Lesson 1, Topic 1
In Progress

Culturally Related Assessments

May 3, 2021

To care for a patient from a different culture, the nurse should assess the patient’s beliefs. Patients cannot be expected to accept care and health teaching if they do not believe that the practices will help them to recover.

Brief examples of specific beliefs and practices of some cultures are presented later in this chapter. Stereotyping an individual according to common cultural practices should be avoided. The individual may or may not accept all of the practices within a culture or subculture.
When the nurse assesses a patient, several areas should be explored: communication, space, time, social organization, religious beliefs, health practices, and biologic variations.

Communication

The most apparent communication variation is the language spoken. Whether the nurse and the patient can understand each other must be determined. When patients do not understand what is being said, they sometimes say yes or nod the head nonetheless, giving the mistaken impression of agreeing with the nurse. Many people do this to avoid embarrassment or to be polite. The nurse must not assume that the patient or the family understands.

Sometimes, the patient understands some English, or the nurse speaks some of the patient’s language. If patients have a poor grasp of English, they may tire quickly when trying to understand what is being said. Questions and directions should be kept brief and simple. It is better to go back later and provide more information than to give long explanations. Sometimes, the patient’s ability to read written English is better than his or her speaking ability. In such cases, the patient benefits from written explanations accompanied by pictures when possible.

The preferred approach is the use of a professional interpreter. Many health care facilities have employees on call to translate when a language barrier exists. Availability of a translator may require that the nurse work with a family member who is able to translate. Note that this intervention impacts confidentiality surrounding the patient’s care. The patient must understand essential information such as why care is being given and why medications are ordered. The nurse’s responsibility is to make every effort to provide this information to the patient. Use of effective communication techniques is beneficial as the nurse cares for patients from different cultures (Box 6-3).

Even among English-speaking people, different cultural groups assign different meanings to the same words. For example, a person from the United Kingdom may say he is going to take the “lift.” An American is not necessarily going to understand that this refers to an elevator ride. Within the United States, the variety of regional accents further complicates the communication picture. People from different areas of the country (e.g., people from the North and the South) often struggle to understand each other because of the different accents or regional expressions they use. Some cultural or regional groups speak very rapidly, which adds to the difficulty of understanding.

Other cultural patterns also play a role in communication. In some cultural groups, many family members commonly accompany a person to the health care setting. Large groups of family members tend to make communication difficult. They sometimes all try to assist by answering at once. Or perhaps, when in the presence of strangers, a person from another group only answers direct questions and thus appears rude or uncommunicative. Unfortunately, the appearance of rudeness is a common byproduct of a cross-cultural mismatch in communication. Sometimes, a person speaks more loudly to emphasize a point out of the mistaken belief that this helps the hearer understand better. In fact, it often has the opposite effect of the one desired. Members of some cultures interpret the raised voice as rudeness or aggression and shut out the sound altogether.

Consider, in contrast, the use of silence. Silence indicates many things to many cultures: a lack of understanding, stubbornness, apprehension, discomfort, agreement, disagreement, respect, or disdain. In some cultures, the presence of silence may result in feelings of discomfort and anxiety. It is not uncommon for people to make attempts to fill periods of silence with conversation. Among American Indian, Chinese, and Japanese cultures, silence is sometimes used to allow the listener to consider what the speaker has said before continuing. Members of other cultures, such as Russians, the French, and the Spanish, tend to become silent to indicate consensus between parties. In Asian cultures, people often use silence as a sign of respect, especially to elders (see Cultural Considerations box). In contrast, other cultures, such as those of Mexican descent, may use silence when they disagree with a person of authority.

Nonverbal communication is usually expressed through body language. Some groups are more comfortable than others with touching or maintaining eye contact. Touch is particularly culturally or regionally related. In parts of the United States, many people

consider even casual touching inappropriate. In other regions, casual touch and embracing between acquaintances is the norm. Recent immigrants from England and Germany are even less likely to touch each other in public or allow casual touching by strangers. Spanish, French, Italian, Jewish, and South American individuals are likely to be much more comfortable about touching each other and being touched.

Eye contact also has significant cultural interpretations. Many people in the United States regard maintaining eye contact as an indication of openness, interest in others, attentiveness, and honesty. Lack of eye contact is thus interpreted as a sign of shyness, humility, guilt, embarrassment, rudeness, thoughtlessness, or dishonesty. Other cultures have various other reasons for not maintaining eye contact. Some Asian cultures and American Indians relate eye contact to impoliteness or an invasion of privacy. Certain East Indian cultures avoid eye contact with people of lower or higher socioeconomic classes. Among some Appalachian people, maintaining eye contact indicates hostility or aggressiveness.

Assessing the communication variables of a patient from another culture is important. First, an assessment of cultural factors is performed, and then the nurse has to respond appropriately. Every effort should be made to communicate with others at their personal level of comfort to establish good rapport. If the patient is from a culture that avoids eye contact, try to look away when talking with the patient. If touch is unacceptable among casual acquaintances, avoid patting the shoulder or touching a hand when talking with the patient. The nurse should be sensitive to any difficulty a patient is having with the more intimate touching that inevitably accompanies many nursing interventions.

