Chapter 6:Culture and Ethnicity

Carolyne Richardson-Phillips, MS, RN

PNU 145

Fall 2015

Pages 72 – 85

Learning OutcomesBy the end of the section, the PN student will be able to:1.Differentiate culture, race, and ethnicity & describe characteristics of each2.Discuss factors that interfere with perceiving others as individuals3.Discuss the term anglicized and state examples of U.S. cultural characteristics4.Define subculture, list four major subcultures in the US, describe characteristics of each5.List and describe the differences between various subcultural groups as they relate to providing culturally sensitive care6.List ways in which people from subcultural groups differ from Anglo-Americans7.Discuss biologic characteristics & physiologic enzymes variations8.Identify health beliefs & practices9.Explain transcultural nursing & List the aspects of transcultural nursing10.State nursing skills needed to provide transcultural nursing care

Culture

• Values, beliefs, practices of a particular group• Incorporates attitudes & customs

learned through socialization with others

• Includes-language, styles of communication, traditions, religion, art, music, dress, health beliefs, practices

• Passed on from generation to the next• Culture is learned from birth

• Shared by members of a group• Influenced by environment, technology & availability of

resources• Dynamic and ever changing

RACE

• Biologic variations-Genetically shared physical characteristics

• Nurses should not equate race with a particular cultural group

• Leads to two incorrect assumptions:• All people with common physical features share the same culture

• All people with physical similarities have cultural values, beliefs, & practices that differ from those of Anglo-Americans

Minority & Ethnicity• Minority: Groups of people who differ from dominant group in

cultural characteristics such as language, physical characteristics, and/or both

• Ethnicity: bond a person feels about country or place of ancestral origin whether or not person has lived outside the USA• Demonstrated by certain physical characteristics, giving

children ethnic names, ethnic clothing, foods, music, history• Culture Shock: bewilderment over behavior that is atypical of

their culture

Factors: Impact Perception of Individuals• Ethnicity - Stereotyping

• Fixed attitudes about all people who share a common characteristic

• Develop with regard to age, gender, race, sexual preference, ethnicity

• Preconceived ideas: usually unsupported by facts-tend to be neither real nor accurate

• Prevents seeing & accepting another person as unique

Generalizing & Ethnocentrism

• Generalizing: assumes that a person shares cultural characteristics with others of a similar background

• Suggests possible commonalities that may or may not be individually valid

• Nurse-obtain information that confirms or contradicts the original generalization

• Ethnocentrism: belief that your own ethnicity is superior to all others

• Manifested by treating everyone different as deviant and undesirable

Culture of United States

• See Table 6-1, Culturally diverse region

• US culture - Anglo-Americans -Anglicized-or English based

• Subcultures-unique cultural groups co-exist in dominant culture

• Four Major Subcultures:

• African Americans

• Asian Americans

• Hispanic Origin

• Native Americans

Transcultural Nursing

• Nurse Leader-Madeline Leininger

• Providing nursing care within the context of another’s culture

• Assessments of a cultural nature

• Acceptance of each client as an individual

• Knowledge of health problems that affect particular cultural groups

• Planning of care within the client’s health belief system to achieve the best health outcomes

• Nurses need to provide culturally sensitive care

• What is culturally competent care? Providing patients with health care that is sensitive to the values that emerge out of their particular ethnic or religious backgrounds

Cultural Assessment

• Nurse assesses

• Language- communication style

• Hygiene practices, feelings about modesty & accepting help from others

• Clothing or ornamentation

• Religion and religious practices

• Rituals of death and birth

• Family and gender roles

• Methods for making decisions

• Food habits-dietary restriction

• Health beliefs - medical practices

Nurse-Client Communication Assessment

• Silence-Listen

• Language & Communication

• Eye Contact

• Space and Distance

• Touch

• Emotional Expression

• Dietary Customs & Restrictions

• Time

• Beliefs concerning Illness

Language: Communication• Language primary way to share, gather information

• Inability to communicate interferes with sensitive cultural care

• Equal Access:

• Federal Law-Title IV of Civil Rights Act of 1994-people with limited English proficiency-an inability to speak, write, read, or understand English at a level that permits interacting effectively –entitled to same health care & social services as those who speak English fluently

• Joint Commission requires hospitals-provide effective communication for each client

