Salvador named Jose Calderon. At morning report, you learn that he has been a gang member in El Salvador, and because he wanted to stop all gang-related activities, his life was threatened. He fled to the United States and has been granted political asylum. You are told that he has extensive tattoos on his body. What do you know about gang membership in Central America? In the United States? How does membership in a gang address the needs of adolescents? What are the cultural factors that are important to consider when you are planning nursing care for a patient like Jose? For example, how do you view body tattoos? What are the issues related to political asylum, immigration, and the like? How might you assist Jose to meet his developmental needs? What might be the problems he will encounter in the US society or in our health care system?

References Baird, M. B. (2012). Well-Being in refugee women experiencing cultural transition. Advances in Nursing Science, 35(3), 240–263. Baird, M. B., & Boyle, J. S. (2012). Well-Being in Dinka refugee women of Southern Sudan. Journal of Transcultural Nursing, 23(1), 14–21.

Belenky, M. F., McVicker, B., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. (1997). Women’s ways of knowing: The development of self, voice, and mind. New York, NY: Basic Books. BlackDemographics.com. (n.d.). Retrieved from http://blackdemographics.com/households/kpoverty/

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Black Women’s Health Imperative. (n.d.). Retrieved from http://blackwomenshealth.org/issues-and-resources/ black-women-and-hiv-aids/ Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513–531. Campinha-Bacote, J. (2013). People of African American heritage. In L. D. Purnell, (Ed.), Transcultural health care: A culturally competent approach (pp. 91–114). Philadelphia, PA: F. A. Davis Company. Centers for Disease Control and Prevention. (2007). A heightened national response to the HIV/AIDS crises among African Americans. U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/hiv/ topics/aa/resources/reports/heightenedresponse.htm Centers for Disease Control and Prevention (2014). HIV among African Americans Fact Sheet. Department of Health and Human Services, retrieved from: http://www. cdc.gov/hiv/risk/racialethnic/aa/facts/index.html Centers for Disease Control and Prevention. (2008). HIV/AIDS surveillance report, 2008. (Vol. 18, pp. 1–54). Atlanta, GA: US Department of Health and Human Services. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/ report/pdf/2006SurveillanceReport.pdf Centers for Disease Control and Prevention, National Center for Health Statistics. (2010). In Leading causes of death. Retrieved from http://cdc.gov/nchs/deaths.htm Centers for Disease Control and Prevention. (2010). Leading causes of death by age group, black females-United States, 2010. Retrieved from Mortality Tables at http://www.cdc. gov/nchs/nvss/mortality_tables.htm Crist, J. D., Kim, S., Pasvogel, A., & Velazquez, J. H. (2009). Mexican American elders’ use of home care services. Applied Nursing Research, 22(1), 26–34. Demick, J., & Andreoletti, C. (Eds.). (2003). Handbook of adult development. New York, NY: Kluwer Academic/Plenum. Erikson, E. (1963). Childhood and society (2nd ed.). New York, NY: Norton. Family Caregiver Alliance. (2006). Retrieved from http://caregiver.org Giger, J. N., Appel, S. J. Davidhizar, R., & Davis, C. (2008). Church and spirituality in the lives of the African American community. Journal of Transcultural Nursing, 19(4), 375–83. Havighurst, R. J. (1974). Developmental tasks and education. New York, NY: David McKay. Hine, D.C. (1994). Hine Sight: Black Women and the Re-construction of American History. Bloomingdale & Indianapolis: Indiana University Press. Hine, D. C., & Thompson, K. (1998). A shining thread of hope: The history of Black women in America. New York, NY: Broadway Books. Huffington Post. (April 9, 2014). Women in the workforce: What changes have we made? Retrieved from http://www. huffingtonpost.com/mehroz-bair/women-in-the-workforce-wh_b_4462455.html

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Im, E. O., Lee, S. H., & Chee, W. (2010). Subethnic differences in the menopausal symptom experiences, acculturation and menopause among midlife minority women. Journal of Transcultural Nursing, 21(2), 123–133. McCrae, R. R., & Costa, P. T. (2003). Personality in adulthood: A five-factor theory perspective (2nd ed.). New York, NY: Guilford Press. Meleis, A. I., Sawyer, L. M., Im, E. O., Hilfinger Messias, D. K., & Schumacher, K. (2000). Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23(1), 12–28. Millett, G. A., Peterson, J. L., Wolitski, R. J., & Stall, R. (2006). Great risk for HIV infection of black men who have sex with men: A critical literature review. American Journal of Public Health, 96, 1007–1019. Mortality Tables. (2010). Retrieved from http://www.cdc.gov/ nchs/nvss/mortality_tables.htm National Alliance for Caregiving & AARP. (November 2009). Caregiving in the U. S.: A focused look at those caring for someone age 50 or older. Executive summary. Retrieved from www.caregiving.org/data/FINALRegularExSum50plus.pdf National Alliance of State & Territorial AIDS Directors (NASTAD). (May 2008). The landscape of HIV/AIDS among African American women in the United States. African American Women, Issue Brief No. 1, 444 North Capital Street, NW, Suite 339 Washington, DC. Neugarten, B. (1968). Middle age and aging: A reader in social psychology. Chicago, IL: University of Chicago Press. Noble, A., Rom, M., Newsome-Wicks, M., Englehardt, K., & Woloski-Wruble, A. (2009). Jewish laws, customs, and practice in labor, delivery, and postpartum care. Journal of Transcultural Nursing, 20, 323–333. Purnell, L. D. (2014). Transcultural health care: A culturally competent approach (3rd ed.). Philadelphia, PA: F.A. Davis. Shambley-Ebron, D., Dole, D., & Karikari, A. (2014). Cultural preparation for womanhood in urban African American girls: Growing strong women. Journal of Transcultural Nursing. Online 6 May 2014. doi: 10:1177/ 1043659614531792 Shambley-Ebron, D. (2009). My sister, myself: A culture- and gender-based approach to HIV/AIDS prevention. Journal of Transcultural Nursing, 20, 28–36. Shambley-Ebron, D., & Boyle, J. S. (2006a). In our grandmothers’ footsteps: Perceptions of being strong in African American women with HIV/AIDS. Advances in Nursing Science, 29(3), 195–206. Shambley-Ebron, D., & Boyle, J. S. (2006b). Self-care and the cultural meaning of mothering in African American women with HIV/AIDS. Western Journal of Nursing Research, 28, 42–60. U.S. Department of Health and Human Services, HIV/AIDS Bureau. (n.d.). The HIV/AIDS program: Legislation. Retrieved from http://hab.hrsa.gov/law/leg.htm

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Williams, K. C., Hicks, E. M., Chang, N., Connor, S. E., & Maliski, S. L. (2014). Purposeful normalization when caring for husbands recovering from prostate surgery cancer. Qualitative Health Research, 24(3), 306–316. Womenshealth.gov (2012). Minority Women’s Health, HIV/ AIDS. Office on Women’s Health, US. Department of

health and Human Services. Retrieved from http://womenshealth.gov/minority-health/african-americans/hivaids.html Young-Mason, J. (2009). Understanding culture: The art of food from the Annuals of the Caliph’s Kitchens. Clinical Nurse Specialist. CNS, 23, 175–176.

Transcultural Perspectives in the Nursing Care of OlderAdults ●●Margaret A. McKenna

Key Terms Chronic conditions Formal support

Health behavior Illness behavior Informal social support Long-term care

Self-care Traditional medicine or practices

Learning Objectives 1. Demonstrate knowledge of the sociodemographic shift in the older adult population that affects the demand and roles for nurses and other health professionals. 2. Identify how socioeconomic factors, including income level, as well as c ommunity resources will influence the interactions of older adults in the health care system. 3. Integrate concepts of informal and formal support systems and culturally influenced patterns of caregiving to plan appropriate nursing care of the older adult residing in the community. 4. Develop nursing interventions for older adults in a variety of health care contexts that will be perceived as culturally acceptable. 5. Analyze factors affecting the needs of diverse older adults in a continuum of services from health promotion community-based services through care in long-term care facilities.

Nurses and other health professionals are caring for increasing proportions of older adults who are seeking health services in community health sites and health care facilities. Two major factors contributing to this larger population of older adults

are longer lifespans and the growing numbers of aging baby boomers who were born between 1946 and 1964. Approximately 10,000 Americans will celebrate their 65th birthday on each and every day through 2030 (Pew Research Center, 2014). 213

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The population of Americans aged 65 years or older will account for approximately 20% of the population by 2030 (Centers for Disease Control & Prevention, 2013). According to the World Health Organization, most of the developed world countries have applied the age of 65 years to refer to an older person, since this is associated with the age when an individual is likely to be eligible to receive pension benefits. However, there is no universal agreement on the age at which a person becomes old; indeed, an individual might be a tribal elder at the age of 50 or may not selfdefine as being old until well past 70 years of age. Not only is the US population dramatically aging but we are also seeing increases in racial and ethnic diversity among older adults. Between 2010 and 2030, the percent of adults aged 65 years or older who are non-Hispanic White will decline from 80% to 71% (Ortman, Velkoff, & Hogan, 2014). By 2030, older Hispanics will make up 12% of the population, non-Hispanic Blacks 10%, and older Asians 5.4% (Federal Interagency Forum on Aging-related Statistics, 2012). The proportion of racial and ethnic minorities is estimated to grow to 41% in 2050 (Ortman et al., 2014). The older adult population is also diverse in terms of gender, sexual identity, language, education, socioeconomic status, acculturation, and other factors. Social and cultural influences will contribute to diverse patterns of help-seeking behavior among older adults who access health care services, necessitating health care practitioners to provide culturally competent care to meet the patients’ needs and to achieve positive health outcomes. While culture is not the sole determinant of behavior, it is a critical dimension in understanding the interactions of older clients within their families, the encompassing societal context, and health care settings. Therefore, the older clients’ cultural traditions and values will influence how they interact with the health care system and their preferences for their residence, lifestyles, and choice of caregivers. The availability of resources in the community will affect any older client’s options for care and the individual’s movement on a continuum of care.

These community resources include retirement facilities, long-term care institutions typically referred to as nursing homes or skilled nursing facilities, funding for community services, as well as national, state, and local policies. Social and economic factors, including acculturation, influence the retention of traditional cultural values and practices. In assessing older adults, nurses must consider individuals in these multiple contexts—such as whether they operate as caregivers within their own families—to assess and determine the families’ strengths, resources, and capacities for care of aging family members. The context for delivering culturally appropriate care to clients is set by how available and affordable national, state, and local health care resources are for older adults. States, and even rural and urban locations, differ in the range of information and referral sources, acute and extended care facilities, and c ommunity-based services that are available to older adults to support their quality of life. Box 8-1 highlights multiple factors that will interact and shape the context for older adult clients who seek care or use health care services. This chapter is organized in three sections that follow an ecological model, which recognizes that an older adult is a participant in an encompassing societal context, a local community setting, and also interacts in an interpersonal setting that includes family roles. Each of these areas influences the older adult’s help-seeking behavior: 1. The encompassing social and economic fac-

tors affect the affordability and accessibility of health care options for acute, chronic, and long-term care. 2. The older adult’s cultural values, practices, patterns of caregiving, as well as available community resources (informal and formal sources of help) will influence when and where older clients interact in the biomedical health care system or other systems. 3. The older adult is also influenced by his or her nuclear and extended family evident in diverse lifestyles and patterns of health-promoting or

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Box 8-1 Factors that Influence Older Adults’ Responses in Seeking Health Care At the Societal Level ●●

●● ●●

Social and economic factors affect eligibility for Medicare and state medical assistance programs, which can limit older adults in receiving preventive care, acute care, or health care maintenance in the health care system. Changes to control Medicare expenditures force shorter hospital stays. Gaps in health care services put greater burdens on older patients for home and communitybased care.

At the Cultural Level ●●

●●

Cultural values, acculturation, access to traditional sources of health medicine, and logistical factors including language and transportation can all interact in determining when and where older adults will access the biomedical health care system. Different cultural traditions have values that influence patterns in caring for older adult

risk-taking behavior, coping behavior to manage acute and chronic conditions, and decision making about care and services. Chronic conditions may include diabetes, hypertension, arthritis, and other illnesses that require medication, diet modification, or symptom monitoring.

The Older Adult in Contemporary Society: Factors Affecting Health Care This section addresses the encompassing context that surrounds and influences older adult clients: demographic factors of the aging population, socioeconomic conditions, and the theoretical frameworks that shape how older adults in Western society perceive growing older.

●●

family members as they age and require more assistance. Younger family members become acculturated and change traditional behaviors that may differ from older adults’ expectations to be cared for at home.

At the Individual Level ●●

●●

Younger adult family members who are more accustomed to the range of health care options and services may differ in their preferences and health care practices, which can conflict with older adult parents. Female family members who were once expected to be primary caregivers for older family members may be engaged in the workforce and unavailable as caregivers. Families’ economic situations, proximity to the older adult, and sources of formal support in the community will determine options for residence and care needs of the older adult.

Changing Demographics Many older adults are interested in remaining healthy as they age, and there are abundant opportunities for nurses working in health care facilities and in the community to interact with older clients and educate them about healthy lifestyles and health-promoting behavior. With advances in the medical community that contribute to adults reaching old age, nurses and other health care professionals can be active in creating health- promoting environments to meet and sustain healthy outcomes for older adults (Waites, 2012). Some older adults will experience risks for heart disease and conditions including stroke, chronic respiratory diseases, Alzheimer’s, and diabetes. There are 2 to 4 million Americans aged 60 years or older who are historically disadvantaged, including individuals who have been

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arginalized and have very low incomes and who m more frequently have higher levels of disability (CDC, 2013). One study also identified that older lesbian, gay, bisexual, and transgender (LGBT) adults continue to have higher levels of illness, disability, and premature death (FredriksenGoldsen & Muraco, 2012). Older adults with chronic health conditions may have a decreased ability to independently complete activities of daily living, such as managing money or taking prescribed medications. When their functioning status declines, nearly one in five older adults may lose their ability to perform their activities of daily living including bathing, toileting, and dressing. Older adults with chronic conditions that increase with age, such as arthritis, diabetes, and cardiovascular disease (CVD), are more likely to experience physically unhealthy days or even physical distress, which is defined as 14 or more physically unhealthy days annually (CDC, 2013). In individuals 65 years and older, 40% report having at least one disabling condition (Chale, Unanski, & Liang, 2012). Two of three older Americans have multiple chronic conditions, and treatment for this population accounts for two-thirds of the country’s health care budget (USDHHS, 2010). Over 1.3 million older adults are in long-term care facilities; half of these residents are 85 years or older and typically have severe impairments including cognitive impairments or dementia. At all ages, the health status of Hispanics, Asian Americans, African Americans, Native Americans/Alaska Natives, and Native Hawaiians/ Other Pacific Islanders has long lagged behind that of non-Hispanic Whites. CVD affects black adults much more consistently than other racial groups, regardless of differences in socioeconomic status (see Figure 8-1). Older African Americans have the highest rates of hypertension compared to other racial groups and higher rates of diabetes compared to Whites and Asian Americans (Gallant, Spitze, & Grove, 2010). Older adults who are African American, Hispanic (nonWhite), and American Indian/Alaska Native suffer a higher prevalence of CVD and diabetes than do White (non-Hispanic) populations. The rate

Figure 8-1. A nurse assesses an older adult client (michaeljung/Shutterstock.com).

of diabetes for American Indians/Alaska Natives is more than twice that for Whites (CDC, 2013). Similarly, Mexican-born individuals report higher rates of diabetes and related chronic illness, which directly affects higher rates of disability, than individuals in the non-Hispanic elderly population (CDC, 2013). These disparities exist for interrelated reasons, including lower-income levels, lack of insurance including supplemental insurance to Medicare, barriers in access to care, lower quality of care for some health conditions even when the individual is insured and care is received, and individual decisions to not seek care. Both ethnicity and income level affect the older adults’ health status and need for care. Older White males with the highest incomes can generally expect to live more than 3 years longer than

Chapter 8 Transcultural Perspectives in the Nursing Care of OlderAdults

those in the lowest income levels. Low-income seniors are significantly more likely to encounter these health risk exposures: losing a loved one or close friend, overwhelming caregiving demands for someone else, social isolation, and poor quality housing. Elderly African Americans often suffer functional declines at earlier ages than White Americans. Older African American women have a much higher proportion of disabling conditions than older African American men and older White adults (CDC, 2013). Thus, there is no simple correlation between the need for care and increased age; care needs and health status are affected by many dimensions in an older person’s life, including socioeconomic level, ethnicity, and lifestyle risk factors (e.g., dietary habits). There are variations in disability among Hispanic or Latino subgroups. Older Puerto Rican men and women self-reported the highest levels of disability, followed by Mexican- and Dominican-born men and women. Cubans, Central Americans, and South Americans reported fewer disabling conditions, and Spanish-origin men and women reported the lowest disability among Hispanic subgroups (Markides & Gerst, 2011). While foreignborn Hispanic men had slightly lower levels of disability than US-born Hispanic men, there was no foreign-born advantage for Hispanic women (Markides & Gerst, 2011). To serve the growing proportion of older clients and their complex demands, nurses should consider that social and economic factors, cultural variation, and available support interact and affect the illness behavior and related helpseeking responses of older clients. Illness behavior refers to how individuals identify that they are ill, accord symptoms significance, decide to seek care or take action to reduce their symptoms, and decide whether or not to comply with a recommended regimen or option for treatment. As nurses prepare to care for older clients, they must assess the heterogeneity of the population as ethnicity, cultural traditions, social and economic situations, living arrangements, employment status, and migration history of older adults are as varied as they are for younger adults. These

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ackground factors contribute to older adults’ b varied responses to the illness that brings them to the health care system. Adults aged 65 years or older are much more likely than young and middle-aged adults to have low health literacy skills, which means they are more likely to misunderstand medical tests, end up in the emergency room, and have a harder time managing chronic diseases (CDC, 2013). A majority of older adults have trouble understanding everyday health information available in health care facilities, which indicates nurses have a role to make information and instruction understood by all patients.

Socioeconomic Status Affects Health and Illness Behavior The United States has some of the highest expenditures for health care among developed countries, and nearly two-thirds of the health care costs are for treating chronic illnesses. National health care costs are expected to increase by 25% by 2030 with the growing numbers of older adults who have chronic illnesses (CDC, 2013). Medicare spending is projected to increase from $555 billion in 2011 to $903 billion in 2020 (Kaiser Family Foundation, 2011). The cost of caring for each adult aged 65 or older is estimated to be three to five times higher than for younger adults (CDC, 2013). Older adults may have set aside resources for retirement, but these resources may not be sufficient to keep pace with their longer lifespans. Most older adults who retire usually live on a fixed income, but many have increased healthrelated expenses and may cope with the death of a spouse or life partner that also affects their personal financial resources including health care costs. Some older adults decide to continue to work part time to supplement retirement benefits or to pay for health care costs (Tang, Choi, & Goode, 2013). Among ethnic older adults, including Hispanics and African Americans, 40% have no private savings for their retirement and will look to state

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and federal reimbursement programs for health and social service needs. Poverty among some Mexican American elderly may be attributed to occupational history of low wage jobs, periods of unemployment, and lower educational levels as the proportion of Hispanic elderly with no formal education is eight times the rate for non-Hispanic White older adults (Tang et al., 2013). The reality is that many ethnic elderly of color have accumulated fewer financial assets; that is, they have a lower household income and have less income from private pensions than do elderly Whites. More ethnic elderly of color rely on Supplemental Security Income (SSI) as the primary source of income after age 65, whereas a much smaller number of elderly White clients (1 out of 20) rely on this source (Tang et al., 2013). The majority of older adults prefer to “age in place,” that is, to stay in their homes and in their neighborhoods as long as possible (Karlin, Weil, Saratapun, Pupanead, & Kgosidialwa, 2014). One of the major problems that many older adults and their families face is that limited tangible assets and lower equity in their homes may limit possible care options because families cannot afford costly community-based care of the older adult family member. Community-based services may include homemakers, adult day care, transportation, personal care, and short-term institutional care. These services may be provided to some frail elderly who meet eligibility criteria and the support services will enable more elderly to reside longer in their preferred community residences. An example from the caseload of a nurse who provides preventive health care and assessments in a low-income housing complex for older adults illustrates that individuals have different experiences using health care services and Medicare. An 82-year-old woman working as a housekeeper did not seek health care until she had a stroke related to untreated hypertension. She had limited contributions to Social Security owing to an episodic work history, and her illness depleted any savings. She receives Medicare-funded services and continues to receive home health care through Medicaid, which is state-funded health

care coverage for individuals with low income. The home health nurse assessed that this patient and other older patients on her caseload would benefit from nursing visits and medication monitoring, but the patient’s insurance and Medicare will not cover such services. Medicare pays only a small portion of home health care services, and the patient must be medically eligible to qualify. Older adults who have other insurance may have some coverage for additional home health services for a limited period of time. This situation is representative of the experiences of many older adults who have lower socioeconomic status and are affected by the societal interventions, including Medicare, that provide health care coverage for older clients. Providing community-based care has some limitations as frail older adults in very rural areas may have to enter nursing homes as a safe housing option when there are too few community-based support services or assisted living centers to sustain the frail adult. The care that older adults may receive will be influenced and determined by economic necessity as well as environmental situations such as resources for nursing services and homemaker resources. Older adults’ needs for care, their requests for assistance, and the sources of caregivers are also dimensions that are culturally influenced. Nurses and health care professionals see numerous variations in community caregiving support resources, both formal and informal, that are provided for older adults. In addition to the demographic and economic factors that affect the older population, several theoretical assumptions underlie how people feel about aging adults and shape how resources are made available to care for older adults in communities.

Theories of Aging There are several theories of aging that have been very popular over the years and continue to be relevant in explaining how older adults are viewed in society. Disengagement theory focuses on explaining that older adults whose status is

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Figure 8-2. Active seniors enjoy a birthday celebration at a community center.

linked to employment perceive less self-worth in retirement when relieved of their roles and responsibilities. Activity theory describes that older adults may substitute recreational and meaningful opportunities to take the place of previous occupations and careers. Active older adults are recognized for contributing as family caregivers and as volunteers for social service organizations among other productive activities. Continuity theory focuses on supporting adults to remain engaged by adapting patterns of behavior from their younger adulthood to keep them involved into older adulthood. Erickson’s developmental theory advances that older adults may struggle with the tension between maintaining the integrity of their experience while facing the reality of declining physical and mental functions. In late older adulthood, individuals may despair with the perception that life is too short and with old age comes less authority and power (Erickson & Erickson, 1997), but they may also find joy in being a keeper of meaning and holding enduring relationships (Agronin, 2014). Cohen (2011) has described that older adults may “sum-up” their lives, which

includes a search for larger meaning in life, before having an “encore” phase of reflecting, reaffirming, and celebrating the major themes of their lives. Older adults participating in community center activities are shown in Figure 8-2.