When the nurse violates cultural beliefs and practices, it is likely to interfere with establishing a therapeutic relationship with the patient and the patient’s family. Do not expect to completely adjust individual personal cultural practices, but make an effort to understand and accept the differences among practices in various cultures. Do not judge the patient’s behavior according to personal practices.

Space

Cultural interpretation of space varies and is an important element of assessment. Cultures assign different comfort areas to personal space. Generally, in Western cultures, people in a casual or public setting are most comfortable when they can maintain 3 to 6 feet between them during a conversation (Giger, 2012). Closer contact is reserved for more intimate relationships. Members of some cultures are accustomed to more close contact and sometimes inadvertently invade the space of a person from a Western culture. Occasionally, the need for personal space also manifests itself in a desire to use a certain space. For example, perhaps a resident in a nursing home always wishes to sit in a particular chair or in a specific part of the room. Another resident chooses to sit at the same table for each meal. If someone changes any of these arrangements, either of these residents may become upset.

Body movements are often culturally related. In the United States, certain gestures are generally understood by most longtime citizens. However, some commonly used gestures have the potential to offend someone from another culture. For example, a circle formed with the thumb and forefinger means “A-OK” in the United States. To someone from Brazil, this is an obscene gesture. Traditionally, Italian or Jewish people use more body movements to illustrate or emphasize what they are communicating than do individuals from Asian cultures. As noted previously, touch is used more commonly in some cultures than others (Giger, 2012).

Time

The measurement of time and the rhythms of people’s activities and interactions often have different meanings in various cultures. These different meanings have the potential to create some problems in the care of patients from other cultures. Traditional nursing practice emphasizes that medications and treatments are provided on a rigid schedule. The United States and many Northern European cultures generally give a high priority to being on time for appointments, and people typically expect everyone to follow this pattern. Japanese American culture also places emphasis on promptness and the adherence to fixed schedules, especially when meeting with a person who is regarded highly. People in many cultures believe that other concerns regarding time are more important. In Eastern cultures, including Chinese, East Indian Hindu, Filipino, and Korean, schedules and time are much more flexible concepts. Some Asians spend a lot of time getting to know someone and view abrupt endings to a conversation as rude. Mexican Americans may be late for an appointment because they focus more on a current activity and are less concerned about a previously planned meeting. According to Giger (2012), this concept, known as “elasticity,” implies that future activities are possible to recover but not present ones. If these cultural differences are not understood, the nurse may feel angry when a patient is late for an appointment, fails to come at all, or does not follow therapeutic schedules.

Perception of time or time orientation also varies among cultures. Many people in the United States tend to be future oriented. Present actions are taken based on a future outcome. An example is a person who takes medication to treat hypertension to prevent illness. Among members of other cultures, notably African American or black, Hispanic, and American Indian, individuals tend to be more present oriented. Sometimes, like people described previously who prolong a current encounter rather than rushing off to be on time for another one, a present-oriented person chooses to satisfy a current, more urgent need rather than prepare for a less immediate one that is some time away. A pregnant woman, for instance, may miss her own health care provider’s appointments to take care of her family; if her older child needs a ride to school, the mother skips the appointment and drives the child. A patient with this belief system is often difficult to encourage to follow through on treatment for a chronic illness. Such a patient perhaps views the cost of a medication for hypertension to prevent future problems as an optional expense. Paying the rent or buying food for the family is a current need that takes precedence.

Social Organization

Cultural behavior is socially acquired, not genetically inherited. How nurses react to members of other cultures reflects an internalized response that is part of their own culture. Often, we are not aware of the strong impact these patterns of cultural behavior have each day in our lives. We may behave in a hostile manner toward a person of a particular ethnic group or a person with a different skin color merely because of an inner, culture-related belief. It is important to recognize these biases and to deal with them rationally. Understanding other cultures, and that one culture is not superior over another, helps to overcome prejudices that have nothing to do with an individual.

Self concept is also influenced by culture and cultural identity. Individuals view themselves as part of a particular social group. They describe themselves in terms such as “African American” or “black,” “Hispanic,” “German American,” “Irish Catholic,” or “Texan.” Clearly, these descriptions vary greatly. What is important is to understand how the person sees herself or himself. A good cultural assessment takes this self-description into account.
The varying social structures within a culture also have an impact on how individuals and families function. Some cultures are patriarchal, and the men (often the oldest) make most of the decisions. In a culture that is matriarchal, the women usually make the decisions about health care, provide the care, and discipline the children. The structure of the family is important to determine in a health care setting. For example, a family in a patriarchal society sometimes delays any decision making regarding health care for one of the family members until the oldest man in the family is consulted. Another family, in a matriarchal society, expects the women to give care to a family member in the hospital.

The description of family may differ among cultures. Some family structures are based on biologic relationships. Others are based on meeting basic needs for family by forming a group among unrelated individuals. Knowledge of the family structure assists the nurse to better understand the patient. A common mistake is to assume that every family is a traditional nuclear family. In fact, this family structure is becoming increasingly rare. Knowing who the patient depends on for comfort and decision making and how the patient describes the family is more important.