• Required to use trained certified interpreters

Nurse-Client Communication• If nurse not bilingual

• Request interpreter• Look at client, not interpreter when asking questions• Use Web sites• Refer to an English/foreign language dictionary• Use cards/pictures• If someone understands a little English– speak slowly- clearly

not loudly, using simple words and short sentences; repeat without changing words

• Avoid technical terms/ slang words• Pantomime • Ask questions that require “Yes-No” answers• Give client time to respond- Be patient

Nurse - Client Communication (cont’d)• Cultural aspects

• Native Americans: tend to be private and hesitate to share information

• Interpret questions as prying or meddling• Believe that no other member can speak for someone else• Feel uncomfortable when items written down as they view oral as the

form of remembering• Nurse: be patient, if possible write notes after• African Americans: tend to hesitate to give information and may

mistrust medical establishment• Latinos: sit closely to interviewers, let interactions unfold slowly • May be embarrassed to ask person to speak slowly• Latino men-protective, authoritarian regarding women & children-

Expect to be consulted in decision making• Asian Americans: Respond with brief or more factual answers-little

elaboration- value simplicity, meditation, and introspection• May not openly disagree with authority figures

Cultural Assessment (cont’d)• Eye Contact

• Anglo-Americans: make & maintain eye contact• May offend Asian Americans or Native Americans• Believe lingering eye contact: invasion of privacy or sign of disrespect• Arabs: may misinterpret as being sexually suggestive

• Space & Distance • Closeness: comfort-support - may threaten other cultures-causes

discomfort• Asian Americans – prefer more than an arm’s length away• Provide explanations when close contact needed (care, procedures)

• Touch • Native Americans-strong handshake-offensive• Southeast Asia- head considered sacred- Only relatives can touch• Nurses/caregivers- ask permission before touching area• Area between female’s waist & knees private; should not be touched by

any other male other than husband; Note: If a male nurse-ask permission, explain, allow husband to

stay in room

Cultural Assessment (cont’d)• Emotional Expression

• Anglo & African Americans: express positive & negative feelings• Asian & Native Americans: control their feelings-expressions of

discomfort• Latino men- control feelings-expressions-if expressed –

interpreted as less manly• Machismo- men considered strong-deal with emotions privately

• Time • People view clock time, social time differently• Punctuality-may vary in some cultures

Nutritional Dietary Customs & Restrictions• Food: means of survival

• Choices may be dictated by cultural practices• Eating has social meaning relates to communal

togetherness, reward, celebration, punishment relief of stress

• Religious beliefs-practices may impose rules and restrictions based fasting & food preferences

• Nutrition Notes: dietary changes when move or changes made-some traditional foods less eaten; adopt American diet-sugar, salt, fat, calories-less fruits, fiber, vegetables eaten• Hispanics/central America: drink atole-heated mixture of masa harina

(corn meal); Piloncillo (Mexican brn sugar-cin, vanilla choc or fruit-trad celebration & comfort

• African Americans: may include greens, grits, corn bread, & beans-cooked in fat-Southern roots

• Asian Americans: rice & rice noodles, mixtures of beef, chick, fish, soybean products, boychoy cabbage, bean sprouts-flavors with-MSG, soy, oster, bean & fish sauce, peppers-foods salty & spicy

• Native Americans: fry bread from corn, meat, fish, chick, pigs, cattle

Dietary-Religious Beliefs• Orthodox Judaism

• Kosher meals- approved by a Rabbi

• Meat & Dairy –not eaten together-Usually No pork

• Catholics• May not eat meat on Fridays

during Lent• Church of Jesus Christ of

Latter-Day Saints (Mormonism) • Prohibited- coffee, tea,

alcohol

• Seventh Day Adventists • Vegetarian diet• No caffeine

• Muslims (Islam)• Pork & alcohol forbidden

• Buddhists, Hindus, Sikhs • Strict vegetarians

Beliefs Concerning Illness

• Three cultural views- explains illness or disease

• Biomedical or scientific perspective- Base beliefs about health and disease on research findings

• EX: micro-organisms cause disease

• Handwashing reduces infection

• Naturalistic or holistic perspective

• Humans and nature must be in balance-harmony to remain healthy

• Illness = an outcome of disharmony

• Asian Americans -Yin & Yang theory

• Balanced forces promote health

Beliefs Concerning Illness• Latinos: Hot-Cold theory

• Illness is an Imbalance between components of hot & cold attributes

• Magico & Religious perspective

• Cultural belief supernatural forces control disease, health

• Faith healing- spiritual rituals (shamans)-along with herbs

• Witchcraft/Voodoo

Beliefs Concerning Illness• Coining- (CAO GIO) –a common medical practice followed in