The Older Adult in the Community: Cultural Influences In community settings, we observe differences in how culturally and ethnically diverse older adults’ life experiences will shape their health behavior and illness behavior. Older adults may carry out positive health behavior, such as not smoking, eating healthy foods, or maintaining regular exercise. Older adults could have walked daily when living in their home countries and eaten diets high in vegetables. When they are relocated into an urban setting, they may no longer feel safe to walk in unfamiliar areas and they may alter their diets to include available prepared and packaged foods. Among refugees from different regions, i ncluding

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Eritrea and Ethiopia in East Africa, as well as immigrants from Eastern bloc nations, many have lived through civil wars, ethnic tensions, and political revolution, and they feel depleted in trying to cope with more changes in their lives after leaving their homelands. As aging adult immigrants, they may experience adjustment problems that warrant care in the health and mental health care system, but at the same time, they may distrust the system or have very limited experience in seeking biomedical health care. Nurses who are providing care to clients whose background differs from their own need to be sensitive to assessing the client’s culture. Individuals who have immigrated from the same country or region will differ in their needs and in the ways that their cultural background influences their health- and illness-related actions. These differences are based on a number of factors: ●● ●●

●●

Regional or religious identity Situation in their homeland that may have prompted them to emigrate Length of time they have spent in the country where they resettled or immigrated including degree of acculturation Proximity to immediate family or extended family members Network of friends and social support from their homeland Link with ethnic, social, and health-related institutions

To illustrate intragroup differences, we can look to the total Hispanic American population, where persons of Mexican descent are most numerous (54%), Cubans represent 14%, Puerto Ricans 9%, and other Spanish-speaking countries represent 24% (CDC, 2014). Many educated and professionally well-established Cubans immigrated to the United States in the 1960s, remained, and are now retired. In contrast, families emigrating from Mexico have been younger, some older Mexican immigrants returned to their homeland, and older Mexican Americans do not have as long a life expectancy as their Cuban American peers. The life experiences of

the individuals, including their occupations and education, and their acculturation will affect their expectations for care in their advancing years. Astudy of Hispanic American elders living in the community concluded that the participants who were more acculturated to mainstream culture reported better mental health, but not physical health, than less acculturated peers (Buscemi, Williams, Tappen, & Blais, 2012). There is an incredible amount of diversity among Asian American, Native Hawaiian, and other Pacific Islanders as there are more than 40 distinct ethnic groups. Of the immigrant groups that have been represented in the United States for several generations, including Chinese, Japanese, and Filipinos, the Chinese and Filipino elderly are the most numerous. Newer immigrants include Koreans and Thais; among the refugees, the Vietnamese elderly are more numerous than Cambodians, Laotians, and Hmong. The percent of Asian Indians is growing in some regions as elder family members reunite with their adult children who relocated to North America in skills-based immigration (Sudha, 2014). Culture influences how individuals view aging, define health, manage interpersonal crises, and face alterations in health that accompany aging. Nurses should consider that for older adults, health has multiple dimensions: physical functioning, social and emotional well-being, and quality-of-life measures, including life satisfaction and happiness. Older adults differ in their perceptions of health but generally regard their physical activity and psychological well-being as indicators of health. Poor health refers to self-reported problems with physical functioning or a need for assistance to complete daily activities. Older adults are inclined to seek health information and to make behavioral changes to maintain their independence into old age. Older adults who use self-help strategies to maintain their health generally report better psychological wellbeing and physical functioning than older adults who do not use these approaches. Nurses typically provide information about the risks of not exercising as well as the benefits of increasing

Chapter 8 Transcultural Perspectives in the Nursing Care of OlderAdults

activity or stopping smoking or adopting healthy eating habits. Nurses may also ask older clients about the circumstances that lead to a lack of exercise and then help clients to take small steps such as seeing how others fit exercise in their lives. Nurses who are aware of cultural variations can appreciate that older individuals will have different value orientations underlying their decisions to adopt healthy behavior over at-risk behaviors. Older adults who have peer support anticipate a possible setback in changing a behavior and plan how to get past a challenge, and use incentives through self-talk and rewards will be more likely to make positive health changes. See health promotion goals for the prevention of CVD in older adults in Table 8-1. Practitioners should seek to understand the difficulties and different approaches that affect individual case management. Interventions should take into account older adults’ cognitive ways of coping and practical strategies and support these strategies. For example, the matriarch of an extended family who has always valued the social benefits that come from sharing meals with family members may be reluctant to stop that practice and substitute exercise and lowfat meals. Older adults will also have learned responses in their help-seeking behavior to cope with chronic illness and to assess new illness

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symptoms. Some older African Americans have been more resourceful in their problem solving, planning, and coping that may be due in part to the lack of access to health care including mental health services that they may have experienced over time (Vinson, Crowther, Austin, & Guin, 2014). Culture will influence the older person’s expec tations of what constitutes illness and will also influence whether the older adult uses traditional sources of health care, such as practices conducted by healers or actions that are known as family remedies. Older clients may preserve their traditional values that connect them to their origins and give meaning to their lives. Researchers have described the simultaneous use of Western medicine and traditional Chinese health practices that focus on restoring harmony and balance in the body and spirit among some groups of Chinese immigrants. Nurses should assess if any clients’ use of traditional treatments is carried out due to a cultural preference or if a client has limited access to biomedical therapy and resorts to other sources of care (Sorkin & Ngo-Metzger, 2013). Many older clients could have grown up with limited preventive care and associate health care only with emergent conditions, so nurses should assess the older client’s previous experiences in the health care system.

Table 8-1: Health Promotion Goals to Prevent Cardiovascular Disease Older Adults (Centers for Disease Control and Prevention, 2013) Goal

Health Professionals’ Actions

Indicators of Success

Reduce the number of older Americans who need cardiovascular treatment by increasing healthpromoting behaviors and health protective actions to reduce disease risks

PROMOTE smoke-free air policies and effective tobacco packaging labels. SUPPORT education programs, wellness programs, and efforts to reduce sodium and eliminate trans fats in the food supply. INCREASE awareness of heart disease and stroke and their risk factors. BUILD local partnerships to enhance the effectiveness and efficiency of efforts to prevent heart attack and stroke (CDC, 2013)

Increase in the number of older adults completing health education programs offered in their communities. Reduction in numbers of older adults who smoke. Diverse groups of older adults complete wellness programs that are tailored to be culturally appropriate to encourage all individuals with different lifestyles to reduce their disease risks through increasing exercise and eating healthy. Communities respond by creating safe and accessible walking paths to increase use by older adults.

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Traditional Beliefs or Practices Older adults may have strong recollections of traditional beliefs and related remedies from their childhood. As an example, while the origins of their beliefs are very different, some Somali patients may believe illness is caused by spirit possession while some Hmong patients may believe that an illness can be caused by evil spirits if one’s own spirit has left the body. Some Hindu and Sikh patients may believe that illness is due to karma, one’s actions in past lives. Some older Asian Indian immigrants might follow Ayurveda, which includes the use of spices and herbs for cold, congestion, diabetes, and heart problems (Brar, Chhibber, Srinivasa, etal., 2012). Older Chinese adults experiencing chronic pain, musculoskeletal problems, and headaches might follow traditional practices including herbal medicine, massage, acupuncture, or dietary therapy. Some older Vietnamese immigrants may also use traditional remedies as well as biomedicine, but they may not disclose the use of traditional medicine to a provider, so the nurse should ask a patient what he or she does to relieve symptoms such as the ingestion of certain foods for medicinal properties.

Case Study 8-1 Using Traditional Medicine Sopha Danh, as a young mother in her 20s, fled with her two young children from Cambodia, settled first in the southeast United States, and then relocated to the Pacific Northwest in the late 1970s. Prior to fleeing from Cambodia, members of Sopha’s extended family were tortured and died during a decade of genocide. The extended trauma resulted in patterns of posttraumatic stress disorder and depression being common among older Cambodian refugees. Older Cambodian Americans have the highest rates of disability among any of the Southeast Asians (Yang, Burr, & Mutchler,

An example of eliciting information from a patient is given in Case Study 8-1. The patient in the case study immigrated as a young woman, but not all immigrants are young. Many immigrants who migrated after the age of 50 experience more depression, which is associated in part with their increased dependence. Depressed older adults are more likely to have lower self-rated health and may have more functional impairment. This suggests that nurses should assess the quality of the older adult’s relationships, as well as their functioning status. The older adult usually does not have an option to work, nor is public assistance an option, so the family must provide for the older adult members. Older family members may reciprocate services for younger family members. As part of a nursing assessment, the nurse should note if older adults are primary care providers for grandchildren or other family members and if an illness episode in the older adult disrupts the family. Older adult clients may also use traditional medicine or practices from their family of origin as a means to prevent illness. Traditional preventive measures as well as actions to treat symptoms may combine several actions such as 2012). More Cambodian refugees also rate their health as poor and have poor physical functioning when compared to Pacific Islanders who were similar in age and other demographic features (Wagner, Kuoch, Tan, Scully, & Rajan, 2013). When Sopha becomes acutely ill and her adult children bring her to a biomedical provider, she does not trust a male health care provider and is very reluctant to adhere with the biomedical care. Sopha is more familiar with traditional medicine, and her experience in help seeking is with traditional healers who took time to develop a relationship with patients. When the biomedical provider starts to elicit Sopha’s history, and acknowledges how trauma affects health behavior, and when Sopha’s younger family members help to interpret the cultural differences, the provider develops care recommendations that Sopha accepts.

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Box 8-2 Guidelines for Communicating with Older Adult Clients ●● ●●

●●

Elicit the client’s views on why the client thinks he or she has symptoms. Ask what home remedies or treatment the client has used and what treatment the client expects. Respond with information about the biomedical model using words the client can understand. Negotiate with the client what he or she accepts about the biomedical health care model and will likely comply with. Create a positive environment by being patient, inviting, and sitting close to the client so the client can hear you (avoid standing above the client). If working with an interpreter, position yourself so the client sees you. Typically, address the client in formal terms.

a magical or religious element, burning a candle, offering cornmeal to the spirits, wearing an amulet, or reciting a prayer. A traditional healer is someone who is well respected for demonstrating unique abilities to relate to a person seeking help and decrease the person’s discomfort. To assess the older adult’s cultural beliefs and practices, the nurse can demonstrate a nonjudgmental attitude and develop culturally appropriate communication as shown in Box 8-2. The use of traditional sources of health care concurrently with or in place of the biomedical health care system is not limited to members of recently migrated cultural groups, but is common to nearly all individuals. Several chronic conditions that often accompany age, including osteoarthritis or diabetes, increase the likelihood that older adults will use traditional sources or self-care to treat their symptoms. An older adult doing self-care may choose an over-the-counter medication and may use other popular remedies before, during, or after the use of prescribed sources of care. Nurses can show an interest in the client and ask them about any actions they take to

●●

Ask the client if a family member can also be present to help the client remember or participate in any client teaching. Have printed instructions in the client’s native language, if possible. Have nonverbal methods of communication, including photographs or symbols to convey instructions, especially for clients who do not read their home language or English. Be aware if the client wants to make decisions or defer to family members as the decision makers about care issues. Demonstrate new skills that the client has to learn and discuss medications in words the client will understand. Show the client medications and help the client identify how to remember to take medications. Ask the client to repeat instructions to you.

treat their conditions, in order to assess the older client’s concurrent use of traditional practices, folk medicine, or popular medicine. Case Study 8-2 illustrates that assessing the client’s use of alternative sources of treatment is useful in developing a care plan that the client will accept.

Understanding Culture Change Some older adults have relocated to different regions of the country or have made a significant transition in their late adult years to be close to younger family members or for other reasons. Older clients may have the common experience of relocating or migrating, but they may vary in adjusting to new settings and to a new social environment (Keith,2014). Cultural change can contribute negatively to mental health, and this psychological stress is more intense for older refugees. For example, among some Central American immigrants living in a metropolitan area in the United States, their perceived stress was correlated with their psychological health. An example of a refugee making many social and financial adjustments is in Case Study 8-3.

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Case Study 8-2 How an Older Client Treats Pain Mrs. Teadora Matthews is an 83-year-old retired seamstress who has hypertension, high cholesterol, obesity, and degenerative joint disease, which makes her joints painful and limits her mobility. She was raised in Romania, immigrated to the United States as a young woman, married a man in the mid-western United States, raised a family, and now lives in the same home as her daughter and grandchildren. She has been the primary caregiver for her grandchildren and remains active as a

Case Study 8-3 Older Adult Adopts New Practices Mr. Sylvestre Longo is very proud to have been born in Burundi, in central Africa. However, due to the strife, ethnic conflict, and genocide, he had to flee in his native country. He lived in refugee camps in Tanzania for almost 30 years before he was relocated by an international relief agency to Washington State. The Burundian refugees initially received financial assistance upon arrival in the United States, but after months of limited support, members of the community sought work in order to pay rent, meet their basic needs, and partially repay the costs of their relocation. Several of the Burundians learned of a social service organization that was recruiting refugees and immigrants to participate in a pilot project to develop their employment and English language skills while learning farming. The Burundians learned English vocabulary while also improving their diet by eating homegrown lettuce, beans, kale, chard, and root vegetables. The Burundians also became more physically active when they were planting and harvesting their plots and working in the fields, which also contributed to the new farmers developing peer relationships.

volunteer receptionist at her church. Her joint pain causes her to miss her planned volunteer work, and she uses over-the-counter remedies including ointments, topical applications, and pain relief patches to reduce her pain. The nurse assesses that Mrs. Matthews tolerates a great deal of pain while carrying out her usual activities and remaining as active as possible. Her occasional use of the topical remedies does not interfere with the Mrs. Matthews’ prescribed medications for her other conditions. Mrs. Matthews believes that self-medicating and using rubbing compound decreases her pain, which allows her to participate in her preferred family and volunteer activities. The nurse will continue to assess whether the use of an alternative source of treatment would interfere with a prescribed care plan.

When Mr. Longo experiences shortness of breath and he seeks treatment through a neighborhood health clinic, a nurse elicits basic information about his health history, his social network, and his life transitions. Although he is only 50 years old, he is regarded as an elder among the other Burundians, who are in their 30s, some of whom lived their entire lives in refugee camps. Mr. Longo often attends monthly get-togethers of the local Burundians in which the younger, more acculturated members help to explain the cultural practices of their adopted country, such as completing applications to get entry-level jobs, buying food in large markets, and making appointments to request financial assistance. Mr. Longo’s nurse identifies several of his health-promoting behaviors. His informal social network could offer him some informational support to comply with his prescribed medications. She also assesses that he eats a diet high in fresh vegetables. This is in contrast to many immigrants and older adults who have income only from public benefits; typically, they have very limited access to fresh food when they live in neighborhoods without grocery stores (Yamashita & Kunkle, 2012). The nurse also assesses that Mr. Longo walks daily because he cannot afford other transportation, and this regular exercise contributes to his overall health and decreased risk factors for chronic conditions.

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Box 8-3 Assessing Older Adults’ Social Roles ●●

●● ●●

Family relationships and social interaction of the older client within the family—that is, the role the older adult has with a spouse, partner, adult children, and grandchildren as well as the role of the elder with peers and others in a social network Environment to which the older client will return Adherence of the client and the family to traditional values including the preferences of the patient to prepare, cook, or eat traditional foods. Adoption of new nutritional patterns

The nurse in this case study assesses several areas that are relevant to assess for any older adult client to maintain good health; these are listed in Box 8-3. For many Burundian refugees and other refugees and immigrants, low socioeconomic status could be a barrier to health care, especially for early diagnosis and treatment of chronic conditions. Access to affordable health insurance is increasing for many low-income individuals, but paying insurance premiums often remains a challenge. Some of the older immigrants from East Africa experience mild declines in their health when they gradually become less active and modify their diets to eat more of the prepared high carbohydrate foods that are abundant in their new country. Supplemental nutrition programs including community lunches high in fresh vegetables and a protein serve several purposes of supporting positive mental health through peer interaction and stimulating healthy eating practices to promote health. These communal meals often increase the participants’ intake of healthy foods and decrease their risks for poor nutritional status, which are associated with some older adults’ functional limitations, cognitive dysfunction, decreased physical activity level, social isolation, alcohol or substance abuse, or other factors.

●● ●● ●● ●●

●●

of eating prepared and packaged foods in place of traditional foods Linguistic or social isolation of the older client Desire to maintain a moderate level of activity Ability to take personal responsibility for one’s health Access to services and amenities including a safe place to exercise, senior center, and transportation Significance of spirituality and religious practices to health

Caregiving of Older Adults Older family members are part of the informal social support in their families, so they may be

the caregivers for grandchildren or younger family members and they may receive assistance and support from other family members (see Figure 8-3) (Khan, 2014). If the older adult becomes ill, then families may have to adapt to find an alternate caregiver. Older adults in their family social support networks may also be in need of assistance and nurturing. Consider the preferences of the older person and his or her family members, as well as the capacities of the older adult for selfcare and the willingness and capabilities of the families to offer support and assistance with care. The type and duration of support that can be provided by family members must be considered in relation to sources of formal support from home health workers, hospice care, and visiting nurses and therapists that could be used to sustain the family care. There are many contexts for formal support and health care for the older adults. The image of care for older adults in skilled nursing facilities has given way to a continuum of services that includes self-care, supported self-care, assisted living communities, and skilled care. The roles

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Figure 8-3. Grandparents are often the primary caregivers for grandchildren or younger family members (Rob Marmion/Shutterstock.com).

that family members take in each of these levels of care vary according to cultural, socioeconomic, and demographic characteristics. Although intergenerational caregiving is becoming increasingly common for some families across the United States, families in other countries have values more consistent with caring for aging parents in extended families. All families have culturally influenced patterns of responsibility to care for older family members, but these patterns vary across cultures. Culture influences the role that the family members will take in the care of older family members. Nurses and health care professionals must be increasingly aware of how social and economic factors may alter families’ retention of traditional values that affect caring for older family members. Nurses working with older adults should be sensitive to the evolving needs of family caregivers that will be influenced by the caregivers’ acculturation and their time since immigration, factors that place the caregiver between value systems. The economic necessity that two adults in many households must work to provide adequate household income has contributed to a decline in the availability of adult female children as

caregivers to parents and grandparents. Adult children and other family members may be available to provide episodic assistance, emotional support through short visits, or some financial assistance to purchase in-home services. Because it is not possible to talk about older adults or their families as if they were a homogeneous group, it is necessary to consider that cultural diversity and lifestyle choices may determine the options for care of the older adult. Several examples of community care options for older adults are highlighted in Table 8-2. In caring for older adults, community nurses may have to coordinate how families caring for older adult members can access and use formal support services (visiting nurse services, chore services, adult day care) and informal support services (family members, neighborhood volunteers, meal delivery). Nurses are giving increasing attention to assessing the caregiver’s capacities, needs, and resources in planning for extended care of an older adult at home. A nurse needs to assess the caregiver’s health and well-being as well as that of the older adult client, considering a caregiver may be a working mother sandwiched in the care of an older parent and adolescent

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Table 8-2: Highlights of Selected Health Care Studies of Caregiving and Older Adults Study Author (Date) Topic or Group Studied

Cultural Concepts Relevant in Care of Older Adult Client

Implications for Nursing Care

Friedemann, M., Buckwalter, K. C., Newman, F. L., & Mauro, A.C. (2013) Four groups in South Florida: Cubans, other Hispanic, Caribbean Black, and White elders who were being cared for in the community.

Four groups of caregiver respondents had similar feelings of obligation, emotional attachment, use of family or community help for older family members. They also similarly acknowledged the role of spirituality.

Families’ cultural values and emotional reactions to caring for a family member determined how they balanced their caregiving with available formal or community sources. Intergroup and intragroup differences should be assessed to plan appropriate care.

Sudha, S. (2014) Asian Indians from Tamil or Telugu ethnic groups who resided in North Carolina. Older adults and their midlife adult family members were interviewed. Some older South Asians have a pattern of moving between India and North America as their health and financial circumstances change.

Coresidence of elder family members with adult children, called joint families, was a social norm in South Asian populations. Older family members sometimes spent time to live in the households of their different children to increase interaction and decrease interpersonal tensions.

A major concern of the midlife and older adults has been affording health care. Many immigrant seniors have not been able to afford insurance and only sought health care with emergent needs. Some relief is likely with certain provisions of the Affordable Care Act.

Wang-Letzkus, M., Washington, G., Calvillo, E. R., & Anderson, N. L. R. (2012) Older diabetic Chinese Americans living in southern California.

Two adult day care centers serving community-based Chinese elders were the sites of a study using a community-based participatory research approach. The nurse researchers emphasized a colearning atmosphere and included community advisors at each site to promote information exchange with the participants.

Elder participants considered diabetes to be a social stigma, and they did not wish to speak of their illness. Chinese elders did desire to pass along their wisdom to younger generations, so bilingual research assistants, who were students, encouraged the elders to discuss their life experiences.

c hildren, or a caregiver may be a retired worker in her 60s with a chronic illness. Not only are clients more diverse, but their potential family caregivers vary widely in socioeconomic status, educational levels, and acculturation patterns. These factors will influence whether the caregivers, who are often wives, daughters, or other close relatives, will be expected to care for older family members.

support, or receiving some kind of aid or physical assistance, such as accompanying a person to an appointment. Many older adults are deprived of the informal social supports due to losses: ●●

●●

Separation from immediate family members because of geographic mobility Age-related segregation caused by increased nuclear families in neighborhoods Loss of spouse or partner because of death or illness Loss of leisure pursuits or entertainment due to illness, loss of income, or declining physical abilities

Dimensions of Social Support

●●

Social support has been delineated in three ways: affective support, or expressions of respect, and love; affirmational support, or having e ndorsement for one’s behavior and perceptions; and tangible

It is especially important for many older adults to have social, emotional, and physical sources of

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support to assist them to remain as independent as possible. We know that social support may mitigate the negative effects of social stress, but the exact mechanisms are unclear. We do understand variations in these patterns of support, which helps to prepare nurses who work in acute, extended-care, or community settings. Some minority older adult clients may have more connections to kin in their support networks, but they may also be more vulnerable to conflicts in tight-knit networks; this is less common for older adults who have multiplex networks of family, friends, neighbors, and coworkers (Lincoln, 2014). Having sufficient social support has been associated with positive health-related quality of life. Mobilizing social support along with spiritual dimensions was related to decreasing depression and improving health-related quality of life for some Korean American older adults (Lee, Kim, & Han, 2013). In a different study, remaining self-reliant, having strong social support, having adequate income, and being in good health all contributed to positive quality of life in a study of health care implications of aging lesbians (Averett & Jenkins, 2012). Culture may influence the types of social support family members offer to older clients, and nurses may assess that families’ size and structure affect how informal support is provided. Some families, including German Americans, and families of English heritage often have a linear structure. The expectation is that adult children will assume care responsibilities for aging parents, and grandchildren will assume caregiving for aging parents and grandparents when needed. Another family structure is collateral when the perceived bonds are more diffuse. Parents, aunts, uncles, grandparents, and family friends may be part of the collateral bonds of families. Among families with a collateral structure are some Irish, Polish, and African American families, who expect to receive and to provide informal support among all collateral contacts. The expectation for care among many Irish families is that relatives must assist each other when needed. Many Irish and Irish American families would agree

that their relatives are obliged to enter into generalized reciprocity. Being a member of a large extended family does not ensure being a recipient of informal support, but brings an expectation of providing social support to older family members (Gallant et al., 2010). Socially isolated older adults may have more self-reported health problems but may “do without” health care services due to their income status and lack of social support. When these older adults do seek care, they tend to be sicker and need more extensive care. Access to needed services in a timely manner could help older adults address health conditions and promote wellbeing in the short term. In addition to cultural variation in patterns of giving help and support, socioeconomic status will influence the amount and level of assistance that family members provide to older adult family members. Demographic factors, such as family size, migration patterns, rural/urban residence, and socioeconomic factors, including income level and educational level, affect patterns of family support to their older members. These factors may determine the availability of family members to offer assistance and may influence the type of support that is offered. Thus, nurses must assess the influence of these factors on the older adult’s social support network and identify that demographic and socioeconomic factors may be blended with culturally influenced patterns of behavior. There are elders of American Indian nations who have lived in urban areas and have developed cultural resilience through bridging their native and dominant cultures, while also maintaining a strong sense of identity (Grandbois & Sanders, 2012). Many elder Native Americans tend to socialize less outside of their extended families and expect that the needs of extended family members will come before those of the individual (see Figure 8-4). Native American values support the care of older family members in the home, but the pool of available caregivers is diminishing because of some of the same patterns observed for other families that includes

Chapter 8 Transcultural Perspectives in the Nursing Care of OlderAdults

Figure 8-4. Elderly Navajo women on the reservation.

employment mobility. Elder Native Americans living in multigenerational households are more likely than White peers to have significant disabilities (CDC, 2013). A pattern that has been seen in some Native American families is that each adult child, in birth order, assumes the burden of responsibility and cost of care for the aging parent, which may exhaust the son’s or daughter’s personal financial resources.