Religious Beliefs and Health Care

Religious beliefs are frequently entwined with cultural beliefs. Some cultures expect all members to adhere to a particular religion. In these societies, religious and cultural beliefs are difficult to separate. In the United States, wide variations are found in religious practices (Box 6-4). In addition, as people from varying cultures intermarry, religious practices also become more varied.

Data for religious affiliations are not collected by the U.S. Bureau of the Census, making an accurate way to determine the numbers of followers of the various religions in the United States difficult. Despite the inability to quantify the religious preferences in the country, nursing care clearly is affected by patients’ religious beliefs and practices. The nurse must be aware of and open to the wide range of such beliefs to ensure that care provided is sensitive to the needs of individual patients.

Assessment of family and social organization becomes increasingly more complicated as our society brings together more and more diverse cultures. It is not unusual for a family to be bicultural or biracial or to follow two different faith practices. Be constantly on

guard against making assumptions about patients based on appearance, language, ethnic origin, names, or religious practices. Assessment of the individual and family on their own terms helps the nurse to understand the person.

Health Practices

For many years, the belief popular in the United States was that modern biomedical health care was the best and only way to treat diseases. Today, many health care providers still find it difficult to believe that any alternative therapies are as effective as the biomedical methods that they have seen used for many years. In recent years, a variety of alternative health services such as folk remedies, holistic therapies, and spiritual interventions has aroused attention in the traditional medical community. Scientific research is being done in these areas to determine the effectiveness of these methods. Some are now accepted more readily and are sometimes used concurrently with biomedical methods (see Chapter 17).

Several factors are driving this change in thinking about health care. Some of the long-established methods have become less effective, notably antibiotics used to treat infections. A number of complementary therapies and folk remedies have been shown to be effective in treatment of certain diseases. More health care providers with varied backgrounds and beliefs about health and illness now practice in the United States. Increasing mobility and use of electronic media have resulted in more sharing of information, which has promoted diversity. Movement of cultural groups to new areas provides exposure of new information and methods of managing health issues (Figure 6-1). Some health care practices among cultures are benign and ineffective, and others are therapeutic and useful. The concern lies with those that can pose danger to health and wellness. It is important to allow patients to follow practices that are in accordance with their cultural identity and personal beliefs when they are receiving health care in the traditional health care system, without allowing the effectiveness of either approach to be compromised. The characteristics of four basic concepts of health beliefs are described in Table 6-2. For many years, Western cultures have almost universally used the biomedical method of

treating illness and maintaining health. Folk medicine encompasses many different traditions in cultures around the world. It often includes native healers who use a variety of methods in treating disorders (Figure 6-2). At times, this belief system also incorporates religious practices and magic. Within this system, methods are used to manipulate the environment to improve health.
Do not assume that patients born in the United States accept the biomedical view of health care. Individuals in many subcultures of the United States practice folk medicine. These people sometimes avoid seeking care from health care providers or practice folk medicine while also receiving traditional care.
As our medical system becomes more open to considering a variety of alternative health care systems, the nurse is expected to understand the relationships between different views. Assessing the health practices of patients is an important part of achieving this understanding. If individual beliefs are discussed openly, the patient will probably be more willing to tell the nurse about using other health care methods in addition to those directed by the health care provider. Be aware that this information has to be shared with the doctor to prevent conflicts among treatments.
Biological Variations

Cultural groups are identified in a variety of ways. In some instances, the members share strong biologic characteristics. This is especially true if the cultural group is primarily made up of individuals from a particular race or geographic region. When assessing these individuals, include these characteristics. Some of the obvious ones are body structure, skin color, and hair color and texture. For example, the nurse probably expects a cultural group from the Scandinavian region to have many people with blond hair and blue eyes. Asians are likely to have straight, coarse, dark hair. More important to health care practice, is a family history of diseases that are common within the ethnic group. Some diseases, such as sickle cell anemia, are more frequently found among those of African ancestry. Other diseases, such as diabetes, asthma, or heart disease, tend to be more prevalent among certain cultural groups. Even with consideration of diet, diabetes occurs more frequently among American Indians.
Another important health consideration is the effect of culturally determined dietary practices. Many traditional foods are high in saturated fats, sodium, and sugar. If these foods are eaten frequently, they have the potential to affect patients’ health and the health of their family members. In some cases, members of some cultural groups have dietary deficiencies caused by low intake of protein, complex carbohydrates, and fresh fruits and vegetables. When assessing the patient, include questions to determine whether the patient follows cultural dietary practices or eats a more general diet. Several diverse cultural groups (Chinese, Korean, Mexican, Puerto Rican, and Vietnamese) have beliefs that diseases and foods are classified as either “hot” or “cold.” The diet is adjusted according to the perceived balance, and thus, diseases are treated with the proper foods. This practice sometimes leads to a failure to meet basic nutritional needs and to dietary problems (see Chapter 21).