Southeast Asian community- as a treatment for symptoms such as a cough, cold, fever, headache• Heated ointments containing herbs or other ingredients, including

camphor, menthol, wintergreen, eucalyptus, peppermint, or cinnamon oils, are rubbed into chest, back or head

• A coin or the back of a spoon is then rubbed vigorously in a linear fashion for 15-20 minutes over the spine, along ribs, or head, until a reddened area appears.

• This practice is felt to release "bad wind". Minor burns may result, although usual presentation is as linear abrasions or bruising, which take a few days to resolve. Practice has been misidentified as child abuse in reports

Coining

Beliefs Concerning Illness

• Cupping- Chinese -helps facilitate release of heat and toxins from area. Before cups are applied, skin is often "prepped" with a hammer called a plum blossom. It has 7 very fine points that help open up the skin.

• Increases blood flow -provides a neurological stimulus

• Before placed on skin the inside air is quickly heated. Once cup is on skin the air cools which creates a vacuum. Suction helps restore blood flow to area, thus releasing the toxic by-products of metabolism that accumulate in areas of muscle pain. 

• After the cups have been removed, many of these red spots fade over several hours but several may bruise superficially giving the skin a "pepperoni" appearance for up to 7-10 days.

Cupping

Biologic & Physiologic Variations• Skin: for dark skin use natural or bright artificial light

• Best structures to inspect-palms of hands, feet, abdomen-least pigmentation

• All skin regardless of a person’s ethnic origin contains an underlying red tone-its absence or a lighter appearance-means pallor (anemia or inadequate oxygen)

• Color of lips, nail beds-common sites for assessing cyanosis in white people

• Conjunctiva & oral mucous membranes-provide more accurate data-Sclera –for jaundice

• Less obvious-on dark skin-rashes/bruising/inflammation• Hair & texture

• Inherited characteristic• Variations range from straight to curly

Assessment: Biologic (cont’d)

Skin

Keloids: irregular, elevated thick scars-common among dark skin clients

Biologic & Physiologic Variations (cont’d)

• Hypopigmentation & Hyperpigmentation

• Skin not uniform in color

• Hypopigmentation

• Skin becomes damaged-temporary redness-then fades to a lighter hue

• Vitiligo-disease-produces white irregular patches on skin- absence of melanin

Biologic & Physiologic Variations (cont’d)• Hyperpigmentation-Mongolian spots-from migration of

melanocytes into fetal epidermis

• Dark-blue areas on lower back, abdomen, thighs, shoulders, or arms of darkly pigmented infants & children

Three Inherited: Enzymatic Variations• Prevalent among various U.S. subcultures: Lactase Deficiency; G-6-

PD Deficiency; ADH Deficiency (alcohol dehydrogenase)• Lactase Deficiency- intolerance to dairy

• Lactase-digestive enzyme that converts lactose, the sugar in milk, into simpler sugars glucose & galactose

• Nurse: teaches the client and family:• Avoid milk, dairy products & packaged foods that list dry milk solids or whey• Use non-dairy creamers; drink lactaid• May use Kosher foods-these are prepared without milk• Obtain calcium from green leafy green vegetables, dates,

prunes, canned sardines, salmon, egg yolk, whole grains, dried peas and beans, calcium supplements

• Use liquid tube feeding formulas & bottle fed infants: prepared without milk

• S & S: cramps, intestinal gas, diarrhea 30 minutes after ingesting milk or foods w/ milk; may last 2-hrs

Enzymatic Variations: G6-PD • G-6-PD –enzyme helps (RBC) red blood cells to metabolize glucose

• RBCs vulnerable during stress-increases metabolic needs• RBCs destroyed at a greater rate-if new production not made

quickly-anemia develops• African Americans & Mediterranean countries lack this enzyme• Manifested in males-female carry and transmit faulty gene

• NURSE- Monitor Lab results, obtain medication history

ADH Deficiency• ADH-(alcohol dehydrogenase)