Variations Among Members of Cultural Groups The large older Hispanic population includes very diverse individuals who not only represent different countries, traditions, and acculturation status but who also have many variations in their patterns of social support from friends and family. While there are intragroup and intergroup differences, some patterns have been observed in studies of Hispanic elders. Older Cuban Americans are more likely than Mexican Americans and older Puerto Ricans to get together often with friends. Older Mexican Americans are more

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likely than either Cuban Americans or Puerto Ricans to attend church and to have daily contact with their children (Friedemann, Buckwalter, Newman, & Mauro, 2013). There are also significant variations in groups of older Asian Americans and Pacific Islanders. Older Korean Americans may have immigrated with their highly educated adult children, but a higher proportion of the older clients wish to live independently from the adult children. The Korean American elderly may socialize with their peers through Korean churches but some are more likely to be lonely and isolated than Chinese, Japanese, and Filipino elderly (Park, Roh, & Yeo, 2011). The nurse may look for ways to support an older adult immigrant in making ties to his or her home country to enhance self-esteem and feelings of belonging. Nurses may ask if an older adult can talk to a group of children at an ethnic community center, such as the Ukrainian Community Center, El Centro de la Raza, or the Polish Association. The older adult can also tell the history of his or her immigration to adolescents who may be tracing their cultural heritage for an oral history project. Senior adults may also be connected to school-age children by walking them to and from school or tutoring them through an after-school project. Nurses who are working with ethnic elderly clients may want to look for resources in the local community to do outreach to these community members and to involve them in their care.

The Older Adult: Caring for Individual Clients At an individual level, older adults continue to meet developmental tasks similar to the way young adults and middle-aged adults also fulfill developmental tasks. The developmental tasks that older adults achieve include the satisfaction of basic needs, such as safety, security, and dignity, and the fulfillment of integrity and selfactualization. For the majority of older adults,

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meeting these needs is intertwined with the lifestyle and the residence of the older adult. The older adult also usually prefers to maintain selfesteem through exercising self-determination in planning where he or she will live. Older adults may confer with their family members in discussing what housing option provides a safe environment where risks for injury or falls are reduced and social and health supports are available for the older adult. Depending on whether older adults reside in a community setting or an institutional residence, the individual may find an outlet for individual or group activity, volunteer efforts, artistic activity, or socialization that are sources of self-esteem. For most older adult clients, participating in some meaningful activity contributes to the positive fulfillment of the developmental tasks of aging (see Figure 8-5). Across different cultural groups, aging is a developmental experience for individuals who are in a stage of reflecting on life experiences and finding meaning in their lives. Older adults may have many transitions that are chosen or are inevitable with growing older. These often include retirement, grandchildren, changed living arrangements, family mobility, declining

health, and deaths of family members including a spouse, siblings, or children. Older adults may assume new roles, and nurses who work with older adults in community settings can reinforce changing roles as opportunities for positive growth. Nurses often view the strengths and residual abilities that older clients possess rather than dwelling on the losses, and in doing so, the nurse promotes optimal functioning when the older adult may be experiencing unavoidable dependency. Cultural factors, including the cultural group history, and life experiences, including immigration, will interact and determine the older client’s efforts to achieve security, autonomy, and integrity. In achieving integrity, the older client has a need to bring closure to life and acceptance of eventual death. A nurse may assess this need in a client’s family and be a sensitive listener when the client works through the steps of achieving integrity. Older clients need time for a purposeful life review. The older adult may relinquish some aspects of their typical responsibilities, such as paying bills, to an adult child, so they can be free to spend time on other activities or have more time to reflect.

Figure 8-5. Older adults volunteering at a community center.

Chapter 8 Transcultural Perspectives in the Nursing Care of OlderAdults

Faith and Spirituality Many older adults experience an increase in religion or spirituality, which is evident in showing increased humanistic concern for future generations, changing relationships with others, and spending time coming to terms with one’s mortality. Older adults respond differently to these spiritual development tasks as influenced by their culture, life experiences, and individual qualities. Religion and spirituality may be a source of emotional support, a psychosocial resource, or a coping mechanism for older adults who experience challenging health conditions, losses in personal relationships and fulfilling roles, and stress. Previous studies have found that older adults’ immigration status and countries of origin influence different religious and spiritual participation and devotion behavior. Some African American female elders have reported higher importance of religion and spirituality in their lives when compared to younger adults, and church-based social support was related to positive well-being and life satisfaction (Krause, 2010). Another example of spirituality is evident in older black Caribbean elders with higher education who were more likely to attend church services, while the younger and less educated black Caribbeans reported more devotional nonorganized behaviors (Chatters, Nguyen, & Taylor, 2014). There are examples of older adults perceiving benefits of religiosity and spirituality. Some elder Japanese Americans reported that religion brings them peace while some Thai elderly, who were studied, reported attending temple helps them find meaning in life, which is a way to maintain health in later life (Iwamasa & Iwasaki, 2011). In a study of some elderly Koreans, religiosity was related with greater life satisfaction (Park et al., 2011) and with improved health status (Lee & Hwang, 2014).

Decisions on a Continuum of Care Many older adults will require three types of care: (1) intensive personal health service, depending on the presence of acute and chronic conditions;

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(2) health maintenance and restorative care, depending on chronic conditions; and (3) coordinated nursing, social services, and ancillary services that may be provided on an episodic basis for older clients in the community. Many older adults will require care and assistance to manage chronic conditions; a public health goal is to encourage adults to adopt and follow health- promoting actions in their earlier years to minimize the occurrence of chronic conditions. Depending on their level of ability or disability, older adult clients may choose to continue to live in their own home with assistance, with family members, in an assisted living residence, or in a skilled nursing facility. Nurses will observe that older clients express different attitudes that range from resignation to acceptance when they must change residences. The nurse can assess that the older client’s attitudes about community or facility residence have been influenced by social and peer groups, and the nurse can be sensitive to the older client’s reactions. Families have often developed culturally influenced patterns of caregiving and social support. The nurse may assess the following: Does the family modify the environment and assist in home care so that the older adult remains at home? Do children and grandchildren share tasks, provide meals, and run errands so the grandparents can live alone? Do family members have a plan to have relatives share responsibility to provide support and supervision for an older family member? Does the older family member have caregivers and alternates who can provide care as needed if the older adult wishes to remain at home? Some differences have been noted in the patterns of living arrangements according to ethnic background. When family assistance and informal as well as formal sources of health care and social support are coordinated in a plan of care, some older adults may remain in a community setting longer before being cared for in long-term care facilities. The proximity of the older adult to younger family members who are willing and prepared to provide assistance with activities of daily living, transportation, nutrition, respite care, and

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social support may defer or delay nursing home placement for older family members (Kolb, 2013). Nurses must also assess that the values of independence and self-reliance may be very strong for some older clients, and they may refuse any assistance from family members, so the nurse should evaluate clients’ behaviors relative to underlying values. The adult children of older parents may feel obliged to respect their elders and provide home care when possible. As an example, some older Koreans have felt that their children should care for them, which is consistent with the value of filial responsibility (Kolb, 2013). However, these families, much like many other families of different cultural backgrounds, often face employment and financial challenges that limit their availability to care for aging parents, so the options for community care or nursing home placement should be considered. The interaction of factors including the availability, acceptability, and affordability of a skilled nursing facility that is in proximity to the ethnic populations also definitely impacts the overall residence patterns by members of cultural and ethnic groups (Khan, 2014). Older adults who for the majority, if not all, of their lifetime have spoken their native language and surrounded themselves with friends who also shared their customs might find it enormously difficult to enter a skilled nursing facility that would appear quite different in its practices. Nurses and other health care professionals are not always aware that certain behaviors, such as an insistence on schedules, order, and cleanliness, might not be valued equally by all older adults. Older adults may feel especially uncomfortable if they do not understand why they are awakened at a certain time, required to be dressed, and asked to participate in group socialization and may find the skilled nursing facility to be hostile and unfriendly (Kolb, 2013). Nurses can do much to ease the entry of adults into health care facilities when they assess each resident’s cultural background, food preferences, choices for daily care and personal schedule, and interaction with family members. A nurse may

ask questions on topics that were meaningful to the older client, for example, what was most important for them to maintain in their daily routines and what would they like to do so they could be as independent as possible. Older clients in long-term care facilities have expressed their desires to maintain their quality of life by controlling personal care and making decisions about their personal affairs whenever possible. Some older adults, coping with terminal illnesses and debilitating and painful conditions, may choose to be cared for in hospice care in facilities or in their homes with professional, formal, and informal sources of care. Nurses preparing to care for and support hospice patients who experience chronic pain may refer to evidencebased practices in pain management as shown in Evidence-Based Practice 8-1. Clinical guidelines have been evolving that are based on evidence-based practices for care of the older adult client with acute and chronic conditions who reside in community and institutional settings. Several sources in print and visual media help guide the nurse in assessing the older client; see Table 8-3.

Community-Based Services for Older Adults The skilled nursing facility represents only one option for extended care of the older adult. The current nursing facility resident is typically an individual who has exhausted the opportunities for care in the community after implementing home care and assisted living. Long-term care nursing consultants and nurses working in ambulatory care settings often are asked to assess older clients to help determine the best care option. Criteria that the nurse often considers when recommending the level of care or residential placement include mental orientation, physical mobility restrictions (use of assistive devices and ability to walk unaided), degree of assistance needed to complete activities of daily living, frequency of incontinence, and level of risk for accident or injury if living independently.

Evidence-Based Practice 8-1

Pain Management in Older Adults: Accommodating for Cultural Variation A panel of researchers for the British Pain Society and British Geriatrics Society has published reviews on the assessment of pain and the management of chronic pain in older adults (Abdulla et al., 2013). The majority of cited studies were of community-based adults, but also included adults in residential care. Cited studies had been done on older adults in Australia, the United Kingdom, and North America. The review was designed to identify best practices for clinical providers to implement in managing pain for older adults, including sectors of the old and very old. A study finding was that older adults’ attitudes and beliefs play an important role in mediating the way in which patients engage with treatment and the pain experience in general (pain intensity, psychological distress, functional impairment, and coping strategies used). Another finding based on small-scale studies found that several of the complementary therapies, including acupuncture, transcutaneous electrical nerve stimulation (TENS), and massage, had some efficacy among the older population. These approaches affect pain and anxiety, but require more investigation including research on older adults of different ages. Another finding was that some psychological approaches, including guided imagery and biofeedback training, were useful with subgroups of the older population. Limited evidence also supported the use of cognitive–behavioral therapy among some nursing

Nurses can assess social and cultural factors that influence the care that older adults will need, the resources to meet those needs, and the locations for residence and care that are most acceptable to the client. Nurses must assess the physiologic status of the older adult and consider the safety of the client in a residential setting, including medication management. The nurse should assess for the older clients’ understanding of medication directions, as the client’s eyesight may be failing, and should clarify directions,

home populations, but additional evidence would be needed to extend the findings.

Clinical Implications Nurses working in acute care settings, extended care settings, and in the community interact with patients and their caregivers to negotiate an acceptable pain management plan. Nurses should assess for the patient’s tolerance for pain, past and present experience with pain, effect of pain on quality of life, and the meaning attached to pain; these are all factors that can be influenced by the patient’s cultural background and the patient’s life experiences. The nurse who is striving to be culturally competent will assess the patient’s culturally influenced explanatory model about the cause of the pain and the patient’s expectations of treatments to relieve the pain. Behavioral therapies, which may include meditation, music, imagery, and aromatherapy, were not widely supported in the review but have been reported by groups of older patients to be effective. The nurse may assist in integrating the patient’s preferences to use traditional and popular remedies including cold packs, herbal remedies, heat applications, or other therapies along with the Western prescribed medicines when the traditional or alternative sources would not harm the patient, give comfort to the patient, and do not interact with prescribed medications.

which may be open to multiple interpretations. The cultural values held by the older client and his or her family will influence the available resources, including informal sources of support such as children and grandchildren who are called upon to provide personal care, assistance with activities of daily living, and financial support. Nurses and health care professionals who are aware of the older adult client’s preferences for inhome care or for residence in skilled nursing facilities realize that the client’s economic resources 233

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Table 8-3: Clinical Guidelines for Caring for Older Adult Clients Evidence Base or Focus for Clinical Practice

Reference for Practice

Source

Gerontological nurses are held to standards of Gerontological Nursing, which describe required nursing knowledge and specific nursing skills and abilities. Assessment is identified as a key skill for working with older adult clients.

Hartford Institute for Gerontological Nursing at New York College of Nursing and the American Journal of Nursing developed a visual and print series on assessment of the older adult client, which can be accessed online (http://www. nursingcenter.com).

The How To Try This evidence-based geriatric assessment tools were translated into nursing approaches and guidelines on 30 topics including pain assessment, pain rating scale, nutrition assessment, working with families, predicting pressure sore risk, assessing caregiver strain, and activities of daily living scale.

The Stanford Geriatric Education Center set goals to increase knowledge of evidence-based interventions for diabetes and depression in the elderly and to infuse ethnogeriatrics in the practice of health care professionals.

Stanford Geriatric Education Center, Ethnogeriatric Resources. Publications on diverse older adult populations, as well as webinars and handouts from the Ethnogeriatric webinar series, can be accessed online (http://sgec. stanford.edu).

The 2012 Ethnogeriatric webinar series on Applying Best Practices to Diverse Older Adults and Tackling the Tough Topics in Ethnogeriatrics include why culture matters in elder mistreatment, HIV and aging, pain management, behavioral issues, and elders at risk.

The module series on Meeting the Health Care Needs of Older Adults was developed for social workers and has relevant topics for nurses and other health professionals.

University of Minnesota School of Social Work developed modules on Meeting the Health Care Needs of Older Adults. The modules can be accessed online (http://www.cehd. umn.edu/ssw).

The Health Literacy and Cultural Competency module topics include demographics of older adults, health literacy, cultural competency, health communication, working with interpreters, chronic disease, and pain management.

may affect preferred care options. For the lowincome elderly person, purchasing part-time personal health care services or attendant care that would enable him or her to remain at home may not be an option, so the older adult manages in less-than-desirable or potentially unsafe living situations. Nurses who are working with individual clients and those who are assigned a caseload of groups of older adults in community settings, such as apartment complexes and assisted living centers, will assess the client’s needs, available sources of support from the family, and formal sources of support that are affordable to the client in a total plan of care for each client. Communitybased care typically includes a broad spectrum of services, often using formal and informal networks of caregivers, as well as resources such as home-delivered meals or older adult day care. Local programs through the Division of Aging,

Aging Services, or a comparable agency may leverage available state or federal funds in innovative programs to reduce rental costs to assist elderly clients so they can remain in the community. Local or church-affiliated agencies that recruit and train volunteer visitors and caregivers to the elderly may be used in conjunction with the aging agency programs to enable the fragile older adult to function at home with formal sources of support. These organized sources of support that may include a weekly visitor or a person to do chores for the elderly client may supplement the care and support that family members may provide. For many older adults, the long-held value of independence is so strong that the person would rather live alone, even in poor health, than be a burden to his or her family. Older individuals who are independent or self-sufficient are the most likely candidates for

Chapter 8 Transcultural Perspectives in the Nursing Care of OlderAdults

what are termed continuing care or assisted living retirement communities. There is a wide variety of assisted living programs in terms of size, structure, sponsorship, amenities, cost, and service availability. These are common residential locations that offer the older adult a comfortable apartment, a range of levels of assistance with activities of daily living, meals, social activities, and supervised exercise programs. Some residential communities have an attached facility for the skilled nursing care to move the client to higher levels of care based on the older client’s needs, which may change over time due to acute illness, postsurgical care, and declines in functional abilities associated with falls or accidents. Some older adults choose to relocate to these smaller, safer residences late in their lives to maintain their independence, but those decisions can lead to increased unfamiliarity in new neighborhoods (Lofqvist et al., 2013). The opportunity to interact with peers, and the option to participate in community resources, including cultural events, or shopping trips is fulfilling for some older adults (see Figure 8-6). But other older adults would feel stigmatized by residence in such a facility and would prefer to live in an independent location in the community. Other prospective residents might prefer the stimulation of intergenerational contact outside of an age-related residence and would prefer living on their own. Older adults deciding on any of these options are typically working through developmental tasks of finding where they will feel satisfied and fulfilled and find meaning in their lives. The challenge that the majority of older individuals will face is the high cost of paying for levels of care in residential communities or in skilled nursing facilities. Many older clients and their families assume that Medicare will be the means for paying for such care. However, Medicare has limitations for hospital care and posthospital rehabilitation and does not cover what is termed custodial care of the older client. Older individuals and their families may exhaust their personal resources to cover extended care needs.

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Figure 8-6. Retirees enjoy an activity in their residential community.

There has been an increase in the development of day programs in communities that provide nursing assessment, physical or occupational therapy, group socialization, and nutrition to older adults. These programs may supplement the affective support and tangible assistance that families give, and the programs provide settings that affirm the older clients’ dignity. The range of these services provided at each site varies according to the support of the local community, including volunteers and professional staff. Some sites provide group socialization and nutrition for a lunchtime meal. The older adults are usually ambulatory or able to be independent with assistive devices, so they may be transported to the sites by public or private transportation. Some adult day centers offer programs and services

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for older adults who may be caregivers for their grandchildren. The grandparent may bring the grandchild for well-child examinations and also access a health care provider for himself or herself, so two generations access health care at the same site. The options are expanding for older clients to participate in community-based services such as adult day care, which may follow a social model, a health support model, or a combined service delivery approach (Wang-Letzkus, Washington, Calvillo, & Anderson, 2012). Adult day health programs were endorsed in the 2010 Affordable Care Act as a possible means to extend older adults’ residence in their communities. The number of adult day programs has more than doubled in the last two decades, but the increase is not keeping pace, nor are services being funded at an adequate level to meet the needs of ethnically diverse older adults trying to remain in their familiar settings as they grow older (Brown, Friedemann, & Mauro, 2014). Nurses working in health care facilities or in community settings may want to assess the availability of local health and social enrichment programs and encourage the older adult client to attend a program. Many mutual assistance associations or cultural affiliations may provide programs for older adults to interact with young people and to share cultural traditions. These cultural center programs and similar church-affiliated programs provide a means for older clients to receive affirmational peer support and to reinforce their cultural identity in a way that restores self-esteem and dignity. Other intergenerational programs support older adults becoming involved within the community and the educational system. These types of programs include the Older American Volunteer Program, the Retired and Senior Volunteer Program, and the Foster Grandparents Program. There are also intergenerational child care centers that are demonstrating that older volunteers are resources in the community, and the children and older adults benefit. Evaluations of multigenerational programs found that the older volunteers had a high level of life satisfaction,

including psychosocial adjustment, positive social exchanges, and self-esteem (Pilkington, Windsor, & Crisp, 2012).

Summary A cultural approach to the older client recognizes that individuals are the products of, as well as the participants in, an encompassing societal framework. Within the societal framework, the cultural backgrounds of the older clients will influence their variations in their perceptions, behavior, and practices. Culture serves as a guide to the older client to determine what health-related choices and actions are appropriate and acceptable. Within cultural groups, individual variation is evident in responses to the physiologic signs and the psychosocial demands of increasing age. Examples of older immigrant clients demonstrate that the clients’ views and perceptions may differ from those of family members and from the views of the nurse. The different attitudes, practices, and behaviors among older clients result from their heritage, experiences, education, acculturation, and socioeconomic status. Nurses who are providing care in acute care settings or in the community often ask several questions as part of the nursing assessment: 1. Is the older adult isolated from culturally rel-

evant supportive people, or is the older client enmeshed in a caring network of relatives and friends? 2. Has a culturally appropriate network replaced family members in performing some tasks for the older adult client? 3. Does the older adult expect family members to provide care, including nurturance and emotional support, which family members are unable to provide? 4. Does language create a barrier in the older client’s receipt of services from formal resources? Older adult clients have often developed their own informal support systems for coping with illness and with changes associated with age. Formal

Chapter 8 Transcultural Perspectives in the Nursing Care of OlderAdults

resources may be used to sustain the informal support systems to promote the lifestyle preferred by the older client. Nurses caring for older adult clients should give attention to the client’s family and social roles and develop care plans that maintain and restore the individual to his or her usual roles and patterns of activity. In the future, nurses will assess and work with more older clients as they progress along a continuum of services and through more than one type of residence in the community. Clients may be reluctant to use services for various reasons that include cultural and linguistic differences or prior negative experiences in health care settings. To overcome any of the barriers that are perceived by older clients, nurses can assume several approaches to interact effectively with older adults from diverse groups: ●●

●●

Be sensitive to the life experiences and previous health care experiences of the older clients. Listen attentively to the older client’s complaints, recollections, and strengths. Listen to related conversations to assess for underlying depression. Elicit information about the older client’s preferences for care, including diet and use of self-care remedies, and include them when appropriate. Identify available sources of informal support and confirm availability.

Review Questions 1. What resources, needs, and limitations should

the nurse assess to develop a care plan for a recently discharged 82-year-old chronically ill man who is returning to a single-room occupancy hotel in a crowded inner city location? 2. As the nurse who does health assessments for frail older adults who attend a community comprehensive day program, what information should the nurse assess to identify culturally appropriate care plans or service delivery plans for older Filipino and Chinese American clients? 3. The short-term subacute unit where you are the nurse manager serves a multinational group

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of older clients who are admitted for orthopedic surgery. What cultural assessments do you teach the staff to use in identifying the needs of clients and their families?

Critical Thinking Activities 1. Many local communities offer adult day care for

older adults with chronic health care problems who are residing alone or with family members. Services usually include health screening by a nurse as well as occupational health and/or physical activity sessions for these communitybased older adults. Request permission to attend an activity as an observer and attentive listener. Through observation and, if possible, conversation with a participant, try to assess the levels of self-care that session participants possess and identify the types of assistance that these clients require to remain in the community.

2. If you are a case manager for a managed care

organization, you receive many authorization requests for in-home nursing services to assist older adults who have been discharged home following hospitalization for acute illnesses or surgery. List the factors that you will consider and the types of data that you need to make an informed decision about the nursing and healthrelated services and the duration of services that the older client should receive while at home.

3. In many communities, nurses provide hospice

services to residents in long-term care facilities or to older adults living in other settings. Contact a community-based hospice nurse to request information about how the services meet older adults’ needs for love and belongingness, as well as reflection and recollection that are expressed late in life.

4. With your awareness that cultural traditions

and life experiences influence many older adults to prefer independent living, prepare a letter as a home health nurse to the appropriate official to request government-funded home health services for older adults.

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Markides, K. S., & Gerst, K. (2011). Immigration, aging, and health in the United States. In R. A. Settersten Jr & J. L. Angels (Eds.), Handbook of sociology of aging (pp. 103–116). New York, NY: Springer Science and Business Media. Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: The older population in the United States population estimates and projections. U. S. Department of Commerce., US Census, Current Population Reports Issued May 2014. Park, J., Roh, S., & Yeo, Y. (2011). Religiosity, social support, and life satisfaction among elderly Korean immigrants. The Gerontologist, 52(5), 641–649. Pew Research Center. (2014). Baby boomers retire. Pew research center web site. Retrieved March 15, 2014 from http:// pewresearch.org/databank/dailynumber/?NumberID=1150 Pilkington, P. D., Windsor, T. D., & Crisp, D. A. (2012). Volunteering and subjective well-being in midlife and older adults: The role of supportive social networks. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 67B(2), 249–260. Sorkin, D. H., & Ngo-Metzger, Q. (2013). The unique health status and health care experiences of older Asian americans: Research findings and treatment recommendations. Clinical Gerontologist, 37, 18–32. Sudha, S. (2014). Intergenerational relations and elder care preferences of Asian Indians in North Carolina. Journal of Cross-Cultural Gerontology, 29, 87–107. Tang, F., Choi, E., & Goode, R. (2013). Older americans employment and retirement. Ageing International, 38, 82–94.

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U.S. Department of Health and Human Services. (2010). Multiple chronic conditions: A strategic framework— Optimum health and quality of life for individuals with multiple chronic conditions. Washington, DC: US Dept of Health and Human Services. http://www.hhs.gov/ash/ initiatives/mcc/mcc_framework.pdf Vinson, L. D., Crowther, M. R., Austin, A. D., & Guin, S. M. (2014). African americans, mental health and aging. Clinical Gerontologist, 34(1), 4–17. Wagner, J., Kuoch, T., Tan, H. K., Scully, M., & Rajan, T. V. (2013). Health beliefs about chronic disease and its treatment among aging Cambodian Americans. Journal of Cross-Cultural Gerontology, 28, 481–489. Waites, C. (2012). Examining the perceptions, preferences, and practices that influence healthy aging for African American older adults: An ecological perspective. Journal of Applied Gerontology, 32(7), 855–875. Wang-Letzkus, M. F., Washington, G., Calvillo, E. R., & Anderson, N. L. R. (2012). Using culturally competent community-based participatory research with older diabetic Chinese Americans: Lessons learned. Journal of Transcultural Nursing, 23(3), 255–261. Yamashita, T., & Kunkle, S. (2012). Geographic access to healthy and unhealthy foods for the older population in a US metropolitan area. Journal of Applied Gerontology, 31, 287–313. Yang, M. S., Burr, J. A., & Mutchler, J. E. (2012). The prevalence of sensory deficits, functional limitations, and disability among older southeast Asians in the united States. Journal of Aging and Health, 24, 1252–1274.

Part Three

Nursing in Multicultural Health Care Settings

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Creating Culturally Competent Health Care Organizations ●●Patti Ludwig-Beymer

Key Terms Community-based participatory research Cultural assessment tools

Culturally congruent services Culturally responsive services Culture of safety Institutional racism Limited English proficiency (LEP)

Magnet designation Participatory action research Transcultural nursing administration

Learning Objectives 1. 2. 3. 4. 5.

Assess the need for culturally competent health care organizations. Identify how health disparities can be decreased or eliminated. Evaluate organizational cultures. Describe how organizations can develop cultural competency. Assess culturally competent initiatives designed and implemented by health care organizations.

An individual’s culture affects access to health care and health-seeking behaviors, as well as perceived quality of care. In addition to understanding the culture of clients, however, it is also essential to examine the culture of health care organizations. The interplay of client, provider, and organizational cultures may create barriers, lead to a client’s lack of trust or reluctance to access services, cause cultural conflicts, and ultimately result in health care inequities. Conversely, organizational

culture may facilitate access that decreases health disparities. This chapter serves to augment the current dialogue on creating culturally competent organizations. It defines a culturally competent organization, explains the need for culturally competent organizations, describes mechanisms for assessing organizational culture, and provides strategies for developing culturally competent organizations.

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Defining a Culturally Competent Health Care Organization Cultural competence refers to the ability of health care providers and organizations to understand and respond effectively to the cultural and linguistic needs of clients (Office of Minority Health, 2011). Cultural competence encompasses a variety of diversities, including age, culture, ethnicity, gender, language, race, religion, sexual preference, and socioeconomic status. Cultural competence encompasses a wide range of activities and considerations and includes providing respectful care that is consistent with cultural health beliefs of the clients and family members. A culturally competent organization is broadly defined as an organization that provides services that are respectful of and responsive to the cultural and linguistic needs of the clients they serve.

The Need for Culturally Competent Health Care Organizations: External Motivations Nursing has been at the forefront of cultural competence in individuals and organizations. The Transcultural Nursing Society was established in 1975 to advance cultural competence for nurses worldwide, advance scholarship of the discipline, and develop strategies for advocating social change for culturally competent care (Transcultural Nursing Society, 2014). An expert panel identified ten standards of practice for culturally competent nursing care. Salient to this chapter is Standard 6, Cultural Competence in Health Care Systems and Organizations. The standard holds that “Healthcare organizations should provide structures and resources necessary to evaluate and meet the cultural and language needs of their diverse clients” (Douglas etal., 2014, p. 113). The American Nurses Association (1998) has also been proactive in addressing discrimination and racism in health care and promoting justice

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in access and delivery of health care to all people. The organization supported affirmative action programs in 1972 and passed a resolution on cultural diversity in 1991. ANA (2010) developed a position statement on ethics and human rights in an effort to address institutional racism, environmental disparities, class discrimination, sexism, ageism, heterosexism, homophobia, and discrimination based on physical or mental disabilities. Box 9-1 contains a partial listing of their recommendations. Sigma Theta Tau (Wilson, Sanner, & McAllister, 2003) and the American Organization of Nurse Executives (2011) include publications on diversity and the need for cultural competence in health care. Regulatory agencies address the need for culturally competent organizations. For example, The Joint Commission has set standards, outlined in Box 9-2, to ensure that clients receive care that respects their cultural, psychosocial, and spiritual values (Joint Commission Resources, 2014). The US government has also addressed culturally appropriate health care systems. For example, the Institute of Medicine (IOM) report “Health Professions Education: A Bridge to Quality” (Greiner & Knebel, 2003) identifies five core competencies for all health professionals: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics. Providing patient-centered care includes sharing power and responsibility with clients and caregivers; communicating with clients in a shared and fully open manner; taking into account clients’ individuality, emotional needs, values, and life issues; implementing strategies for reaching those who do not present for care on their own, including care strategies that support the broader community; and enhancing prevention and health promotion. In order to accomplish the goal of meeting clients’ individuality, emotional needs, values, and life issues, the IOM report further indicates that clinicians must provide care in the context of the culture, heath status, and health needs of the client. In addition, National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards), outlined in Box 9-3, were

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Box 9-1 American Nurses Association Recommendations Related to Cultural Competence ●● ●●

●●

All nurses advocate for human rights of patients, colleagues, and communities. Health care agencies pay close attention to potential for human rights violation as they relate to patients, nurses, health care workers, and others within their institutions. Nurses work collaboratively within the profession and with other health care professionals to create moral communities that promote, protect, and sustain ethical practice and the human rights of all patients and professional constituents. Nurse researchers conduct research that is relevant to communities of interest and guided by participation of these communities in

●●

identifying research problems and that strives to benefit patients, society, and professional practice. Nurse administrators assess policy and practice and identify risks for reduced quality of care that may occur as a result of unacknowledged violations of human rights. Nurse administrators actively promote a caring, just, inclusive, and collaborative environment. Nurse administrators look beyond the immediate environment to the wider community for opportunities to contribute or participate in efforts to promote health and human rights.

Source: American Nurses Association. (2010). The nurse’s role in ethics and human rights: Protecting and promoting individual worth, dignity, and human rights in practice settings. Washington, DC: American Nurses Association.

Box 9-2 2014 Joint Commission Standards That Address Culture Leadership Standards LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the hospital. LD.04.01.01 The hospital provides services that meet patient needs. LD.04.07.07 Patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital.

Human Resource Standards HR.01.06.01 Staff are competent to perform their responsibilities.

Rights and Responsibilities of the Individual RI.01.01.01 The hospital respects, protects, and promotes patient rights.

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RI.01.01.03 The hospital respects the patient’s right to receive information in a manner he or she understands. RI.01.02.01 The hospital respects the patient’s right to participate in decisions about his or her care, treatment, and services. RI.01.03.01 The hospital honors the patient’s right to give or withhold informed consent. RI.01.03.05 The hospital honors the patient’s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care. RI.01.03.05 The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials. RI.01.05.01 The hospital addresses patient decisions about care, treatment, and services received at the end of life.

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RI.01.06.05 The patient has the right to an environment that preserves dignity and contributes to a positive self-image. RI.01.07.03 The patient has the right to access protective and advocacy services.

Provision of Care, Treatment, and Services PC.01.01.01 The hospital accepts the patient for care, treatment, and services based on its ability to meet the patient’s needs. PC.01.03.01 The hospital plans the patient’s care. PC.02.01.01 The hospital provides care, treatment, and services for each patient. PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services.

PC.02.02.01 The hospital coordinates the patient’s care, treatment, and services based on the patient’s needs. PC.02.02.13 The patient’s comfort and dignity receive priority during end-of-life care. PC.02.03.01 The hospital provides patient education and training based on each patient’s needs and abilities. PC.04.01.01 The hospital has a process that addresses the patient’s need for continuing care, treatment, and services after discharge or transfer. PC.04.01.05 Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.

Source: Joint Commission Resources. (2014). The Joint Commission Edition. Accessed March 16, 2014 at: http://edition. jcrinc.com

Box 9-3 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care Standards 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

appropriate policies and practices on an ongoing basis.

Communication and Language Assistance 5. Offer language assistance to individuals who have limited English proficiency (LEP) and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. (continued )

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Engagement, Continuous Improvement, and Accountability 9. E stablish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities, and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

12. Conduct regular assessments of community health assets and needs, and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Source: Office of Minority Health, Department of Health and Human Services. (2011). The National CLAS standards. Accessed February 23, 2014 at http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15

developed by the U.S. Department of Health and Human Services’ Office of Minority Health in 2001 and updated in 2011 to advance health equity, improve quality, and help eliminate health care disparities. All people entering the health care system should receive equitable and effective care in a culturally and linguistically appropriate manner. The CLAS standards are inclusive of all cultures and are especially designed to address the needs of racial, ethnic, and linguistic populations that experience unequal access to health services. Ultimately, the aim of the standards is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans.

The Need for Culturally Competent Organizations: Eliminating Health Disparities

disparities in health as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” At the most basic level, disparities are evident in life expectancies. For example, the Centers for Disease Control and Prevention National Vital Statistics System (Hoyert & Xu, 2012) reports that the overall US life expectancy is 78.7 years. However, life expectancy varies by race, with White males (76.6 years) and White females (81.3 years) higher than African American males (72.1 years) and African American females (78.2 years). Annually, the Agency for Healthcare Research and Quality (AHRQ) tracks disparities in health care delivery as it relates to racial and socioeconomic factors. Three themes emerged from the 2012 National Healthcare Disparities Report (AHRQ, 2012):

Disparities in health have long been acknowledged; these racial and ethnic disparities document the reality of unequal health care treatment. The National Institutes of Health (2010) defines

mal, especially for minority and low-income groups. 2. Overall quality is improving, access is getting worse, and disparities are not changing.

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1. Health care quality and access are subopti-

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3. Urgent attention is warranted to ensure con-

tinued improvements in: a. Quality of diabetes care, maternal and child health, and adverse events b. Disparities in cancer care c. Quality of care among states in the south Access (getting into the health care system) and quality care (receiving appropriate, safe, and effective health care in a timely manner) are key factors in achieving good health outcomes. While many believe that access to high-quality care is a fundamental human right, the poor and racial and ethnic minorities often face more barriers to care and receive poorer quality of care when they access care. The U.S. Department of Health and Human Services (HHS) uses a variety of measures to evaluate access to health care. Based on the 2012 National Healthcare Disparities Report (AHRQ, June 2013), blacks experienced better access to care compared to whites for 14% of measures and worse access for 33% of measures. When comparing Hispanics and Whites, Hispanics experienced

better access to care for 14% of the measures and worse access for 71% of the measures. When comparing those below the poverty level to those with high incomes, those with low incomes experienced worse access for all measures. Both Blacks and Hispanics were more likely than were Whites to be unable to receive care or to delay care. HHS also uses a variety of measures to evaluate the quality of health care. Blacks experienced better quality of care compared to whites for 15% of the measures and worse quality of care for 43% of the measures. Hispanics experienced better quality of care for 21% of measures and worse quality of care for 42% of measures. Those with low incomes experienced better quality of care for 5% of measures and worse quality of care for 60% of measures. Between 2000 to 2002 and 2008 to 2010, access measures showed no improvement, and quality of care measures improved more slowly in racial and ethnic minorities than for the total population. Disparities that are worsening over time are summarized in Box 9-4 (AHRQ, June 2013).

Box 9-4 Increasing Health Care Disparities for Select Groups Group

Measures

African American or Blackcompared to White

●● ●●

American Indian/Alaskan Native compared to White

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Asian compared to White

●●

●● ●●

Hispanic compared to non-Hispanic White

●● ●● ●●

Advanced stage invasive breast cancer incidence per 100,000 women age 40+ Maternal deaths per 100,000 live births Hospital patients with heart failure and left ventricular dysfunction who were prescribed ACE inhibitor or ARB at discharge Adults age 50+ who ever received a colonoscopy, sigmoidoscopy, or proctoscopy Adjusted incidence of end-stage renal disease due to diabetes per million population Hospice patients who received the right amount of help for feelings of anxiety of sadness Adults ages 18–64 at high risk (e.g., COPD) who ever received pneumococcal vaccination Home health care patients who have less shortness of breath Adults age 40+ with diagnosed diabetes who received 2 or more hemoglobin A1c measurements in the calendar year Hospital patients with heart attack who received fibrinolytic m edication within 30 minutes of arrival (continued )

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Low income compared with high incomea

●● ●● ●●

People without a usual source of care who indicated a financial or insurance reason for not having a source of care Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy Adults with diabetes with short-term complications per 100,000 population, age 18+

Low income is defined as people whose individual or family income falls below specific poverty thresholds, established annually by the U.S. Bureau of the Census based on family size and composition. Poverty rates vary by race and ethnicity, with 14.3% of individuals and 11.1% of families below the poverty level in 2009. Individual rates vary as follows: 25.8% of Black, 25.3% of Hispanic, 12.5% of Asian and Pacific Islander, and 12.3% of White individuals classified as poor in 2009.

Sources: AHRQ (June 2013). 2012 National Healthcare Disparities Report. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/index.html; United States Census Bureau (2012).

Canada’s experience with universal access to care suggests that access may help to reduce health disparities between groups but does not eliminate them (Alter, Stukel, Chong, & Henry, 2011). Their longitudinal study followed nearly 15,000 people for over a decade and found that clients with lower incomes used more health care resources than did those with a higher socioeconomic status. Regardless, individuals with lower

incomes had poorer health, including depression, hypertension, diabetes, cancer, and cataracts, and were more likely to die during the follow-up. These findings imply that factors in addition to access may account for some health disparities. Potential barriers that contribute to the disparities may be related to demographics, culture, and the health care system itself. Potential barriers are summarized in Box 9-5.

Box 9-5 Potential Demographic, Cultural, and Health System Barriers Demographic Barriers Age Gender Ethnicity Primary language Religion Educational level and literacy level Occupation, income, and health insurance Area of residence Transportation Time and/or generation in the United States

Cultural Barriers Age Gender, class, and family dynamics Worldview/perceptions of life Time orientation Primary language spoken Religious beliefs and practices Social customs, values, and norms

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Traditional health beliefs and practices Dietary preferences and practices Communication patterns and customs

Health System Barriers Differential access to high-quality care Insurance and other financial resources Orientation to preventive health services Perception of need for health care services Lack of knowledge and/or distrust of Western medical practices and procedures Cultural insensitivity and incompetence in providers, including bias, stereotyping, and prejudice Lack of diversity in providers Western versus folk health beliefs and practices Poor provider–client communication Lack of bilingual and bicultural staff Unfriendly and cold environment Fragmentation of care Physical barriers (such as excessive distances) Information barriers

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Although identifying disparities in care is important, it is not sufficient. To reduce health disparities, individuals must deliver culturally competent health care that focuses on risk reduction, vulnerability reduction, and promotion and protection of human rights (Flaskerud, 2007). Organizational culture is one area that may influence both cultural competence and health disparities. A culturally competent organization is extremely complex. Within the health care setting, practitioners must be aware of the effects of culture on individual behaviors.

Assessing Organizational Culture Organizational culture has emerged as an important variable for behavior, performance, and outcome in the workplace. Organizations are complex, with multiple and competing subcultures. The subcultural systems have inherent values and beliefs, folklore, and language; these systems are organized in a hierarchy of authority, responsibilities, obligations, and functional tasks that are understood by members of the organization. Leininger (1996) defines organizational culture as the goals, norms, values, and practices of an organization in which people have goals and try to achieve them in beneficial ways. Organizational culture has been studied as it relates to accountability, change, emotional intelligence, effectiveness, implementation of best practices and research, leadership and management, Magnet recognition status, mentoring, and patient safety. Organizational culture affects not only people working in the institution, such as employees, physicians, and volunteers, but also those who access the institution’s services, such as clients, families, and community members. The social organization of hospitals and other health care facilities has a profound effect on clients, both directly through the care provided and indirectly through organizational policies and philosophy. However, no current studies have linked organizational culture to

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c lient or provider outcomes or to the provision of culturally competent care.

Theories of Organizational Culture A variety of definitions, methods of measurement, and theories for organizational culture exist. There is reasonable consensus on the following (Strasser, Smits, Falconer, Herrin, & Bowen, 2002): ●●

●●

An organization’s culture consists of shared beliefs, assumptions, perceptions, and norms leading to specific patterns of behaviors. An organization’s culture results from an interaction among many variables, including mission, strategy, structure, leadership, and human resource practices. Culture is self-reinforcing; once in place, it provides stability, and changes are resisted by organizational members.

Bolman and Deal’s Organizational Culture Perspective Bolman and Deal (1997) describe four organizational culture perspectives or “frames” that affect the way in which an organization resolves conflicts: human resource, political, structural, and symbolic. The human resource frame strives to facilitate the fit between person and organization. When conflict arises, the solution considers the needs of the individual or group as well as the needs of the organization. The political frame emphasizes power and politics. Problems are viewed as “turf ” issues and are resolved by developing networks to increase the power base. The structural frame focuses on following an organization’s rules or protocols. This culture relies on its policies and procedures to resolve conflict. The symbolic frame relies on rituals, ceremony, and myths in determining appropriate behaviors. To understand how these four perspectives will result in different outcomes, consider typical responses to the following situation. Hospital A is located on the border of two communities. One community is primarily African American. The other community is primarily Hispanic.

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The h ospital has traditionally provided care to African Americans and is well regarded by that community. The hospital has noted, however, that few members of the Hispanic community use its services. The hospital’s board of directors realizes that, to survive, the hospital must expand its client base. The approach to this challenge will vary based on the organization’s culture. Hospital leaders with a human resource perspective are likely to approach the situation by assessing the needs of both communities and the staff. For example, the hospital may convene focus groups with members of the Hispanic community to identify why the hospital’s services are not used by that community. At the same time, the hospital will assess the African American community’s perspective on the hospital’s plan to expand its services and become a more inclusive organization. The hospital will also provide opportunities for staff members to provide input and to express their feelings about the goals of the organization. In the end, the hospital with a human resource perspective will reach a decision that balances the needs of all of these groups while enhancing the goal of expanding the client base. Hospital leaders in a political culture will take a different approach. They will identify key “power” leaders in the Hispanic community. Perhaps they will invite a Hispanic leader to join their board of directors or serve in another advisory capacity, or ask a priest from a Hispanic congregation to serve as a hospital chaplain. In addition, they will actively recruit Hispanic physicians and other clinician leaders. They will build a Hispanic power base within the hospital and use it to reach out to the larger Hispanic community and expand the client base. Hospital leaders in a structural culture will develop policies and procedures to attract more Hispanic clients. For example, they may make certain that all signage appears in both English and Spanish or develop a policy that requires all client educational materials to be available in both Spanish and English. They may require all staff to attend a session on Hispanic culture, and

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may strongly encourage or mandate Spanishlanguage training for key personnel. Hospital leaders in a symbolic culture will use ceremony to meet their goal. They will make physical changes to the environment to attract more Hispanics. For example, they may create or alter a chapel, inviting a priest from a Hispanic congregation to say mass. They may display other religious symbols, such as a crucifix or a statue of Our Lady of Guadalupe, or alter their artwork to be more culturally inclusive. They may also include Hispanic stories and rituals in their internal communications. These leaders will draw on symbols and rituals that will make persons of Hispanic culture more comfortable in the hospital environment and that will attract a larger Hispanic client base. None of these organizational cultures are inherently good or bad, just different. Each presents both strengths and weaknesses, and more than one culture may exist in an organization. For example, an organization may be guided primarily by both human resource and symbolic perspectives. Schein’s Organizational Culture Schein (2004) describes organizational culture at three levels: (1) observable artifacts, (2) values, and (3) basic underlying assumptions. Artifacts are visible manifestations of values. Artifacts may include signage, statues and other decorations, pictures, décor, dress code, traffic flow, medical equipment, and visible interactions. Values are explicitly stated norms and social principles and are manifestations of assumptions. Underlying assumptions are shared beliefs and expectations that influence perceptions, thoughts, and feelings about the organization; they are the core of the organization’s culture. Assumptions define the culture of the organization, but because they are invisible, they may not be recognized. At times, the assumptions of an institution are ambiguous and self- contradictory, especially when an institutional merger or acquisition has occurred.

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Chapter 9 Creating Culturally Competent Health Care Organizations

Organizational Culture, Employees, and the Community Many organizations are aware of the impact of organizational culture on its employees. When filling positions, recruiters consider the “fit” between the organization and the potential employee, because a good “fit” results in better retention and satisfied employees. Nurses and other health care professionals also learn how to determine whether an organization will match their personal values. For example, a nurse who wants to provide care in a culturally competent manner to lesbian, gay, bisexual, and transgender (LGBT) individuals will not be happy in a critical care unit that restricts visitors to nuclear family members. Humans need care to survive, thrive, and grow. According to Leininger (1996), organizations need to incorporate universal care constructs, including respect and genuine concern for clients and staff. These caring organizations are needed for nurses and other staff members. Historically, however, organizations have made few attempts to nurture and nourish the human spirit. An inclusive workplace is characteristic of a caring organization. Such a workplace, however, is not satisfied simply by a diverse workforce. Instead, such an organization focuses on capitalizing on the unique perspectives of a diverse workforce, in essence “managing for diversity” rather than “managing diversity” (Chavez & Weisinger, 2008). An inclusive workplace also reaches out beyond the organization by encouraging members of the workforce to become active in the community and participate in state and federal programs, working with the poor and with diverse cultural groups. Rather than espousing the golden rule (treat others as you wish to be treated), an inclusive workplace treats others as they wish to be treated, in what is sometimes called the platinum rule (Alessandra, 2010). Organizations with inclusive workplaces draw staff members who are committed to cultural competence and who value diversity and mutual respect for differences.

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Although the impact of organizational culture on employees has been acknowledged, the impact of organizational culture on the community being served has received less attention. For years, hospitals and other health care organizations have espoused the view that “If we build it, they will come” (i.e., all that is needed is to offer the services). Now, there is a growing recognition that health care services should be structured in ways to appeal to and meet the needs of various members of the community. Health care leaders recognize that cultural competence in organizations is essential if organizations are to survive, grow, satisfy customers, and achieve their goals. Image is critically important for an organization’s survival. A variety of factors are needed to move an organization toward cultural competence.

Assessment Tools Organizational culture may be assessed in numerous ways. The Magnet Hospital Recognition Program for Excellence in Nursing Services evaluates organizational climate or culture (American Nurses Credentialing Center, 2013) and is used by many organizations as a blueprint for achieving excellence (Schaffner & Ludwig-Beymer, 2003). Evidence-Based Practice 9-1 outlines the original research that resulted in the creation of Magnet designation. Evaluating the five key components of the Magnet model may be helpful in assessing the culture of an organization. These five key components are transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes. Leininger’s (1991) theory of culture care diversity and universality is also helpful in assessing the culture of an institution. Leininger’s culture care model may be used to conduct a cultural assessment of the organization, with dominant segments of the sunrise model identified. An example of such an assessment is provided in Box 9-6. Other cultural care assessment tools are available to assess the culture of an institution. This assessment is then compared with the values

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Evidence-Based Practice 9-1

Magnet Research and the Forces of Magnetism The Magnet Recognition Program for Excellence in Nursing Services grew out of a 1982 descriptive study conducted by the American Academy of Nursing’s Task Force on Nursing Practice (McClure, Poulin, Sovie, & Wandelt, 1983). The study began by asking Fellows from the American Academy of Nursing to identify hospitals that attracted and retained professional nurses who experienced professional and personal satisfaction in their practice. The Fellows nominated 165 institutions. These institutions were viewed as “Magnets.” The task force then began narrowing the list based on specific criteria and the hospitals’ willingness and availability to participate in the study. Data were then collected from staff nurses and nursing directors in 41 hospitals. Nurses identified and described variables that created an environment that attracted and retained wellqualified nurses and promoted quality patient care. Nurses were asked nine questions, which remain valuable for structuring nursing input even today:

7. Describe staff nurse–supervisor relationships in

1. What makes your hospital a good place to

●●

work?

2. Can you describe particular programs that you see leading to professional/personal satisfaction? 3. How is nursing viewed in your hospital, and why? 4. Can you describe nurse involvement in various ongoing programs/projects whose goals are quality of patient care? 5. Can you identify activities and programs calculated to enhance, both directly and indirectly, recruitment/retention of professional nurses in your hospital? 6. Could you tell us about nurse–physician relationships in your hospital?

your hospital.

8. Are some areas in your hospital more successful than others in recruitment/retention? Why?

9. What single piece of advice would you give to a director of nursing who wishes to do something about high RN vacancy and turnover rates in his or her hospital? Staff nurses identified a variety of conditions that made a hospital a good place for nurses to work, specifically related to administration, professional practice, and professional development. Clustered together, a very clear culture of nursing emerged from this descriptive study. Based on findings from the original Magnet study, the Magnet Recognition Program was developed in 1990. The program was created to advance three goals: ●● ●●

Promote quality in a milieu that supports professional practice Identify excellence in the delivery of nursing services to patients/residents Provide a mechanism for the dissemination of “best practices” in nursing services

Clinical Implications As they rotate to different facilities for their clinical experiences, nursing students are in an ideal position to evaluate organizational climate. Nurses and nursing students are encouraged to use the Magnet framework to assess nursing subcultures and determine organizational fit. Reference: McClure, M. L., Poulin, M. A., Sovie, M. D., & Wandelt, M. A.; for the American Academy Task Force on Nursing Practice in Hospitals. (1983). Magnet hospitals. Attraction and retention of professional nurses. Kansas City, MO: American Nurses Association.

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BOX 9-6 Example of Leininger’s (1991) Culture Care Model Used to Conduct an Organizational Assessment in a Hypothetical Hospital Factor: Environmental Context Types of Questions: What is the general environment of the community that surrounds the organization? Socioeconomic status? Race/ ethnicity? Emphasis on health? Living arrangements? Access to social services? Employment? Proximity to other health facilities? Sample Findings: Hospital A is in a lowincome urban setting. The majority of residents in the area are African Americans, with a few Asians and Whites. A public housing complex is located within a few blocks of the hospital. The economy is depressed, and many are out of jobs. Drug abuse and alcoholism are rampant. Families are challenged to survive, and they tend to view disease prevention as unimportant. There is a shortterm perspective on health, which is defined as being able to do normal activities. Several social agencies nearby provide assistance with food pantries. There are no other hospitals within a 5-mile radius. Factor: Language and Ethnohistory Types of Questions: What languages are spoken within the institution? By employees? By patients and clients? How formal or informal are the lines of communication? How hierarchical? What communication strategies are used within the institution? Written? Poster? Electronic? Oral? “Grapevine”? How did the institution come to be? What was the original mission? How has it changed over the years? Sample Findings: Clients primarily speak English. Employees typically speak English, although Polish and Russian are heard, particularly among the housekeepers. The grapevine is alive and well at Hospital A. Although memos and e-mails are circulated, verbal communication is prized throughout the institution. The president/chief executive officer, chief nursing officer, and chief medical officer all maintain an open-door policy in their offices. Posters are also used to communicate, especially in the

elevators. Electronic communication to direct care staff via e-mail has not been successful because computer workstations are in short supply throughout the institution. Hospital A was founded by a Roman Catholic religious order of nuns in 1885. The original mission was to provide care to immigrants and the poor. Immigrants from many nations, including Ireland, Poland, Hungary, and Russia, originally inhabited the area. The mission is still to provide the highest quality of care to the poor and underserved, although that is becoming increasingly difficult financially. Factor: Technology Types of Questions: How is technology used in the institution? Who uses it? Is client documentation electronic? Is electronic order entry in place? Is cutting-edge technology in place in the emergency department (ED), critical care units, labor and delivery, radiology, surgical suites, and similar units? Are instant messaging, text messaging, and tweets used ? Is Web-based technology embraced? Sample Findings: There are a few computer workstations on each nursing unit, which are primarily used by the clinical secretaries. Nurses do not document electronically, and physicians do not use electronic order entry. Hospital A received external funding several years ago to renovate their old ED. The new ED has state-of-the art equipment, as do the critical care units. The labor and delivery area is cramped and overcrowded. Equipment is well worn. Similarly, the surgical suites are dated. The radiology department is scheduled for a major capital investment next year. Factor: Religious/Philosophical Types of Questions: Does the institution have a religious affiliation? Are religious symbols displayed within the facility? By clients? By staff? Is the institution private or public? For-profit or not-for-profit? (continued )

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Sample Findings: Founded by a religious order, Hospital A is very clearly viewed as Roman Catholic. Outside, the hospital is marked with a large cross on its roof. Inside, a crucifix hangs in each client room. A large chapel is used for daily mass. A chaplain distributes communion to clients and staff every evening. Nurses demonstrate a variety of religious symbols. One nurse is seen wearing a cross; another wears a Star of David. Clients adhere to a variety of faith traditions, including Southern Baptist and Black Muslim. Chaplains come from a variety of faith traditions and attempt to meet the needs of diverse groups. Factor: Kinship and Social Factors Types of Questions: What are the working relationships within nursing? Between nursing and ancillary services? Between nursing and medicine? How closely are staff members aligned? Is the environment emotionally “warm” and close or “cold” and distant? How do employees relate to one another? Do they celebrate together? Rely on each other for support? Do employees get together outside of work? Sample Findings: RNs at Hospital A tend to be white and are often the children of immigrants. They are most often educated in associate degree or diploma programs. Aides tend to be African American. There is tension between the two groups especially as the role of the aide has expanded. Nurses tend to be somewhat in awe of physicians. Physicians’ attitudes toward nurses range from respect to disrespect. Many physicians are angry about the erosion of their autonomy and economic security. Most units tend to be tight knit, with celebrations of monthly birthdays and recognition provided when staff members “go the extra mile.” Nurses rarely socialize with one another outside of work. Staff nurses are middle aged (mean age 45). Most of them commute from the suburbs to the hospital and return home after their shift. In contrast, many of the aides are from the immediate community, know each other, and socialize outside of work. Factor: Cultural Values Types of Questions: Are values explicitly stated? What is valued within the institution?

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What is viewed as good? What is viewed as right? What is seen as truth? Sample Findings: The institution clearly identifies its mission and strives to fulfill it in economically difficult times. Its stated values are collaboration and diversity. Although diversity training has been provided to managers, tensions still exist between work groups, particularly because the workforce tends to be racially divided. Factor: Political/Legal Types of Questions: How politically charged is the institution? Where does the power rest within the institution? With medicine? With finance? With nursing? With information technology? Is power shared? What types of legal actions have been taken against the institution? On behalf of the institution? Sample Findings: Historically, Hospital A has been politically naive. It has gone about its mission without regard to the external environment. Recently, the hospital has begun to lobby for better reimbursement for care provided under Medicaid. Institutional power rests with the strong medical staff and department chairs. Factor: Economic Types of Questions: What is the financial viability of the institution? Who makes the financial decisions? How do the salaries and benefits compare with those of competitors in the immediate environment? Sample Findings: Hospital A has a very low profit margin, 0.5%, compared with an industry standard of more than 3%. This means that little money is available for capital improvements, which results in less technology and some units being cramped. Community needs are considered, along with all financial decisions. People are valued, and efforts are made to keep salaries competitive. Starting salaries are increasing for new graduates, and experienced nurses are complaining of salary compression. Factor: Educational Types of Questions: How is education valued within the institution? What type of assistance (financial, scheduling, flexibility) is

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provided for staff seeking advanced degrees? Does the institution provide education for medicine, nursing, and other professions? Are advanced practice nurses utilized? What is the educational background of staff nurses? Nurse managers? Nursing leaders? How does this compare with education of other professional groups? With competing organizations? Sample Findings: With an in-house diploma school, nurses are most often educated at the diploma level. Although flexible scheduling and limited tuition reimbursement are provided, many nurses do not take advantage of the benefits because of the need to work extra shifts to ensure staffing and competing personal and family priorities. All new nurse managers and directors are required to have a BSN; however, most existing managers are educated at

and beliefs of the groups who use the health care organization. Andrews (1998) provides an assessment tool for cultural change that examines demographic/descriptive data; strengths; community resources; continued growth; perspectives of clients, families, and visitors; institutional perspective; and readiness for change. This tool allows organizational leaders to assess the needs of the community they serve and to use their findings to guide strategic planning for the future.

Building Culturally Competent Organizations Cultural competence has been identified as a key strategy for eliminating racial and ethnic health disparities. However, the competence must extend beyond the provider, into the system of health care. It would be naive to assume that building culturally competent organizations will resolve all health disparities. However, when health care is delivered within a culturally competent organization, diverse health care consumers may be more likely to access the services, return

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the diploma level. Nursing students from five different programs rotate through the institution, with first priority given to the hospital’s diploma program. Hospital A provides a summer preceptor program to students from one baccalaureate degree program, and some faculty members are employed during summers and holidays. Medical education is provided at Hospital A, with 150 residents and many 3rd year and 4th year medical students rotating through the facility. The residents, while learning, also provide important service to the community, particularly through their clinic rotations. Students in respiratory, social work, dietitian, physical therapy, occupational therapy, speech therapy, and pastoral care also have clinical rotations at Hospital A.

for services, adhere to the plan of care, and make necessary lifestyle changes. Weech-Maldonado, Elliott, Pradhan, Schiller, Hall, et al. (2012) conducted research to examine the relationship between hospital cultural competence and satisfaction with inpatient care. They found that inpatients reported higher satisfaction with hospitals that had greater cultural competency. The findings were particularly striking among minority patients, who reported higher satisfaction with nurse communication, physician communication, staff responsiveness, pain control, and environmental factors in hospitals with greater cultural competency. Guerrero (2012) examined the extent to which internal and external organizational pressures contributed to the degree of adoption of culturally and linguistically responsive practices in outpatient substance abuse treatment systems. Higher adoption of culturally competent practices was found in programs with more external funding and regulation and with managers who had higher levels of cultural sensitivity. Organizations with a large number of professional staff had lower adoption of culturally competent practices when compared to organizations with fewer professional staff members.

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As with cultural competence in individuals, cultural competency in organizations develops over time as part of a journey. The process involves all aspects of the organization. Malone (1997) describes several strategies for improving organizational cultural competence. Strategies include training that helps the organization to value and manage cultural diversity; rewarding practice that values differences and is culturally appropriate and collaborative; recruiting nurses who are culturally competent; and hiring nurses who are culturally diverse. Purnell, Davidhizar, Giger, Strickland, Fishman, and Allison (2011) provide a guide to developing culturally competent organizations that address four key areas: administration and governance, orientation and education, language, and staff competence. Marrone (2010, 2012) provides a comprehensive assessment of organizational cultural competency. Douglas etal. (2014) recommend ten practices by leaders to build cultural competence in health care organizations, summarized in Box 9-7. Fung, Srivastava,

and Andermann (2012) present a framework, consisting of eight domains, to plan for organizational cultural competence in mental health care service settings. Delphin-Rittmen (2013) describes seven essential strategies for promoting and sustaining cultural competence. For the purpose of this chapter, the concepts identified above have been combined and consolidated. Seven specific areas critical to fostering culturally competent health care organizations are discussed in the sections below: governance and administration, internal evaluation of adherence to cultural competence standards, staff competence, the physical environment of care, linguistic competence, community involvement, and culturally congruent services and programs.

Governance and Administration For the purposes of this chapter, governance is defined as members of the board of directors and any subboards, such as Board Finance or Board

Box 9-7 The Role of Health Care Organization Leaders in Developing Culturally Competent Health Care Systems and Organizations 1. Develop systems to promote culturally competent care delivery. 2. Ensure that mission and organizational policies reflect respect and values related to diversity and inclusivity. 3. Assign a managerial-level task force to oversee and take responsibility for diversityrelated issues within the organization. 4. Establish an internal budget for the provision of culturally appropriate care, such as for the hiring of interpreters, producing multilanguage client education materials, adding signage in different languages, and so on. 5. Include cultural competence requirements in job descriptions, performance measures, and promotion criteria.

6. Develop a data collection system to monitor demographic trends for the geographic area served by the agency. 7. Obtain patient satisfaction data to determine the appropriateness and effectiveness of services. 8. Collaborate with other health agencies to share ideas and resources for meeting the needs of culturally diverse populations. 9. Bring health care directly to the local ethnic populations. 10. Enlist community members to participate in the agency’s program planning committees, for example, for smoking cessation or infant care programs.

Source: Douglas, M. K., Rosenkoetter, M., Pacquiao, D., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., …, Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109–121.

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Box 9-8 Strategies and Tools for Reducing Health Disparities Local research and analysis of disparities Primary health care practices and resources Location of Services Appropriate care

Partnerships Poverty reduction collaborations Early childhood development School-based strategies Public education and policy advocacy Community development and participation

Source: Kouri, D. (2012, March). Reducing health disparities: How can the structure of the health system contribute? Wellesley Institute. Accessed March 16, 2014 at http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/Reducing-HealthDisparities-how-can-health-system-structure-contribute.pdf

Quality. Administration is defined as those individuals who serve as department heads. Together, governance and administration are responsible for ensuring that the organization is continually developing cultural competence. The Wellesley Institute in Ontario (Kouri, 2012) identifies key strategies and tools helpful for reducing health disparities; several strategies helpful for governance and administration to consider are summarized in Box 9-8. Ideally, both board members and administrators reflect the ethnic and racial diversity of the community served. The board and administration set the strategic plan for the organization. The strategic plan sets the direction for an organization and is used to communicate organizational goals and the actions needed to achieve those goals. The strategic planning process should begin with an assessment of community strengths and needs. In a study designed to determine factors related to organizational cultural competence, Guerrero (2013) found that leadership skills and strategic climate in addiction health service settings resulted in a better understanding and responsiveness to community needs. Board members and administration also establish the mission, vision, and values for the organization. The mission statement describes the purpose of the organization, its reason for existing. The mission statement should be inclusive, and the strategic plan should include tactics for developing culturally congruent services and programs to meet community needs, partnering with key community organizations, and d eveloping

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the organization’s cultural competence. The basic premises of an organization, reflected in its mission statement, provide insight into the presence or absence of a commitment to providing culturally competent care. Many organizations also establish a vision and values to guide their culture. The vision projects the future status of an organization and inspires and generates a shared purpose among organization members. Whether or not they are explicitly stated, all organizations have values. Values are the standards that guide the perspective and action of the organization and help to define an organization’s culture and beliefs. As seen in Box 9-9 the mission, vision, and values may also include specific behaviors demonstrated toward both customers and colleagues. Administration also develops the organization’s budget, which is then approved by the board of directors. Financial resources, including funding for capital, staff, and programs for the delivery of care, must be allocated appropriately to foster organizational cultural competence. For example, the environment should be welcoming, with the space and décor appropriate for the cultural groups served. Funding for staff recruitment, orientation, and training is also essential. Funding for the delivery of care must always consider cultural components. For example, funding is needed to advertise new and existing programs, using the venues and languages appropriate to the community. Pictures on the advertising materials must reflect the client population.

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Box 9-9 Edward Hospital Mission, Vision, and Values Mission To support health and strengthen communities by providing outstanding health care services

Compassion Responsibility Collaboration Passion

Vision

Behaviors

Locally preferred, regionally referred, nationally recognized

We will always…

Values Patients first Integrity

Communicate openly Care for you Provide quality

Courtesy of Edward Hospital and Health Services. (2013). Naperville, IL.

Nurse executives can take the lead in developing culturally competent health care organizations. Leininger (1996) defined transcultural nursing administration as “a creative and knowledgeable process of assessing, planning, and making decisions and policies that will facilitate the provision of educational and clinical services that take into account the cultural caring values, beliefs, symbols, references and lifeways of people of diverse and similar cultures for beneficial or satisfying outcomes” (1996, p. 30). Nurse administrators must ensure that organizational policies are culturally sensitive and appropriate and that they recognize the rights of individuals and families. Such policies should incorporate Leininger’s (1991) decisions and actions of culture care preservation/maintenance, culture care accommodation/negotiation, and culture care repatterning/restructuring. Nurse leaders who recognize the importance of transculturally based administration are essential for culturally competent health care organizations. The American Organization of Nurse Executives (AONE, 2011) identifies five nurse executive competencies: communication, knowledge, leadership, professionalism, and business skills. Nurse executive competencies related to diversity are summarized in Box 9-10. Nurse administrators must foster a climate in which

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nurses and other health care providers realize that provider–client encounters include the interaction of three cultural systems: the organization, the providers, and the client (American Nurses Association Council on Cultural Diversity in Nursing Practice, 1991). In culturally competent health care organizations, nurse leaders also recognize the relationship between a culturally diverse nursing workforce and the ability to provide culturally competent patient care. The need to attract students from underrepresented groups is gaining importance (American Association of Colleges of Nursing, 2014) and calls for new partnerships between practice, community, and academic settings. Administration and the board of directors must work together to ensure that the health care organization continues the journey toward cultural competence. This includes setting strategic priorities and funding appropriate programs for staff and clients.

Internal Evaluation of Adherence to Cultural Competence Standards In addition to recognizing and acknowledging the overall culture of a health care organization, organizations must also evaluate how they are adhering to cultural competence standards as an

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Box 9-10 American Organization of Nurse Executives (AONE) Nurse Executive Communication and Relationship-Building Competencies Related to Diversity ●●

●●

Create an environment that recognizes and values differences in staff, physicians, patients, and communities. Assess current environment and establish indicators of progress toward cultural competency. Define diversity in terms of gender, race, religion, ethnicity, sexual orientation, age, etc.

●● ●● ●● ●●

Analyze population data to identify cultural clusters. Define cultural competency and permeate principles throughout the organization. Confront inappropriate behaviors and attitudes toward diverse groups. Develop processes to incorporate cultural beliefs into care.

Source: American Organization of Nurse Executives. (2011). The AONE nurse executive competencies. Accessed February 22, 2014 at www.aone.org/resources/leadership%20tools/PDFs/AONE_NEC.pdf

organization and determine how effectively the organization is meeting the needs of the populations they serve. The evaluation may be conducted in a variety of ways. Roizner (1996) identifies a checklist for culturally responsive health care services. Health care services are evaluated based on their availability, accessibility, affordability, acceptability, and appropriateness. When the organization is evaluated by this model, it is important to consider these “five A’s”: ●●

●●

Are the health services that are needed by the community readily available? In a community with rampant illicit drug use, for example, one should expect to find a variety of types of drug abuse prevention and treatment programs offered that are readily available to the local population. Are health care resources accessible? A pediatrician’s office, for example, might need to expand its hours of operation to accommodate the schedules of working parents. Geographic location should be considered in terms of proximity to public transportation, traffic patterns, and available parking. Structural changes may also be needed to accommodate specific types of clients, such as those who use wheelchairs. Are the services affordable? Partnerships between public and private organizations may be needed to ensure that services are afford-

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●●

able. A sliding scale might be developed to accommodate the needs of people with limited financial resources. Are the services acceptable? Providers need to carefully consider this question. Do community members who use the services perceive the services to be of high quality? Do community members value the services? Are the waiting rooms stark, dimly lit, or untidy? Is the furniture worn or the reading material frayed and outdated? Providers need to understand what makes services acceptable to the community they seek to serve. Community members may avoid a particular agency or institution because services are delivered in a noncaring and patronizing fashion. Are the services appropriate? Community members may not use services if they do not perceive that these services meet their needs. For example, community members who struggle with dayto-day survival with limited financial and social resources may not use fitness classes. Programs that are disconnected from the daily life of community members constitute a recipe for failure.

Fung et al. (2012) present a methodology for evaluating cultural competence in health care organizations involving mixed qualitative and quantitative methods. An organization may also compare their performance to standards provided by regulatory bodies, government a gencies,

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and professional organizations. Annually, members of the Language, Culture and Religion Committee at some organizations critically compare current practice with Joint Commission and CLAS standards. The committee members determine where there are gaps and develop a strategic plan to address the gaps. The Cultural Competency Assessment Tool for Hospitals (CCATH) allows an organization to assess adherence to the CLAS standards (Hays et al., 2006). The instrument measures 12 composites: leadership and strategic planning, data collection on inpatient population, data collection on service area, performance management systems and quality improvement, human resource practices, diversity training, community representation, availability of interpreter

services, interpreter services policies, quality of interpreter services, translation of written materials, and clinical cultural competency practices (Weech-Maldonado, Dreachslin, et al., 2012). Weech-Maldonado, Elliott, Pradhan, Schiller, Dreachslin, et al. (2012) found that hospitals that were not-for-profit, served a more diverse inpatient population, and were located in more competitive and affluent markets exhibited a higher degree of cultural competency. To evaluate how effectively the health care organization is meeting community needs, a variety of data elements may be considered, including clinical data and patient satisfaction. Health care organizations should assess their own practices to determine if there are unknown disparities in care. As an example, Figure 9-1 presents

80 70 National Average Turn Around Time: 59.00 60 50 40

Overall Mean Turn Around Time: 36.39

30 20 10 0

Pain Management Mean Turn Around Time (minutes)

Total # of Patients

White

37.19

257

Black or African American

31.75

Asian

38.32

Unable to Determine

24.70

Hispanic

36.90

Figure 9-1. Example of emergency department information for turnaround time for pain medication in clients with long bone fracture by race/ethnicity, FY2013 (Data from Edward Hospital at Edward-Elmhurst Healthcare).

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data for long bone fracture pain management from an emergency department. The mean and median turnaround time for pain medication is shorter than the national average for all groups, but is slightly longer for the Asians compared to all other populations at the author’s hospital. Examination of the data helps the organization to determine the causes of the variations.

Staff Competence Individual health care providers are essential for building culturally competent organizations. All staff members must be competent; this is especially critical for direct care nurses and other staff members. Many times, nurses and other care providers interact based on their own cultural values, experience, and preferences. They need to be taught how to interact with patients from diverse cultures to provide patient-centered care and serve as patient advocates (Sherrod, 2013). Key processes, including organizational support, orientation, and ongoing education, are needed to enhance staff competence. The human resource department typically provides organizational support for staff. The department plays a key role in ensuring that recruitment and hiring activities reflect the diversity of the community they serve. The department can also prioritize recruitment of bilingual staff members and ensure appropriate compensation. Policies, position descriptions, and performance reviews, typically overseen by human resources, must reflect cultural competence. Orientation and ongoing education are needed for employees at all levels to develop and foster cultural sensitivity and competence. Diversity in its broadest terms should be discussed in orientation. This should include race, ethnicity, religion, age, gender, sexual orientation, socioeconomics, and educational backgrounds of both clients and staff members. Volunteers and medical staff members also need to be oriented to the organization’s culture, strategy, and expectations. Beyond orientation, ongoing education is needed to reinforce the learning. While staff

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cannot learn about all diversity, they should be equipped with a general cultural framework and have specific knowledge about the cultural groups for whom they most often provide care. A first step to learning about culture is to identify the values and worldview of one’s own culture. This may be facilitated through reflection and discussion. By acknowledging one’s own beliefs, staff members may be helped to avoid stereotyping and cultural imposition. A variety of formats may be used to educate staff, including live education sessions, electronic learning, journal clubs, and discussion groups. Inviting members of a particular culture or religion to discuss their beliefs and practices is often engaging for both the community and staff. To help hold staff members accountable for their actions, performance reviews must reflect the organization’s commitment to cultural competence. Nurses and other health care staff members need training to ensure appropriate care and accurate data. Gomez, Le, West, Santariano, and O’Connor (2003) found that while 85% of hospitals reported collecting data on race, approximately half of them obtained the data by observing a client’s physical appearance. In addition, only 12% of the hospitals reported having a procedure for recording the race and/or ethnicity of a client with mixed ancestry, and 55% reported never collecting ethnicity data. Regenstein and Sickler (2006) found that 78.4% of hospitals collect race information, 50.4% collect data on client ethnicity, and 50.2% collect data on language preference. However, only 20% have formal data collection policies, and fewer than 20% use the data to assess and compare care quality, health services utilization, health outcomes, or patient satisfaction. According to a report from the Commonwealth Fund and the American Hospital Association’s Health and Research Educational Trust (HasnainWynia, Pierce, & Pittman, 2004), fewer than 80% of hospitals collect data on race and ethnicity. Most often, data are collected because of a law or regulatory requirement. However, the information that is collected may not be accurate or valid.

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The report recommends that hospitals standardize who provides the information, when it is collected, which racial and ethnic categories should be used, and how the data are stored. Staff members need to be taught why this is important and how to collect the information. Culturally competent staff is essential for building culturally competent health care organizations. Staff members who lack the competency may fail to take the client’s culture seriously, misinterpret the client’s value system, and elevate their own value systems. This posture is culturally destructive because it minimizes the other person’s culture. Culturally competent staff members will take time to ask questions about what the client prefers and listen attentively. In the end, this will increase understanding, trust, collaboration, adherence, and satisfaction. Nurses and other health care providers can help the organization grow in cultural understanding. If they listen and attend carefully, health care providers have a valuable window directly into the world of their clients. They can take what they learn and share it with the administration to improve the cultural responsiveness of their organization. Individuals and groups of clinicians can also develop special programs to meet the needs of the specific populations they serve. Speaking the language is a definite advantage.

The Physical Environment of Care The physical environment should always be assessed. Approaching this assessment as a potential client is helpful, and a variety of factors should be considered. What message does the organization send through its physical surroundings? How is the facility organized physically? How does the entryway present the culture of the organization to the public? Is the entrance warm and inviting? Is the signage prominent? What languages are included on the signs? Is information presented clearly and unambiguously? Are amenities available to clients and their family members? Are the doors open or closed? Do people talk with one another, and what languages are

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spoken? What is the traffic pattern, and what is the general flow of traffic? Does the environment appear calm or turbulent? Are the staff members attentive and courteous? A physical environment may send unintentional messages. For example, consider the birthing center at a city hospital. The hospital’s service area is undergoing tremendous changes, with a large influx of African American, Hispanic, Indian, and Polish American populations. The birthing unit is beautifully and tastefully decorated with oak furniture and pastel prints. Every picture on the walls, however, shows a Caucasian family. This clearly sends a message of exclusivity rather than inclusiveness. When this is brought to the attention of the nurse manager, she is completely dumbfounded and quickly takes steps to rectify the situation. Ethnocentrism and stereotyping are in play here, and it takes a degree of cultural competence to identify this and bring it to recognition and resolution. Organizational leaders must also assess the physical environment of care to identify potential barriers. A flow chart is a helpful tool for determining such barriers. For example, in an effort to provide comprehensive women’s health programs in a caring fashion, organizational leaders may examine the steps for admission to the hospital for the delivery of a baby. To determine this, staff members walk through the care process and create a flow chart that outlines the steps. Staff members must be alert, in particular, for possible sources of confusion for parents at this highly stressful time. The flow chart can then be used to design changes in the environment that can be implemented to decrease barriers and improve services.

Linguistic Competence Language is a major barrier to quality health care (Office of Minority Health, 2013). The Institute of Medicine (2002) reports that 51% of providers believe that clients do not adhere to treatment because of culture or language. At the same time, nurses and other health care providers report

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having received no language or cultural competency training (Baldonado et al., 1998; Park et al., 2005). Twenty-two percent of medical residents feel unprepared to treat patients who have LEP (Weissman et al., 2005). Similarly, while both nurses and baccalaureate nursing students perceive an overwhelming need for transcultural nursing, only 61% report confidence in their ability to provide care to culturally diverse patients (Baldonado et al., 1998). Providing care to non– English-speaking patients presents a special challenge. Addressing this challenge begins when the nurse determines the preferred language for health care discussions from the patient. This information must be recorded and shared with all health care providers. Patients must be informed that an interpreter will be provided for them at no cost. Interpreter services may be provided in person, by videoconferencing, or by telephone. Competent interpreter services are necessary when providing care and services. Because communication is a cornerstone of patient safety and quality care, every patient has the right to receive information in a manner he or she understands. Effective communication allows patients to participate more fully in their care, is critical to the informed consent process, and helps practitioners and health care organizations give the best possible care. For communication to be effective, the information provided must be complete, accurate, timely, unambiguous, and understood by the patient. Many patients of varying circumstances require alternative communication methods, including patients who speak and/or read languages other than English, patients who have limited literacy in any language, patients who have visual or hearing impairments, patients on ventilators, patients with cognitive impairments, and children. Health care organizations have many options to assist in communication with these individuals, such as interpreters, translated written materials, pen and paper, and communication boards. It is up to the hospital to determine which method is the best for each patient. Various laws and regulations and guidelines are relevant to the use of

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interpreters. These include Title VI of the Civil Rights Act, 1964; Executive Order 13166; policy guidance from the Office of Civil Rights regarding compliance with Title VI, 2004; Title III of the Americans with Disabilities Act, 1990; state laws; and the American Medical Association’s Office guide to communicating with LEP patients (AMA, 2007). Policies addressing interpreter services should be in place, and staff members should be educated on them. Signage, consent forms, patient education, and other written materials should be translated and available in the most commonly spoken languages. Written materials should augment, not substitute for, discussion in the patient’s language. The organization should evaluate written documents for cultural sensitivity. When collecting data, such as patient satisfaction or quality of life surveys, the organization should provide the surveys in the patient’s preferred language. The organization should also work with the community to address health literacy and provide and encourage attendance at English as a Second Language classes. Large health care organizations may have resources to secure trained professional interpreters and bilingual providers. Regardless of setting, however, Youdelman and Perkins (2005) suggest the following eight-step process for developing appropriate language services: 1. 2. 3. 4. 5. 6. 7. 8.

Designate responsibility Conduct an analysis of language needs Identify resources in the community Determine what language services will be provided Determine how to respond to LEP patients Train staff Notify LEP patients of available language services Update activities after periodic review

Community Involvement Understanding what culturally competent health care means from the standpoint of patients is an important step in building culturally competent

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organizations. Napoles-Springer, Santoyo, Houston, Perez-Stable, and Stewart (2005) conducted 19 community focus groups to determine the meaning of culture and what cultural factors influenced the quality of their medical visits. Culture was defined in terms of value systems, customs, self-identified ethnicity, and nationality. African Americans, Latinos, and non-Latino Whites all agreed that the quality of health care encounter was influenced by clinicians’ sensitivity to complementary/alternative medicine, health insurance discrimination, social class discrimination, ethnic concordance between patient and provider, and age-based discrimination. Ethnicity-based discrimination was identified as a factor for Latinos and African Americans. Latinos also described language issues and immigration status factors. Overall, participants indicated greater satisfaction with clinicians who demonstrated cultural flexibility, defined as the ability to elicit, adapt, and respond to patients’ cultural characteristics. Health care institutions exist to provide care. A variety of factors, such as tobacco and alcohol use, poor diet, and physical inactivity, contribute to mortality in the United States and Canada. Addressing these factors requires individual behavioral change, community change, social change, and economic change. Health care organizations cannot confront these complex factors in isolation; they must partner with their communities to build trust in their institutions and meet the needs of their local communities. Community partnerships may be configured in a variety of ways. Hospitals and health care systems usually articulate their desire to improve the health of the communities they serve. Historically, hospitals have fulfilled this mission through charity care, health care provider education, health care research, community education programming, and community outreach (Pelfrey & Theisen, 1993). However, true improvements in the health of a community require the focused efforts of the entire community. Such improvement may occur only in partnerships with community members and community organizations.

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An ethnographic study of community (Davis, 1997) revealed five themes related to the experience of community caring. Three of these themes are of particular significance to this discussion: (1) Reciprocal relationships and teams working together are central to building healthy communities, (2) education with a focus on prevention is key to enhancing health, and (3) understanding community needs is a primary catalyst for health care reform and change. Health care professionals in culturally competent organizations collaborate with surrounding communities to conduct community health assessments. In community mapping, staff collect a variety of data, including demographics, health status, community resources, barriers, and enablers. Both strengths and needs are identified from the perspective of the community. All of the data are then used collaboratively with communities to set priorities. An example of such a community assessment is provided in Box 9-11. Data from these assessments are used to set priorities and guide the planning and implementation of key initiatives. These initiatives are most well accepted when they are sponsored by a variety of community organizations rather than by a single health care organization such as a hospital. Focus groups may assist an organization in assessing how well they are meeting the needs of the populations they serve. For example, the Boston Pain Education Program worked collaboratively with community representatives to develop a culturally sensitive, linguistically appropriate cancer pain education booklet in 11 languages and for 11 ethnic groups. Focus groups were used to develop materials that would empower patients and families to more effectively partner with health care professionals and manage pain in culturally competent ways (Lasch etal., 2000). Community-based participatory research or participatory action research may be helpful in understanding a community and developing health improvement initiatives with community members. The method uses collaborative,

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Box 9-11 Community Assessment Example The Advocate Lutheran General Hospital completed an assessment of the communities it serves. By analyzing data from clinical practice, staff members realized that Hispanics made up an increasing proportion of the population and were the most frequently underserved population. As a result, a family practice physician initiated the idea for a community center for health and empowerment. A coalition composed of individuals from social services, health care agencies, schools, police, churches, businesses, city government, and other community services also identified the Hispanic community as underserved. This group provided an etic, or outsider, view of the Hispanic community. To provide a local, or emic (insider), view, community members worked with health care personnel to design and conduct a door-todoor community assessment. Leininger’s theory of cultural diversity and universality served to guide the assessment. The assessment process involved 2 focus groups, 15 community interviewers, and 220 door-to-door interviews. In addition, 5 meetings, attended by 180 community members, were held to report the findings to community members and solicit their input on how to maintain strengths and address needs. As a result, numerous task forces were formed to preserve strengths or mediate needs. The major strengths identified were access to friends and families to socialize and get support,

articipatory approaches to develop sustainable p services (Koch & Kralik, 2006). An example is a participatory action research project that is addressing organizational barriers to cultural competence in hospice care through a university– community–hospice partnership (Reese, 2011). In addition, the National Center on Minority Health and Health Disparities (NCMHD), located within the National Institutes of Health, has funded disease intervention research in reducing and eliminating health disparities using community-based participation research that is jointly conducted

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prenatal and postnatal care, and pediatric care. The major needs identified were affordable housing, programs to help immigrants, Spanish-speaking dentists, and activities for youth. The community was involved in key decision making from the beginning, including selecting the site for the center, choosing the name for the center, and establishing a sliding scale for fees. The bilingual center provides primary health care services, a Women–Infant–Children program run by the county health department, and a community empowerment program. A salaried community outreach worker coordinates the community empowerment program. In collaboration with businesses, churches, and city services, community members have undergone training in group work and priority setting. Monthly dental services through a dental van were added at the center. Activities for youth were identified as concerns in the community assessment. As a result, community members and center personnel have actively partnered with the park district, schools, churches, and the police to provide recreational activities for the youth. The community also uses this as an opportunity to celebrate their cultural heritage. Health promotion materials and activities are also provided through collaboration.

by health disparity communities and researchers (NIH, 2010). Conducting community assessments requires cultural awareness and sensitivity. Interpreting the data requires knowledge of the cultural dimensions of health and illness. Using the data to develop and implement programs in conjunction with the community requires the ability to plan and implement culturally competent care. The skill of a transcultural nurse or other culturally competent health care professional is invaluable in these situations.

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Culturally Congruent Services and Programs Culturally competent nurses and other health care providers are able to develop and evaluate culturally competent initiatives. Many important factors must be considered in planning programs across cultural groups. In many cases, cultural competence must be demonstrated with multiple

Case Study 9-1 Caring Hospital, a not-for-profit hospital, serves clients who differ in multiple ways, including socioeconomic status, education, race, ethnicity, religion, language, and culture. Organizational leaders embrace Leininger’s theory of culture care. In particular, nursing leaders believe that nursing care must be congruent with the client’s culture in order to promote the client’s health and satisfaction. Through a healthy community program, the hospital remains grounded in the reality of their clients. The healthy community program, developed and staffed by two nurses with community health backgrounds, is responsible for broadly defining community-based health promotion initiatives that address individual, social, and community factors. Their goal is to establish partnerships with community members and governmental and community organizations to ensure that everyone has access to the basics needed for health; that the physical environment supports healthy living; and that communities control, define, and direct action for health. The nurses in the healthy community program bring together resources from settings both within and outside their hospital. For example, they work closely with other community-focused staff members, such as home care and parish nurses. They also work with multiple external organizations, such as local health departments and other government agencies, religious institutions, community businesses, schools, and other health care entities. These nurses work specifically with the c ommunities

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cultures simultaneously. For example, one hospital in the Chicago area provides care for individuals who speak 64 different languages. This calls for much effort and creativity on the part of patients, health care providers, and interpreters. Case Study 9-1 describes the development and implementation of a culturally competent initiative. This case study focuses on one c ulturally

surrounding their facility. In this way, they acknowledge the specific needs of diverse groups. The healthy community nurses use Leininger’s culture care diversity and universality model in their practice. They use data gathered from cultural assessments to assist them in understanding the communities they serve. They consider environmental context, ethnohistory, language, kinship, cultural values and lifeways, the political and legal system, and technologic, economic, religious, philosophic, and educational factors. They understand the interactions among the folk system, nursing care, and the professional systems. They also understand the importance of using the three culture care modalities: preservation/maintenance, accommodation/ negotiation, and repatterning/restructuring. Because of their community health backgrounds, the nurses are knowledgeable about disparities in health. The nurses use data from a variety of sources, including hospital-specific data, census tract data, and health department data, to help them understand health and access disparities in their area. They also talk to community members and to health care providers to identify competing priorities. Using these processes, they discover that their communities have not achieved the Healthy People 2020 immunization goals for children by the age of 2 years. To address the lack of immunizations, the nurses acknowledge that the issues that affect immunizations are multifaceted. The immunization schedule changes frequently and is quite complex. Even health care providers have difficulty interpreting it. Communication with parents has been sketchy and has been complicated by controversy. Immunizations are sometimes seen by parents as nonessential for young children until they enter elementary school.

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Immunizations may not be easily accessible, available, and affordable. Parents may make decisions based on misinformation, rumor, or hearsay. The nurses know, however, that c ommunity members want to keep their children healthy and that immunizations have contributed greatly to reduced illness in individuals and better overall health for the community. They also know that community members prefer to have their children immunized in a consistent place, as part of an overall medical home. Because the childhood immunization levels are suboptimal in the communities served by the hospital, childhood immunization is selected as a quality initiative. A group of consumers and clinicians is convened to implement a program with the goal of increasing immunization to the Healthy People 2020 goals. There is much discussion on the best way for increasing immunization rates, using a broad-based program. The group considers mailed, telephoned, e-mailed, and texted reminders and opts to combine texted reminders with follow-up by mailed reminders. Various materials are developed in both English and Spanish, and incentives are put into place to assist parents. Babies are automatically enrolled in the program when they are born in the hospital. Mailings occur at regular intervals and include a personalized letter indicating what vaccines are due, a vaccine record, vaccine information statements, and a growth and development newsletter. Additionally, incentives are mailed to help keep

the parents m otivated to use preventive services. Materials are written at a sixth-grade level. All materials are reviewed for cultural congruity, and the illustrations include babies from various ethnic groups. New materials are developed as needed, based on a continuous assessment of the needs of the parents. For example, reproducing all the materials in all the languages used by clients is too expensive, so a multiple-language brochure is developed in the 11 most common languages. The brochure explains the program and asks that non–English-speaking and non–Spanish-speaking families obtain help in translating the materials. In addition, after families express a major concern about the multiple injections required to keep their babies fully immunized and their babies’ resultant distress and crying, a “calming strategies” flyer is developed. Because financial barriers still exist among parents seeking immunizations for their children, the healthy community nurses implement several additional strategies. First, they work with physicians and help them enroll in the Vaccines for Children program, making vaccines available at no cost or low cost right in their offices. They also work with the staff in physicians’ offices to enhance their role in fostering childhood immunizations. In addition, they work with the health department to provide monthly immunizations onsite at the hospital.

competent program provided to a community; however, additional programs, targeting the needs of other groups, may also be envisioned. For example, adult immunizations are a challenge for many communities, so a program might be developed that focuses specifically on older adults and their immunization needs. Similarly, programs might be instituted to deal with other health issues of concern to community members. The case study demonstrates the importance of incorporating an understanding of culture in every aspect of an initiative. To design and implement an effective program, the cultural values of patients must be understood and addressed.

Overcoming the Barrier of Institutional Racism in HealthCare

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Prejudice, racism, stereotyping, and ethnocentrism are present in health care settings. Institutional racism, sometimes referred to as institutionalized racism, is defined as differential access to goods, services, and opportunities based on race (Peek et al., 2010); this includes differential access to health insurance. The dominant subgroup is often ignorant of its own p rivilege. For example, services may be organized for the

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convenience of providers, and providers may be unaware that inconvenient hours or locations are affecting the community members who seek services. In contrast to individual behaviors, institutional racism occurs when systematic policies and practices disadvantage certain racial or ethnic groups. Institutions may be overtly racist, as when they specifically exclude certain groups from service. More often, however, institutions are unintentionally racist. For example, a dress code that requires everyone to wear the same hat would institutionally discriminate against Sikh men, who are expected to wear turbans, and Muslim women, who wear the hijab or veil. Institutions don’t necessarily adopt such policies with the intention of discriminating and often revise their practice once the discrimination is identified. Institutional racism is an international concern. In England, institutional racism is defined as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin” (McKenzie & Bhui, 2007, p. 649). Henry, Houston, and Mooney (2004) suggest that health care in Australia is institutionally racist and that such racism represents one of the greatest barriers to improving the health of Aboriginal and Torres Strait Islander people. Examples include funding inequities, differences in performance criteria, and differences in treatment regimens. Reports in Sweden and the United Kingdom suggest continued concerns about discrimination and inequity in services (Bhopal, 2007). Differences in the treatment of mental illness have been documented in England and Wales (McKenzie & Bhui, 2007). Contributing factors include the actions of individual staff members and policies that are based on the needs of the ethnic majority population rather than considering the needs of minority populations (Bhopal, 2007). Cultural differences and lack of knowledge create institutional racism, and indifference nurtures it. Cultural differences must be acknowledged and celebrated rather than denigrated (Henry et al., 2004). Health care organizations must be built upon the cultural values of the people they

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serve. The strategies outlined in this chapter and throughout this book are needed to overcome institutional racism and build culturally competent health care organizations.

Summary As with individuals, the quest for organizational cultural competence is a continuous journey. There is always room for improvement. To be truly effective in improving patient care for all, health care services and social services that take cultural diversity into account must make an organizational commitment to cultural competence. Cultural competence cannot live in one or two nurses; it must be systemic. It must involve individuals at all levels of the organization: governance members, administrators, managers, providers, and support staff. In addition, an organization must have a mutually beneficial relationship with the community it serves to achieve cultural competence and must involve community members in its quest for cultural competence.

REVIEW QUESTIONS 1. What types of access, health care, and health

outcome disparities exist nationally? In your community? 2. How does the culture of an organization affect the quality of care provided? 3. What tools or models are helpful for assessing organizational culture? 4. How does an organization’s culture influence or affect its employees? 5. What specific areas must receive attention in order to build culturally competent health care organizations?

CRITICAL THINKING ACTIVITIES 1. An excellent way to understand a cultur-

ally competent organization is to assess the organizational culture using the “five A’s”

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described in this chapter. With some of your classmates, compare and contrast the availability, accessibility, affordability, acceptability, and appropriateness of one health care organization. Discuss what actions could be taken by the organization to increase its cultural competency. 2. Use Leininger’s (1991) theory of culture care

diversity and universality to assess the culture of the same organization. Box 9-6 in this chapter provides an example of how Leininger’s culture care model can be used. Compare and contrast the values and beliefs of the organization with the values and beliefs of the groups using the

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health care organization’s services. What areas would be most problematic, and why? 3. Many members of ethnic or minority communi-

ties lack adequate access to care because they do not have adequate health insurance. Often, these individuals use the emergency departments (EDs) of city hospitals for episodic care. Visit a busy ED. What languages do you hear? Assess the physical environment to determine potential barriers to culturally competent care. Develop a flow chart that outlines the steps a client takes when he or she seeks care in an emergency room. Identify changes that would decrease barriers and improve services if they were implemented.

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Kouri, D. (2012, March). Reducing health disparities: How can the structure of the health system contribute? Wellesley Institute. Accessed March 16, 2014 at http://www. wellesleyinstitute.com/wp-content/uploads/2012/09/ Reducing-Health-Disparities-how-can-health-systemstructure-contribute.pdf Lasch, K. E., Wilkes, G., Montuori, L. M., Chew, P., Leonard, C., & Hilton, S. (2000). Using focus group methods to develop multicultural cancer pain education materials. Pain Management Nursing, 1(4), 129–138. Leininger, M. (1991). Culture care diversity and universality: A theory of nursing care. New York, NY: National League for Nursing Press. Leininger, M. (1996). Founder’s focus: Transcultural nursing administration: An imperative worldwide. Journal of Transcultural Nursing, 8(1), 28–33. Malone, B. L. (1997). Improving organizational cultural competence. In J. A. Dienemann (Ed.). Cultural diversity in nursing: Issues, strategies, and outcomes. Washington, DC: American Academy of Nursing. Marrone, S. R. (2010). Organizational cultural competency. In M. Douglas & D. Pacquiao (Eds.), Core curriculum in transcultural nursing and health care. Thousand Oaks, CA: Sage. Marrone, S. R. (2012). Organizational cultural competency. In L. Purnell (Ed.). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis. McClure, M. L., Poulin, M. A., Sovie, M. D., & Wandelt, M. A.; for the American Academy Task Force on Nursing Practice in Hospitals. (1983). Magnet hospitals. Attraction and retention of professional nurses. Kansas City, MO: American Nurses Association. McKenzie, K., & Bhui, K. (2007). Institutional racism in mental health care. BMJ, 334(7595), 649–650. Napoles-Springer, A. M., Santoyo, J., Houston, K., PerezStable, E. J., & Stewart, A. L. (2005). Patients’ perceptions of cultural factors affecting the quality of their medical encounters. Health Expectations, 8, 4–17. National Institutes of Health. (2010). Accessed February 21, 2010 at http://www.nih.gov Office of Minority Health, Department of Health and Human Services. (2011). National CLAS standards. Accessed February 23, 2014 at http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 Office of Minority Health, Department of Health and Human Services. (2013, April). Accessed February 23, 2014 at http://minorityhealth.hhs.gov/templates/browse. aspx?lvl=2&lvlID=16 Park, E. R., Betancourts, J. R., Kim, M. K., Maina, A. W., Blumenthal, D., & Weissman, J. S. (2005). Mixed messages: Residents’ experiences learning cross-cultural care. Academic Medicine, 80(9), 874–880. Peek, M. S., Odoms-Young, A., Quinn, M. T., GorawaraBhat, R., Wilson, S. C., & Chin, M. H. (2010). Racism in healthcare: Its relationship to shared decision-making

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and health disparities. Social Science and Medicine, 71(1), 13–17. Pelfrey, S., & Theisen, B. A. (1993). Valuing the community benefits provided by nonprofit hospitals. Journal of Nursing Administration, 23(6), 16–21. Purnell, L., Davidhizar, R. E., Giger, J. N., Strickland, O. L., Fishman, D. & Allison, D. M. (2011). A guide to developing a culturally competent organization. Journal of Transcultural Nursing, 22(1), 7–14. Reese, D. J. (2011). Proposal for a university-communityhospice partnership to address organizational barriers to cultural competence. American Journal of Hospital & Palliative Care, 28(1), 22–26. Regenstein, M., & Sickler, D. (2006). Race, ethnicity, and language of patients. National Public Health and Hospital Institute. Accessed February 21, 2010 at http://www.naph.org Roizner, M. (1996). A practical guide for the assessment of cultural competence in children’s mental health organizations. Boston, MA: Judge Baker’s Children’s Center. Schaffner, J. W., & Ludwig-Beymer, P. (2003). Rx for the nursing shortage. Chicago, IL: Health Administration Press. Schein, E. H. (2004). Organizational culture and leadership (3rd ed.). San Francisco, CA: Jossey-Bass. Sherrod, D. (2013). Ask, listen, respect. Nursing Management, 44(11), 6. Strasser, D. C., Smits, S. J., Falconer, J. A., Herrin, J. S., & Bowen, S. E. (2002). The influence of hospital culture on rehabilitation team functioning in VA hospitals. Journal of Rehabilitation Research and Development, 39(1), 115–125. Transcultural Nursing Society. (2014). Accessed March 2, 2014 at http.www.tcns.org

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United States Census Bureau. (2012). Income, Expenditures, Poverty, & Wealth. The National Data Book 2012 Statistical Abstract. Accessed March 16, 2014 at http://www.census. gov/compendia/statab/2012/tables/12s0710.pdf Weech-Maldonado, R., Dreachslin, J. L., Brown, J., Pradhan, R., Rubin, K. L., Schiller, C., & Hays, R. D. (2012a). Cultural competency assessment tool for hospitals: Evaluating hospitals’ adherence to the culturally and linguistically appropriate services standards. Health Care Management Review, 37(1), 54–66. Weech-Maldonado, R., Elliott, M. N., Pradhan, R., Schiller, C., Dreachslin, J., & Hays, R. D. (2012b). Moving toward culturally competent health systems: Organizational and market factors. Social Science and Medicine, 75(5), 815–822. Weech-Maldonado, R., Elliott, M., Pradhan, R., Schiller, C., Hall, A., & Hays, R. D. (2012c). Can hospital cultural competency reduce disparities in patient experiences with care? Medical Care, 50, S48–55. Weissman, J. S., Betancourt, J. R., Campbell, E. G., Park, E. R., Kim, M., Clarridge, B., & Maina, A. W. (2005). Resident physicians’ preparedness to provide cross-cultural care. Journal of the American Medical Association, 294(9), 1058–1067. Wilson, A. H., Sanner, S. J., & Mcallister, L. E. (2003) The Honor Society of Nursing, Sigma Theta Tau International Diversity Paper. Accessed February 23, 2014 at http:// www.nursingsociety.org/aboutus/PositionPapers/ Documents/Diversity_paper.pdf Youdelman, M., & Perkins, J. (2005). Providing language services in small health care provider settings: Examples from the field. The Commonwealth Fund. Accessed October 17, 2005 at http://www.cmwf.org

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Transcultural Perspectives in Mental Health Nursing ●●Joanne T. Ehrmin

Key Terms Cultural blindness Cultural blind spot Cultural norms

Cultural pain Culture shock Disenfranchised grieving Historical unresolved grief Historical trauma

Interpersonal communication Mental health Shared decision making

Learning Objectives 1. Recognize the importance of cultural values, beliefs, and practices when planning and implementing mental health nursing care. 2. Examine best practice treatment options in caring for culturally diverse mental health clients. 3. Understand the influence of culture on decisions about mental health care. 4. Evaluate strategies to provide competent transcultural mental health nursing care. 5. Recognize the importance of evidence-based transcultural mental health nursing research in caring for clients seeking mental health care in a culturally congruent and competent manner.

Mental health and mental illness are described as two extreme end positions on a continuum, with many varying degrees between mental health and mental illness. Dealing with the loss of a job, the emotional pain of grieving the loss of a loved one, and having a severe mental illness, such as schizophrenia or bipolar disorder, all fall along this continuum. A landmark Supplement to Mental Health: 272

A Report of the Surgeon General: Culture, Race, and Ethnicity (2001) brought a focus to mental health and culture, race, and ethnicity for the first time in such a clear and distinct manner (Manson, 2003). According to Galson (2009), interim Surgeon General, mental disorders are frequently “untreated, underdiagnosed, misdiagnosed, ignored, stigmatized, and dismissed” (p. 190).

Chapter 10 Transcultural Perspectives in Mental Health Nursing

In this chapter, we discuss mental illnesses within a transcultural nursing perspective, exploring how culture influences the way in which we interpret and behave with mental illnesses. The goal of this chapter is to help nurses gain the necessary knowledge and skills to improve the mental health and well-being of clients from all cultural backgrounds. As culture strongly influences how clients experience illness, and culture is the framework for the interpretation of that experience, transcultural mental health nursing knowledge is integral for culturally competent mental health care. According to the American Psychiatric Association (2013), mental disorders are defined according to “cultural, social and familial norms and values” (p. 14). Furthermore, culture provides the framework that is used to interpret “the experience and expression of the symptoms, signs and behaviors that are criteria for diagnosis” (p. 14). The concept of cultural norms is relevant to transcultural mental health nursing, as one’s culture shapes what is considered normal and, by default, what is considered abnormal. Cultural norms are patterns, values, meanings,

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expressions, beliefs, practices, and experiences that are typical of specific cultural groups. Such norms are learned and passed down by family, friends, communities, and other members of the cultural group (Figure 10-1 shows students learning to make drums, a tradition that is passed down from one generation to the next). Given the broad influence of culture, culture and mental health care are described as intricately related and dependent on one another. In fact, there is growing evidence that culture influences perceptions and attitudes with respect to mental illness (Mellor, Carne, Shen, McCabe, & Wang, 2013). Many people think of wellness in terms of illness, concluding the absence of illness indicates wellness. The distinction between disease and illness is relevant to mental health nursing care. Disease comes out of the medical model, is objective, is physiologically based, and requires a “cure,” whereas illness is subjective, comes from the perspective of the client, is culturally based, and requires “care.” According to Eisenberg (1977), “patients suffer ‘illnesses’; doctors ‘diagnose’ and treat diseases” (p. 2). Illnesses are perceived by

Figure 10-1. Drum making is taught to students to help them learn about traditional Native American culture. These classes help to keep the Native American cultural values, beliefs, and practices alive with youth in the community and demonstrate a sense of pride in traditional customs and lifeways (Ruffino, 2013, p. 28).

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the client as a disruption in their daily activities. Diseases, on the other hand, are abnormalities in the anatomy and/or physiology of the body. For example, an individual may feel ill-health as tired, fatigued, anxious, or irritated, and the diagnosis out of the medical model may be posttraumatic stress disorder. Traditional healers are often more open “to the psychosocial context of illness” (p. 2). Interestingly, disease can occur without illness and illness can also occur without disease. An individual who feels ill may first self-medicate and then consult with family, friends, local healer, pharmacist, and so on. Numerous sociocultural factors are considered prior to reaching out to the traditional health care system and providers. What may be perceived as illness or disease in one culture may not have the same meaning in another culture. Since culture determines how clients experience illness, and culture is the framework for the interpretation of that experience, transcultural mental health nursing knowledge is necessary for culturally competent and congruent mental health care.

Defining Mental Health Within a Transcultural Nursing Perspective The World Health Organization (WHO) (2014a) indicated that “over 450 million people suffer from mental disorders.” WHO further postulated: “Mental health is an integral part of health; indeed, there is no health without mental health” (WHO, retrieved 2-14). Interestingly, the definition of mental health, by WHO, has not been changed since 1948. WHO included mental well-being in their definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Included in this definition is the implication that “mental health is more than the absence of mental disorders or disabilities” (WHO, 2014). WHO (2014b) further specified that mental health is “a state of well-being

in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” and that this understanding of mental health can be interpreted “across cultures” (p. 1). WHO further elaborated that “mental well-being, historically has frequently been misunderstood and forgotten.” In the Rural Healthy People 2020 Report, survey results of state and local rural leaders indicated that mental health and mental disorders are the third most often identified rural health priority (Bolin & Bellamy, 2013). Furthermore, WHO (2013) identified a comprehensive mental health action plan for 2013 to 2020. The plan encourages community-based mental health care and focuses on recovery, moving away from a strictly medical model and deals with income, education, and “other social determinants of mental health in order to ensure a comprehensive response to mental health.” WHO (2013) identified there are numerous determinants of mental health at any given point in time for an individual, including “social, psychological and biological factors.” Some of the social/psychological factors include persistent poverty, risks of violence and human rights violations, gender discrimination, and social exclusion. There are also biological factors including chemical imbalances. According to the National Alliance on Mental Illness (NAMI) (2014), mental illness is a condition that “disrupts a person's thinking, feeling, mood, ability to relate to others and daily functioning.” NAMI identified some of the most serious mental illnesses include “major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), and borderline personality disorder.” Leininger (Leininger, 1991a; Leininger & McFarland, 2002), in Culture Care Diversity and Universality: A Theory of Nursing, theorized the importance of identifying what is common and universal among cultures, while at the same time understanding there is individual diversity within cultures. Diversity for transcultural mental health

Chapter 10 Transcultural Perspectives in Mental Health Nursing

nurses encompasses not only culture and ethnicity but also gender, sexual orientation, socioeconomic status, age, physical abilities or disabilities, religious beliefs, and political beliefs or other ideologies (Figure 10-2). Gaining a better understanding and more in-depth knowledge base of patterns of values, beliefs, and practices for mental health care can be used as one “tool” in caring for clients, families, and communities from diverse cultural groups. This is different from simplistic overgeneralizations that can lead to stereotyping a particular culture. Stereotyping is a “fixed, overgeneralized belief about a particular group or class of people” (Cardwell, 1996). Stereotypes can lead to erroneous misrepresentations of diverse cultural groups, age groups, gender identity, etc. Stereotypes can be used as an underlying rationale to distort mental illness symptoms and misdiagnose culturally diverse individuals, families, and communities. Stereotypes can also serve to exploit culturally diverse clients, particularly in the area of mental health care, where differences in group norms can sometimes be used to inappropriately label clients with a mental

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health diagnosis. Dow (2011) identified the dangers of racism and stereotyping, particularly for migrants, which can increase an already high level of stress, thereby adding to the psychological burdens migrants experience, possibly even threatening their survival. She further identified racism and stereotyping as being more prevalent in communities with minimal cultural diversity. Transcultural nurses do not promote stereotyping of clients, families, and communities because of unique characteristics. Stereotyping labels people and is a form of prejudice that is damaging and harmful to any recipient, let alone a client with a mental illness! Furthermore, stereotyping is generally inaccurate and is often based more on the individual expressing the stereotypical view than the cultural group being targeted. Stereotyping identifies a cultural group or members of that culture as identical and indistinguishable from each other. Some examples of common stereotyping are beliefs that African Americans are “better at sports” and “dancing” than are other cultural groups. Other examples of stereotypes are that Irish Americans are “quick tempered,” or Turkish women are “belly dancers.”

Figure 10-2. Transcultural nurses practice within a framework of sensitivity, knowledge, and skill to promote health and care for individuals diagnosed with a mental illness in culturally congruent ways (Monkey Business Images/Shutterstock.com).

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Identifying people as all looking the same or thinking the same is stereotyping. Transcultural mental health nursing does not promote applying a stereotypical “cookbook” approach to mental health care. Another concept that is important to consider in transcultural mental health nursing is ethnocentrism. “In its mildest form, ethnocentrism presents as subconscious disregard for cultural differences; in its most severe form, it presents as authoritarian” (Sutherland, 2002, p. 280). Ethnocentrism can manifest as feelings of superiority or discrimination with respect to one’s own group or culture over another group or culture. For example, ethnocentrism can manifest as a belief that one’s own religious beliefs are superior to another group or culture’s religious beliefs and that one’s own health care beliefs and practices are superior to another culture’s health care beliefs and practices. US-trained health care professionals are frequently guilty of the latter ethnocentric assumption. Many cultural groups have distinct patterns of values, beliefs, and practices that can be used as a basis for providing mental health care in a culturally congruent and competent manner. However, many individuals and families belonging to specific cultural groups may have more diverse mental health care needs than do those of the cultural group norm. The term “norm” is used to identify patterns of values, beliefs, and practices specific to mental health that have been identified through research and caring for culturally diverse clients, families, and communities.

Population Trends and Mental Health The US population is projected to increase in age and cultural diversity as we move toward the middle of the century. Given the increasing numbers of elderly in the United States, it is important to understand trends in utilization of mental health care services for older p opulations

of all cultures. According to the 2010 U.S. Census, the United States is projected to become a more diverse nation. In fact, the United States is expected to become a “majority–minority” nation by 2043. Currently, minorities (Hispanic, African American, Asian, American Indians, Alaska Natives, etc.) represent 37% of the US population and are expected to represent 57% of the population in the United States by 2060. The implications and need for educated transcultural mental health nurses are immense (United States Census Bureau, 2012). According to National Institute of Mental Health (NIMH) (2012), mental illnesses are identified as “common” in the United States. Approximately 43.7 million adults (approximately 19% of all adults in the United States), aged 18 or older, were currently, or within the past year, diagnosed with a mental, behavioral, or emotional disorder and excluding substance use disorders. When broken down by culture, Asians had the lowest percentage of adults diagnosed with mental illness (13.9%) and American Indian/Alaska Natives had the highest percentage of adults diagnosed with mental illness (28.3%). There is evidence of underutilization of mental health services by many minority groups. Community education and outreach programs are needed to increase mental health service use in older ethnic minority populations (Jang, Kim, Hansen, & Chiriboga, 2007). Although mental health nurses care for clients of all age groups and all cultural groups, the current and future trends in population projections do have major implications for transcultural nursing and mental health services in the United States. According to Kessler, Chiu, Demler, and Walters (2005), approximately 26.2% of Americans 18 years old and older, or 1 in 4 adults, suffer each year from a mental disorder that is defined in the Diagnostic and Statistical Manual, 4th edition (DSM-IV), of the American Psychiatric Association (APA) mental disorders. Of those cases, more than one-third are mild. However, approximately 6%, or 1 in 17 individuals, suffer from a “serious mental illness,” including suicide,

Chapter 10 Transcultural Perspectives in Mental Health Nursing

mental or substance abuse, nonaffective psychosis, bipolar I or II disorder, or acts of violence. The institutionalized view of mental health care as portrayed in the movie “One Flew Over the Cuckoo’s Nest” (1975) is no longer the norm for care today. Increasingly, mental health care is moving from state and general “mental” hospitals to community-based service centers. The U.S. Department of Health and Human Services’ Center for Mental Health Services (CMHS) is the Federal agency within the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) charged with improving prevention and mental health treatment services in the United States. For 2008, CMHS statistics for utilization of community-based mental health treatment was 19.15%, as compared to treatment in state hospitals and other psychiatric inpatient settings just over 2%. The cultural diversity of mental health clients is increasing, as is the use of community-based mental health treatment centers. These statistics can help to guide the direction nursing will take in meeting the needs of mental health clients.

Decision Making and Mental Health Care Consumers of mental health care (clients, families and significant others, and communities) are more knowledgeable now than they have ever been in the past. With the advent of the Internet, mental health care information is more widely available to those seeking knowledge. Continuous news broadcasts offer health care information to both consumers and professionals alike. National and international news and research breakthroughs are increasingly available to consumers, almost as soon as they are available to professionals. In addition, our society is more open to talking about mental health conditions, such as depression and bipolar disorder, in ways that would have been unthinkable just two decades ago.

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Clients, families, and significant others want an active role in decision making about their mental health care, and they use numerous resources to make those decisions. Mental health clients, particularly, can become agitated when their voice is not heard or taken into consideration with regard to treatment decisions. For culturally diverse clients with mental health care needs, and diverse values, beliefs, and practices that may not be understood by health care providers, this can be even more frustrating and can lead to misunderstandings on both sides. Clients may feel misunderstood and isolated in a health care system that can seem cold, frightening, rigid, and controlling. Offering support and clear communication can be key to bringing about favorable outcomes for all clients, but it can be particularly challenging with clients, families, and significant others from diverse cultural groups seeking mental health care. The U.S. Department of Health and Human Services (2010) propose shared decision making (SDM) as a practice to advance mental health care. SDM encourages providers and consumers to collaborate on mental health care for the consumer. Mental health care providers can offer suggestions for treatment options depending on the needs of the consumer. In addition, by making the consumer an integral part of the mental health plan of treatment, it demonstrates a commitment to the autonomy and decision-making role of the consumer (Schauer et al., 2006). It has become important for mental health care professionals to attempt to include clients and family members in care decisions. At times, this can be problematic for mental health care providers, particularly if the mental health status of the client is considered to be questionable in making critical personal decisions regarding his or her own care. Consumer treatment input can also seem a daunting task for those care providers who have based practice decisions on a strictly authoritarian framework. Understanding and taking into account the client’s values, beliefs, and practices is crucial to ensuring favorable outcomes. Evidence-based or “best” practice options

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can be discussed with clients and family members who are able to participate in care decisions. However, the ultimate decision lies with the client and his or her family or relatives. It is important for nurses to assess the knowledge level of their clients, family members, and/or significant others regarding the client’s status and care the client is receiving. Try to include the client in decisions affecting his or her care whenever possible.

Disparities in Mental HealthCare Reducing and eliminating disparities in health care has been a focus of numerous initiatives in recent years. Healthy People 2020 (2015) identified mental disorders are one of the most common causes of disability and further identified one of the main goals was to “improve mental health through prevention and by ensuring access to appropriate, quality mental health services.” The American Psychological Association (APA) (2015) called for reform in disparities in mental health status and care. APA identified that mental health is frequently lacking for diverse minority communities. In addition, concerns were raised about mental health symptoms that are “undiagnosed, underdiagnosed, or misdiagnosed for cultural, linguistic, or historical reasons.” The National Institute of Nursing Research (NINR) identified strategies to reduce and eventually move toward elimination of health disparities among a number of underrepresented cultural groups. The Federal Collaborative for Health Disparities Research selected mental health disparities as one of four areas that merited immediate national research attention (Safran et al., 2009). When asking the question “What can nursing do about health disparities?” Smith (2007) suggested that nursing has lost its vision and capacity for caring, which qualifies the profession to address disparities. Caring is essential to the theory and practice of nursing. Nursing “has been seduced by the scientific model” (p. 285),

and Smith asked the question about where that leaves nursing with respect to human suffering. She further identified nursing is more alienated with respect to the needs of oppressed groups. It is imperative that all health care providers, including mental health nurses, care about and reach out to those individuals and families suffering from mental health care disparities. Disparities in mental health treatment have existed from the earliest historical recordings. Those with behavior that was considered to be “abnormal” were thought to be “deranged” or “mad,” and in many cases, they were sent to asylums, under the harshest of conditions, to live out the remainder of their lives. Psychiatric mental health nurses have been at the forefront in paving the way for the humane care and treatment of mental health clients and, yet, mental health still remains wrought with disparities and stigma that do not exist for many other health conditions (see Evidence-Based Practice 10-1). Gluck (2014) defined stigma as “a perceived negative attribute that causes someone to devalue or think less of the whole person.” Individuals with mental illness have been identified as one of the most highly stigmatized groups in the American culture. Gluck further identified that many individuals with a mental health disorder may define stigma with such phrases and terms as feeling discriminated against, hurtful, and humiliating. The first Surgeon General’s report on mental health identified disparities among diverse cultural groups in seeking and being treated for mental illness: “Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services. A major factor in mental health disparities, particularly for underrepresented and underserved cultural groups was the deinstitutionalization of mental health care in the mid 20th Century. Moving mental health clients from psychiatric state hospitals to community-based settings never fully materialized. Instead, individuals with mental health problems frequently ended up in emergency rooms for short-term treatment. Eventually jails and prisons became the long-term placement

Evidence-Based Practice 10-1

Overcoming Stigma for Those Seeking Mental Health Treatment Unfortunately, mentally ill people have evoked adverse responses across various cultures, frequently leading to living with the mental illness, rather than seeking treatment, for fear of being labeled and rejected by society. Stigma is a word with Greek origins, which referred to a symbol cut or burnt into the body, and was used to signify something negative about the moral status of the individual. It was further identified that stigma could lead to a “spoiled identity” and “damaged sense of self” (Goffman, 1964, p. 116). According to the Surgeon General’s report on mental health, mental illness stigma is “the most formidable obstacle to future progress in the arena of mental illness and health” (Hinshaw, 2007, p. x). The pain of mental illness is difficult enough, “but the devastation of being invisible, shameful and toxic, can make the situation practically unlivable” (Hinshaw, 2007, p. xi). Mental illness “affects personal well being, economic productivity, and public health, fueling a vicious cycle of lowered expectations, deep shame, and hopelessness” (p. x). Untoward consequences of mental illness, stigma, and discrimination can impact nearly every aspect of an individual’s life, as well as the lives of their family and significant others. Rao, Feinglass, and Corrigan (2007) theorized that “diagnoses of mental illness are given based on deviations from sociocultural, or behavioral norms. Therefore, mental illness is a concept deeply tied to culture, and accordingly, mental illness stigma is likely to vary across cultures” (p. 1020). Given the importance of understanding stigma associated with mental illness, it is concerning that limited research has been conducted on this phenomenon. Cheon and Chiao (2012) identified that “cultural variations in automatic affective reactions toward mental illness suggest that cultural differences in the meanings or assumptions associated with mental illness may underlie cultural variations in stigma. For example, for the Asian culture, danger and mistrust are associated with mental illness (Abdullah & Brown, 2011). Hansson, Jormfeldt, Svedberg, and Svensson (2013) conducted a study with mental health care

staff and mental health care patients themselves about attitudes and beliefs about mental illness. Mental health care staff caring for patients with a psychosis and staff working with inpatients held the most negative attitudes. Overall, patient attitudes were in keeping with those of the staff. The researchers expressed concerns about staff holding negative attitudes and beliefs about their patients with mental illness, and the impact on treatment and development and implementing evidence-based services. The researchers also identified the importance of developing interventions that would focus on both patient and staff beliefs about mental illness, in order to facilitate a more recovery-oriented outcome.

Clinical Implications It is important for nurses and other health care providers caring for individuals, family members, and significant others to understand the impact of mental health stigma on the patient diagnosed with a mental illness. Understanding the stigma of mental illness can even influence the patient, family, and significant others’ willingness to contact health care providers for treatment and can help caregivers help patients, families, and significant others understand mental illness within the context of health care. If nurses are to help the patient deal with the untoward effects of stigma associated with mental illness, it is crucial that nurses get in touch with their own biases and negative attitudes about mental illness. It is also important for nurses to understand that the patient, family, and significant others may resist a mental illness diagnosis, based on the societal and specific cultural values, beliefs, and practices associated with mental illness. Peer discussions among nurses about personal and professional values, beliefs, and practices associated with mental illness could facilitate getting in touch with negative attitudes and beliefs about mental illness. Nurses can also participate in workshops and other educational experiences to improve their understanding of cultural values, beliefs, and (continued )

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Overcoming Stigma for Those Seeking Mental Health Treatment (continued) ractices related to mental illness in general and to p specific mental illness diagnoses.

References Abdullah, T., & Brown, T. L., (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review, Clinical Psychology Review, 31, 934–938. Cheon, B., & Chiao J. Y. (2012). Cultural variations in implicit mental illness stigma. Journal of Cross-Cultural Psychology, 43(7), 1058–1062.

Goffman, E. (1964). Stigma. London, UK: Penguin. Hansson, L., Jormfeldt, H., Svedberg, P. & Svensson, B. (2013). Mental health professionals’ attitudes towards people with mental illness: Do they differ from attitudes held by people with mental illness? International Journal of Social Psychology, 59(1), 48–54. Hinshaw, S. P. (2007). The mark of shame: Stigma of mental illness and an agenda for change. New York, NY: Oxford University Press. Rao, D., Feinglass, J., & Corrigan, P. (2007). Racial and ethnic disparities in mental illness stigma. The Journal of Nervous and Mental Disease, 195(12), 1020–1023.

for many individuals with mental health diagnoses (Safran et al., 2009). These disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender” (U.S. Department of Health and Human Services, 1999, p. vi). Historically, racism in America has led to difficulties in acknowledging and/or discussing differences in cultural values and lifeways for diverse cultural groups. Bell and Peterson (1992) indicated that slavery, segregation, and institutionalized racism have resulted in numerous problems faced by African Americans, resulting in what the authors labeled as cultural pain. Cultural pain is defined as feeling “insecure, embarrassed, angry, confused, torn, apologetic, uncertain, or inadequate because of conflicting expectations of and pressures from being a minority” (Bell & Peterson, 1992, p. 8). Leininger (1995) identified cultural pain as “the suffering, discomfort, or unfavorable responses of an individual group towards an individual who has different beliefs or lifeways, usually reflecting the insensitivity of those inflicting the discomfort” (p. 67). A number of diverse cultural groups have experienced what is called historical trauma (also referred to as Historical Unresolved Grief or Disenfranchised Grieving; see EvidenceBased Practice 10-2). Evans-Campbell (2008) discussed historical trauma in Native American

and Alaska Native communities and defined historical trauma as: “a collective complex trauma inflicted on a group of people who share a specific group identify or affiliation-ethnicity, nationality, and religious affiliation. It is the legacy of numerous traumatic events a community experiences over generations” (p. 320). In contrast to personal traumatic experiences, “the concept of historical trauma calls attention to the complex, collective, cumulative, and intergenerational psychosocial impacts that resulted from the depredations of past colonial subjugation” (Gone, 2013). Yellow Horse Brave Heart and DeBruyn (1998, p. 60) observed that “American Indians experienced massive losses of lives, land, and culture from European contact and colonization resulting in a long legacy of chronic trauma and unresolved grief across generations.” Past emotional harm done to people of a diverse culture includes such examples as the Jewish holocaust, slavery of African American people in the United States, internment of Japanese Americans in America during World War II, and treatment of American Indians. In order to help individuals heal from historical unresolved grief or historical trauma, nurses need to understand how experiences of the past shape the present and future (Struthers & Lowe, 2003; Yellow Horse Brave Heart & DeBruyn, 1998). Helping clients to move through

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Evidence-Based Practice 10-2

“Historical Unresolved Grief” or “Historical Trauma” Certain cultural groups, including First Nations such as American Indian, Native Alaska, and Canadian Aboriginal, have experienced what is called “historical unresolved grief” or “historical trauma.” They have experienced loss of people, land, and culture as a result of European colonization. This phenomenon “contributes to the current social pathology of high rates of suicide, homicide, DV, child abuse, alcoholism, and other social problems among American Indians” (p. 60). Other cultural groups experience the phenomenon of historical unresolved grief or historical trauma as well, as a result of, for example, the Jewish holocaust, slavery of African Americans, and the internment of Japanese Americans during World War II. Nurses can help specific cultural groups grieve the past traumatic event(s) and allow them to acknowledge the events that occurred. It is important to help individuals, groups, and communities identify methods and solutions to move forward in the healing process. Gone (2013) identified First Nations’ communities have repeatedly linked their high rates of mental health distress with historical traumatic experiences of European colonization. Gone differentiates historical trauma from posttraumatic stress disorder in three different aspects: First, historical trauma is more complex in what preceded it, how it evolved, and the outcome. Second, historical trauma is a collective phenomenon shared by communities following deliberate conquest, colonization, or genocide. Finally, historical trauma is cumulative in its effect over time. Gone further stipulated various

traditional cultural practices to help First Nations suffering from historical trauma, such as talking circles, pipe ceremonies, sweat lodges, and other cultural practices for therapeutic healing purposes. (See Figures 10-1, 10-4, and 10-5 for other examples of healing tribal ceremonies and activities.)

the process of unresolved grief is an important care measure nurses and other health care providers must consider when caring for individuals and families from cultures who have experienced horrific events or trauma in the past. Often, interventions are directed toward the community at large rather than focused on specific individuals. Working with clients, families, and communities and encouraging their voices to be heard is key to

helping those who have experienced pain associated with racial, social, and economic disparities and oppression. Johnston and Boyle (2013) conducted an ethnographic study with Northern British Columbian Aboriginal mothers with adolescents diagnosed with fetal alcohol spectrum disorder and observed that the mothers who participated in the study lived within a marginalized

Clinical Implications As individuals, families, and communities continue to grieve the emotional pain associated with historical trauma, it is important for transcultural mental health nurses to acknowledge the emotional feelings (insecurity, embarrassed, angry, confused, torn, apologetic, uncertain, or inadequate) associated with such grief and the conflicting expectations of and pressures from being a minority. It is important for transcultural mental health nurses to facilitate a safe and healing environment for individuals, families, and communities to work through the feelings associated with historical unresolved grief or historical trauma. References Bell, P., & Peterson, D. (1992). Cultural pain and African Americans: Unspoken issues in early recovery. Hazelden Publishing Center City, MN. Gone, J. P. (2013). Redressing First Nations historical trauma: theorizing mechanisms for indigenous culture as mental health treatment, Transcultural Psychiatry, 50(5), 683–706. Yellow Horse Brave Heart, M., & DeBruyn, L. M. (1998). The American Indian holocaust: Healing historical unresolved grief. American Indian & Alaska Native Mental Health Research, 8(2), 60–82.

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and poverty-stricken context. Intergenerational alcohol abuse had played a major role in all of the women’s lives. “Mothering from the Margins” was a major theme discovered in the study. The women’s lives were “framed within a post colonial context of racial prejudice and stereotypical notions of Aboriginal motherhood” (p. 65). The researchers suggested that nurses need to take a leadership role to reduce health disparities with marginalized and poverty-stricken populations, particularly when there is evidence of prejudice, including stereotyping. It is important for nurses to advocate on behalf of such individuals and communities. Zayas, Torres, and Cabassa (2009) compared mental health diagnostic agreement in an outpatient unit with Hispanic and non-Hispanic health care providers. The non-Hispanic care providers rated client’s functional ability and the severity of symptoms significantly worse than do the Hispanic care providers. The authors noted that because the mental health labor force is primarily non-Hispanic, Hispanic individuals are likely to be assigned a non-Hispanic care provider. The authors questioned the possibility of the care provider’s cultural and social biases, and wondered if those factors were responsible for the discrepancy in diagnoses. It is important for mental health professionals not only to identify but also to understand racism and the role it plays in mental health, at both a conscious and unconscious level, in order to eradicate racial inequalities in mental health care.

Mental Health Care for Immigrants There has been extensive debate about immigration policy during the past several years in the United States as well as internationally. In the United States, the debate has become heated politically with political parties arguing the implications, from their standpoint, of immigration policies. Health care for those immigrants

who are not in this country legally has also been extensively debated, again with both sides stating the merits of their views on whether such immigrants, or undocumented individuals, have a right to health care in this country. At the same time, however, there has been minimal understanding of these issues from the perspective of the undocumented immigrants and the impact immigration has on their mental health (see Evidence-Based Practice 10-3). Use of the terms “illegal alien,” and “illegal immigrant,” is increasingly identified as “racially charged” and offensive terminology to describe “undocumented workers,” or “undocumented immigrants.” In fact, according to the PEW Research Center (2013), a nonpartisan think tank located in Washington, D.C., use of the term “illegal alien” reached its low point in 2013, dropping to 5% of terms used. It had consistently been in double digits in the other periods studied, peaking at 21% in 2007. According to the Central Broadcasting System (CBS) (2014), Supreme Court Justice Sonia Sotomayor, the first Hispanic Supreme Court Justice, uses the term “undocumented immigrants” rather than the term “illegal alien.” Justice Sotomayor identified that “labeling immigrants criminals seemed insulting to her.” She further stated: “I think people then paint those individuals as something less than worthy human beings and it changes the conversation.” The undocumented worker’s voice is generally absent in policy debates and implementation. In fact, undocumented immigrants are “often forced to live in the shadows of society for fear of deportation,” which further alienates and silences the voice of the undocumented immigrant (Summers-Sandoval, 2008, p. 581). Setting aside the political debate, transcultural mental health nurses have cared for both documented and undocumented immigrants for many years and are increasingly caring for those immigrants who are feeling the emotional pressures of such a political climate. The term culture shock was coined by the anthropologist Kalervo Oberg (1960) to describe individuals, such as immigrants, who enter a new culture. Culture shock

Evidence-Based Practice 10-3

Mental Health Needs of the Immigrant Population Based on the 2009 American Community Survey (ACS), approximately 38.5 million or 12.5% of the population in the United States are foreign born (U.S. Census Bureau, 2010). Schock-Giordano (2013) found that assimilation into the American culture may have a negative impact on mental health. The mental health needs of the immigrant population increase with the stresses encountered in learning the values, beliefs, and practices of a new culture. In addition, language and financial needs can limit the immigrant population from seeking adequate health care services, particularly mental health services. The immigrant population faces numerous challenges in seeking professional mental health care, including a lack of understanding of the mental health care system and how to go about accessing mental health services (Dow, 2011). A major barrier that can impede an immigrant from seeking mental health care services is language. Immigrants may delay seeking mental health care based on fear of not being able to communicate or a fear of embarrassment about their language difficulties. Misdiagnoses may result from difficulties with communication and may impede appropriate mental health treatment (Dow, 2011). In order to provide optimal care to immigrants seeking mental health services, it is important for nurses to facilitate, to the best of their ability, a willingness to understand the client’s perspective and help the client with language difficulties, to communicate their symptoms and perceptions about their mental health state. It is important for nurses to let the immigrant client know they are willing to listen, help interpret, and understand the client’s perspective about their symptoms within a nonjudgmental setting. Particularly for the immigrant client with financial and insurance difficulties, it is most important for the nurse to work with the

lient and the health care system to facilitate the c client’s care or their ability to access available and appropriate care, including a certified translator if needed. Immigrants from diverse cultures have unique patterns of beliefs and values as to the meaning of health or illness. These patterns of beliefs and values, interpreted within a distinct cultural context, then influence how symptoms are identified and interpreted and determine when to seek mental health services and appropriate treatment (Dow, 2011). It is important for mental health care providers to interpret symptoms and perceptions within a cultural context, in order to determine appropriate care. To provide culturally congruent mental health care, it is important for nurses to assess for the client’s understanding of symptoms; their migration story and potential trauma associated with their immigrant status; spiritual and religious values, beliefs, and practices; stressors associated with acculturation; and available support system, all of which can influence the patient receiving appropriate diagnosis and treatment for their symptoms (Caplan et al., 2013).

is “precipitated by the anxiety that results from losing all our familiar signs and symbols of social intercourse” (p. 177). Oberg suggested that the “signs” or “cues” that people use within a culture—

such as the words people speak—customs people follow, and even nonverbal communication such as gestures and facial expressions are not recognized by those who are new to the culture.

References Caplan, S. Caplan, S., Escobar, J., Paris, M., Alvidrez, J., Dixon, J. K., … Whittemore, R. (2013). Cultural influences on causal beliefs about depression among Latino immigrants, Journal of Transcultural Nursing, 24(1), 68–77. Dow, H. D. (2011). An overview of stressors faced by Immigrants and Refugees: A guide for mental health practitioners, Home Health Care Management and Practice, 23(3), 210–217. Schock-Giordano, A. (2013). Ethnic families and mental health: Application of the ABC-X model of family stress, Sage Open, 1, 1–7. U. S. Census Bureau. (2010). Place of birth of the foreign-born population: 2009.

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This leads to feelings of frustration and anxiety even in those persons who would be considered “mentally healthy.” Imagine how these negative feelings would be confounded for an individual who has entered the country as an undocumented immigrant and fears arrest, detention, and deportation. The concept of acculturation was initially defined by Redfield, Linton, and Herskovits (1936) as “those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original cultural patterns of either or both groups” (p. 149). Acculturation can be a stressful and complex process, particularly for immigrants who experience difficulty adjusting to the new culture. Ho (2014) conducted a systematic review of research on implications of acculturation on Chinese immigrants. Acculturation discrepancy between immigrant Chinese parents and their children, specifically in the American orientation, was indirectly related to a higher level of adolescent delinquency. In other words, “the parents’ acculturation in the host orientation may be more saliently related to children’s conduct or delinquent behaviors” (p. 155). Some individuals

may find themselves unable to work through the stress of acculturation and have great difficulty in modifying their cultural values, beliefs, or practices and feel isolated from their new culture or even from their culture of origin. Depression (see Evidence-Based Practice 10-4) is the most common mental health problem among immigrants in the United States and has been associated with the process of acculturation (Al-Omari & Pallikkathayil, 2008; Choi, Miller, & Wilbur 2009). Immigrants and refugees may be fleeing war and other traumatic political environments and may exhibit symptoms of posttraumatic stress disorder as well as depression (Figure 10-3). Walsh, Shulman, and Maurer (2008) studied immigration distress in young adults immigrating to Israel from Eastern Europe and found young immigrants experienced immigration distress, including feelings of guilt and shame, failure, and incompetence and not feeling wanted, understood, or a sense of belonging. Immigration distress can be a result of economic adversity, language difficulties, loss of support networks, even loss of family members, as well as prejudice and discrimination. Because of the difficulties faced by immigrant

Figure 10-3. In addition to being uprooted or fleeing war-torn and impoverished living conditions in their home countries, many immigrants from diverse cultural groups suffer from mental health issues (hikrcn/Shutterstock.com).

Evidence-Based Practice 10-4

Depressive Disorders Interpreted Within a Cultural Context According to WHO, depression is one of the most common mental disorders and leading cause of disability worldwide (World Health Organization, 2012). “Globally, more than 350 million people of all ages suffer from depression” (2012). Similarly, the U.S. Department of Health and Human services, in the Healthy People 2010 report, identified depressive disorders have been categorized as major, persistent, premenstrual, substance/medicationinduced, depressive disorder R/T another health condition, other specified and unspecified (DSM-V, 2013). Common symptoms among the depressive disorders are “presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes” (p. 155) that significantly affect the individual’s ability to carry out functions of daily living. What varies among the depressive disorders are “duration, timing, or presumed etiology” (p. 155). How depression is identified, treated, and talked about is frequently connected to one’s cultural values, beliefs, and practices. In a study about the influences and causal beliefs about depression among Latino immigrants, Caplan et al. (2013) identified disparities in depressive mental health care for Latinos are not completely explained by difficulties with insurance and language but may be more a reflection of the patient’s cultural values, including religious values, and a lack of understanding of these values by health care providers. The researchers found that “the perceived importance of supernatural and religious causation beliefs, which might contribute to a reluctance to fully accept medical interventions” (p. 75). Therefore, it is important for nurses to explore these sensitive areas with their patient’s and/or family/significant others. Patients may be reluctant to discuss deeply held cultural beliefs such as supernatural, voodoo, and various rituals little understood by health care providers, unless an open, accepting discovery mode is provided. Brintnell, Sommer, Kuncoro, Setiawan, and Bailey (2013) conducted a concept mapping study on the expression of depression among Java, Indonesia, participants from local mental health hospitals, aged 15 to 55 years old. Investigators held individual meetings rather than group meetings, related to a cultural

norm of not wanting to share private health information in public. Participants had received a clinical diagnosis of recurrent major depressive disorder depending on severity (2013, p.162). Participants were asked, “How do you experience your illness/sickness?” Six underlying themes were identified: interpersonal relationships, hopelessness, physical/somatic, poverty of thought, discouragement, and defeat. Researchers concluded the findings indicated common features with Western populations with the disorder.

Clinical Implications When health care providers lack an understanding of the diverse cultural groups for whom they provide care, failure to accurately diagnose an individual with the correct diagnosis increases. For example, with depression, Brintnell et al. (2013) concluded that there is a discrepancy in current diagnostic tools to address depressive experiences/illnesses when compared to how individuals actually experience their illness/sickness. The authors concluded the discrepancy could ultimately influence diagnosing depression in diverse non-Western cultural groups. Gwynn et al. (2008) reported that immigrants in the United States who suffered from depression were 60% less likely to be diagnosed than were individuals born in the United States, even if those individuals born in the United States were of the same culture as the immigrants (Gwynn et al., 2008). For example, Asian immigrants who suffered from depression were often inadequately diagnosed and treated, which ultimately led to serious psychosocial and functional impairments (Gwynn et al., 2008). Based on the findings in the Brintnell et al. (2013) study, “religion or spiritual interconnectedness acts as a common coping mechanism and screening tools might benefit by including these aspects” (p. 593). The researchers also suggested the need to place more emphasis on somatic complaints and problems with concentration. It is important for nurses to understand both past and present life experiences are interpreted through the lens of deeply held cultural, religious, and spiritual (continued )

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Depressive Disorders Interpreted Within a Cultural Context(continued) beliefs. It is important for nurses to try to understand beliefs, values, practices, and expectations grounded in one’s culture, to more fully understand a patient’s symptoms, their perspective about their illness, and expected outcomes of treatment for depression. References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (5th ed.). Washington, DC: American Psychiatric Association. Brintnell, S. E., Sommer, R. W., Kuncoro, B., Setiawan, P. G., & Bailey, P. (2013). The expression of depression among

f amilies, their children are at higher risk for depression, anxiety disorders, substance abuse, and other mental health problems. Mental health nurses working with immigrants and their families need to be aware of the risk for mental health problems. Ho (2014) identified nurses are uniquely qualified to identify acculturation discrepancy problems with immigrant parents and children at the clinical and mental health community levels. Based on their holistic perspective and skills, nurses are able to develop links among the individual, family, and social environment, thereby helping to prevent negative child outcomes associated with acculturation in immigrant families. Many immigrants may express their anxiety as somatic complaints, so nurses working with immigrant populations need to be aware of the linkages between somatic complaints, such as headaches, backaches, and the like, and mental health problems (Lamberg, 2009). Bridges, Andrews, and Deen (2012) studied 84 adult Hispanic immigrants in the MidSouthern United States, their mental health needs, and their use of services; they found 36% of participants met the criteria for at least one mental disorder. Forty-two percent of the sample saw a physician in the previous year, primarily because of somatic complaints; however, religious 286

Javanese patients with major depressive disorder: A concept mapping study. Transcultural Psychiatry, 50, 579–598. Caplan, S., Escobar, J., Paris, M., Alvidrez, J., Dixon, J. K., Desai, M. M., … Whittemore, R. (2013). Cultural influences on causal beliefs about depression among Latino immigrants. Journal of Transcultural Nursing, 24(1), 68–77. Gwynn, R. C., McQuistion, H. L., McVeigh, K. H., Garg, R. K., Frieden, T. R., & Thorpe, L. E. (2008). Prevalence, diagnosis, and treatment of depression and generalized anxiety disorder in a diverse urban community. Psychiatric Services, 59, 641–647. World Health Organization. (2012). Fact Sheet N369. Retrieved 4-17-14 http://www.who.int/mediacentre/factsheets/ fs369/en/

leaders were providing mental health services to the participants. Findings indicated that many of the Hispanic immigrants participating in the study recognized mental health services would be beneficial; however, systemic barriers existed, including economic and linguistic. The authors recommended recruiting bilingual medical and nursing students into the health care professions and offering incentives to retain the students. The authors also identified a need to work closely with religious leaders to recognize mental health problems and help to form a beneficial referral system.

Cultural Criteria Changes in Diagnostic Statistical Manual-V In the newest DSM-V, the culture-bound syndromes that have routinely been used by mental health professionals have now been replaced with three cultural concepts. An overview of the three concepts follows, along with the reasons identified for the change in the DSM-V. In addition, several key mental health organizations have come out against the DSM-V, and those organizations and reasons for their views on the DSM-V will be discussed.

Chapter 10 Transcultural Perspectives in Mental Health Nursing

A Cultural Formulation Interview (CFI) has been identified in the DSM-V and is a set of 16 questions clinicians can use in a mental health assessment. The questions are geared to the impact of culture on the individual’s current clinical picture. The three cultural concepts in the DSM-V (American Psychiatric Association, 2013) are cultural syndrome, cultural idiom, and cultural explanation. Cultural syndrome is identified as a cluster or co-occurring group of symptoms found in a specific cultural group or community (e.g., ataque de nervios). The syndrome may not be identified as an illness by the cultural group, yet would be identified as an illness by an outside observer. Cultural idiom of distress is a means of identifying suffering among a cultural group with shared ethnicity and

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religion (e.g., kufungisisa). Kufungisisa is associated with “a range of psychopathology,” including “anxiety, excessive worry, panic attacks, depressive symptoms and irritability” (p. 834). The cultural idioms of distress may not be associated with specific symptoms and may be used to demonstrate discomfort in a variety of situations, including social circumstances versus mental health issues, and cultural explanation or perceived cause is a label that provides a cultural etiology (e.g., maladi moun). “Interpersonal envy and malice cause people to harm their enemies by sending illnesses such as psychosis, depression. A related condition is the ‘evil eye’ (p. 835).” Explanations about the cause may be features or folk classifications used by cultural healers or lay individuals (see Table 10-1).

Table 10-1: DSM-V (2013) Cultural Concepts of Distress Cultural Concept of Distress

Culture

Symptoms

Ataque de nervios

Latino

Intense emotional upset; acute anxiety, anger, or grief; screaming and shouting uncontrollably; attacks of crying; trembling; heat in the chest rising into the head; verbal and physical aggression Dissociative experiences; seizure-like and fainting; suicidal gestures

Dhat syndrome

India Pakistan

Associated with semen loss in young males Anxiety, fatigue, weight loss, impotence

Khyal cap

Cambodians in United States and Cambodia

Panic attacks; anxiety, tinnitus, and neck soreness

Kufungisisa

Shona of Zimbabwe

Anxiety, depression Somatic problems (Indicative of interpersonal and social difficulties)

Maladi moun Sent sickness

Haiti

Humanly caused illness (envy of other’s success, hatred) Attractive, intelligent, and wealthy are at risk

Nervios

Latinos in the United States

Emotional distress Somatic disturbance Inability to function Headaches and brain aches

Shenjing shuairuo

Chinese

Weakness, emotions, excitement, nervous pain, sleep disturbances, 3:5 required

Susto

Some Latinos in United States, Central America, South America

Frightening event causing soul to leave body Unhappiness and sickness Difficulty in key social roles

Taijin kyofusho

Japanese

Interpersonal fear disorder Anxiety and avoidance of interpersonal situations Fear of inadequacy and offensiveness to others

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Part Three Nursing in Multicultural Health Care Settings

The NIMH, the world’s largest and most influential funding agency for mental health research, and a key supporter and funding agency for research for the previous editions of the DSM, withdrew support for the DSM-V. In fact, the NIMH stated that the agency would no longer fund research based strictly on the DSM criteria. The DSM criteria have been used for many years to diagnose and treat clients with mental health illness, as well as serving as the basis for insurance reimbursement payments. Thomas R. Insel, M.D., the Director of the NIMH, identified that a major weakness of the DSM was “its lack of validity.” He further identified the DSM diagnoses “are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure” (Lane, 2013).

Culture-Bound Syndromes Although culture-bound syndromes have been removed from the DSM-V, they are presented here as still existent within the cultures identified and in the mental health system. Various mental health symptoms are experienced by people all over the world. Cultural meanings, beliefs, and practices regarding specific symptoms may vary depending on one’s culture and socioeconomic status within the culture. Although specific identifying terms, manifestations, and meanings within

different cultures may vary, a diagnosis such as depression is similar around the world. However, cultural values, beliefs, and practices shape how various groups interpret symptoms, identify causality, and determine appropriate treatment. In contrast, culture-bound syndromes, also called folk illnesses,

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