• Process of chemical reactions involving enzymes when alcohol is taken

• Breaks down alcohol into acetic acid & carbon dioxide• Asian American & Native Americans-metabolize alcohol at a

different rate than other groups D/T physiologic variations• Affected experience: vascular effects= flushing, rapid heart rate • Metabolites remain in body- are extremely toxic & cause organ

damage• Native Americans high rate of death from alcoholism

Disease Prevalence• Some diseases occur more often and in greater frequency among

subcultures than in general population• Sickle cell anemia• Hypertension (HTN)• Diabetes• Stroke• Chronic liver disease/cirrhosis

• Nurses: need to focus on health education, participate in community screenings, campaign for more equitable health services

Health Beliefs & Practices

• Folk medicine- health practices unique to a particular group of people

• Methods of disease prevention or treatment outside modern conventional practice

• Generally lay providers-rather than formally educated & licensed individuals give treatments• Curandero (Latino practitioner who is thought to have spiritual

and medicinal powers)• Shaman (holy man with curative powers)• Herbalist• Chiropractor

Curandero Shaman

Chiropractor

Herbalist & Herbs

Health Beliefs & Practices Cont.• Acupuncture

• Aromatherapy

• Spiritual healing

• Reiki

• Therapeutic touch

Religious Beliefs • Orthodox Judaism

• Sabbath• Autopsy & Burial

• Catholicism• Religious items• Birth control, abortion,

Baptism• Jehovah’s Witness

• Blood Transfusion• Seventh Day Adventists

• Strict dietary laws• Sabbath

• Christian Scientists• Prayer• May have lay practitioners

assist with healing

• Church of Jesus Christ of Latter-Day Saints (Mormonism)• Anointing of the sick• Certain liquids &

prescription meds• Muslims

• Ramadan & fasting• Orthodox Sikhs

• Hair• Hinduism

• Modesty & hygiene• Application of a pundra• Labor & delivery• Death & cleaning of body

Examples of Health Traditions, Model & Themes

Demonstrate Culturally Sensitive Nursing• Nurses:

• Learn-obtain knowledge of different cultures

• Learn to speak a second language

• Use culturally sensitive techniques to improve interactions

• Be familiar with physical differences

• Utilize accurate physical assessment techniques

• Learn or ask about cultural belief’s concerning health, illness, and techniques for healing

• Consult the client on ways to solve health problems

• Modify or gradually change unsafe practices

Demonstrate Culturally Sensitive Nursing• Nurses:

• Never verbally or nonverbally ridicule a cultural belief or practice

• Integrate helpful or harmless cultural rituals in the plan of care• Avoid removing religious items/clothes• Provide culturally preferred food• Advocate routine screening for diseases• Apologize if cultural traditions or beliefs are violated• Learn the social aspect of the client & family • Facilitate rituals by the person that the client identifies as a healer

within his or her belief system

Nursing Process• Assessing: pain, physical, psychosocial, emotional, spiritual,

dietary, communication, and cultural status

• Diagnosing: NANDA-nursing diagnoses

• Planning: form a nursing care plan with client that includes his-her cultural beliefs to maintain, protect, & restore health

• Implementing care: includes cultural preservation, accommodation, negotiation

• Evaluating: comprehensive assessment

References• Aromatherapy Retrieved 5/1/14 from web site:

http://en.wikipedia.org/wiki/Aromatherapy• Faith Healing Retrieved on 5/1/14 from web site:

http://en.wikipedia.org/wiki/Spiritual_Healing• Folk Medicine retrieved on 5/1/14 from web site:

http://en.wikipedia.org/wiki/Folk_medicine • Images: retrieved from web site:googleimages.com on June 12, 2015• Jenko, M., Raye, S. Transcultural Nursing Principles An Application

to Hospice Care. Retrieved 5/1/14 from web site: http://www.redorbit.com/news/health/1372127/transcultural_nursing_its_importance_in_nursing_practice/

• Reiki Retrieved on 5/1/14 from web site: http://www.reiki.org/faq/WhatIsReiki.html

• Therapeutic Touch Retrieved 5/1/14 from web site: http://en.wikipedia.org/wiki/Therapeutic_touch

• Timby, B. K. (2013) (10th ed.). Fundamental Nursing Skills and Concepts. Philadelphia: PA., Lippincott Williams & Wilkins

• U.S. Census Briefs. Retrieved on August 20, 2015 http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf