Transcultural Nursing


Culturally Mediated Characteristics

Nurses should be aware that patients act and behave in a variety of ways, in part because of the influence of culture on behaviors and attitudes. However, although certain attributes and attitudes are frequently associated with particular cultural groups, it is important to remember that not all people from the same cultural background share the same behaviors and views. Although the nurse who fails to consider a patient’s cultural preferences and beliefs is considered insensitive and possibly indifferent, the nurse who assumes that all members of any one culture act and behave in the same way runs the risk of stereotyping people. The best way to avoid stereotyping is to view each patient as an individual and to find out the patient’s cultural preferences.

  1. SPACE AND DISTANCE. People tend to regard the space in their immediate vicinity as an extension of themselves. The amount of space they need between themselves and others to feel comfortable is a culturally determined phenomenon. Because nurses and patients usually are not consciously aware of their personal space requirements, they frequently have difficulty understanding different behaviors in this regard. For example, one patient may perceive the nurse sitting close to him or her as an expression of warmth and care; another patient may perceive the nurse’s act as a threatening invasion of personal space. Research reveals that people from the United States, Canada, and Great Britain require the most personal space between themselves and others, whereas those from Latin America, Japan, and the Middle East need the least amount of space and feel comfortable standing close to others. If patients appear to position themselves too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, patients should be permitted to assume a position that is comfortable to them in terms of personal space and distance. Because a significant amount of communication during nursing care requires close physical contact, the nurse should be aware of these important cultural differences and consider them when delivering care.
  2. EYE CONTACT. Eye contact is also a culturally determined behavior. Although most nurses have been taught to maintain eye contact when speaking with patients, some people from certain cultural backgrounds may interpret this behavior differently. Some Asians, Native Americans, Indo-Chinese, Arabs, and Appalachians, for example, may consider direct eye contact impolite or aggressive, and they may avert their own eyes when talking with nurses and others whom they perceive to be in positions of authority. Some Native Americans stare at the floor during conversations, a cultural behavior conveying respect and indicating that the listener is paying close attention to the speaker. Some Hispanic patients maintain downcast eyes as a sign of appropriate deferential behavior toward others on the basis of age, gender, social position, economic status, and position of authority. Being aware that whether a person makes eye contact may be a result of the culture from which they come will help the nurse understand a patient’s behavior and provide an atmosphere in which the patient can feel comfortable.
  3. TIME. Attitudes about time vary widely among cultures and can be a barrier to effective communication  between nurses and patients. Views about punctuality and the use of time are culturally determined, as is the concept of waiting. Symbols of time, such as watches, sunrises, and sunsets, represent methods for measuring the duration and passage of time. For most health care providers, time and promptness are extremely important. For example, nurses frequently expect patients to arrive at an exact time for an appointment, despite the fact that the patient is often kept waiting by health care providers who are running late. Health care providers are likely to function according to an appointment system in which there are short intervals of perhaps only a few minutes. For patients from some cultures, however, time is a relative phenomenon, with little attention paid to the exact hour or minute. Some Hispanic people, for example, consider time in a wider frame of reference and make the primary distinction between day and night. Time may also be determined according to traditional times for meals, sleep, and other activities or events. For people from some cultures, the present is of the greatest importance, and time is viewed in broad ranges rather than in terms of a fixed hour. Being flexible in regard toschedules is the best way to accommodate these differences. Value differences also may influence a person’s sense of priority when it comes to time. For example, responding to a family matter may be more important to a patient than meeting a scheduled health care appointment. Allowing for these different views is essential in maintaining an effective nurse-patient relationship. Scolding or acting annoyed at a patient for being late undermines the patient’s confidence in the health care system and might result in further missed appointments or indifference to health care suggestions.
  4. TOUCH. The meaning people associate with touching is culturally determined to a great degree. In some cultures (eg, Hispanic, Arab), male health care providers may be prohibited from touching or examining certain parts of the female body. Similarly, it may be inappropriate for females to care for males. Among many Asian Americans, it is impolite to touch a person’s head because the spirit is believed to reside there. Therefore, assessment of the head or evaluation of a head injury requires alternative approaches. The patient’s culturally defined sense of modesty must also be considered when providing nursing care. For example, some Jewish and Islamic women believe that modesty requires covering their head, arms, and legs with clothing.
  5. COMMUNICATION. Many aspects of care may be influenced by the diverse cultural perspectives held by the health care providers, patient, family, or significant others. One example is the issue of informed consent and full disclosure. In general, a nurse may argue that patients have the right to full disclosure about their disease and prognosis and may feel that advocacy means working to provide that disclosure. Family members of some cultural backgrounds may believe it is their responsibility to protect and spare the patient, their loved one, the knowledge of a terminal illness. Similarly, patients may, in fact, not want to know about their condition and may expect their family members to “take the burden” of that knowledge and related decision-making. The nurse should not decide that the family or patient is simply wrong or that the patient must know all details of his or her illness. Similar concerns may be noted when patients refuse pain medication or treatment because of cultural beliefs regarding pain or belief in divine intervention or faith healing. Determining the most appropriate and ethical approach to patient care requires an exploration of the cultural aspects of these situations. Self-examination by the nurse and recognition of one’s own cultural bias and world view, as discussed earlier, will play a major part in helping the nurse to resolve cultural and ethical conflicts. The nurse must promote open dialogue and work with the patient, family, physician, and other health care providers to reach the culturally appropriate solution for the patient.
  6. OBSERVANCE OF HOLIDAYS. People from all cultures celebrate civil and religious holidays. Nurses should familiarize themselves with major holidays for members of the cultural groups they serve. Information about these important celebrations is available from various sources, including religious organizations, hospital chaplains, and patients themselves. Routine health appointments, diagnostic tests, surgery, and other major procedures should be scheduled to avoid those holidays a patient identifies as significant. Efforts should also be made to accommodate patients and family or significant others, when not contraindicated, as they perform holiday rituals in the health care setting.
  7. DIET. The cultural meanings associated with food vary widely but usually include one or more of the following: relief of hunger; promotion of health and healing; prevention of disease or illness; expression of caring for another; promotion of interpersonal closeness among individuals, families, groups, communities, or nations; and promotion of kinship and family alliances. Food may also be associated with solidification of social ties; celebration of life events (eg, birthdays, marriages, funerals); expression of gratitude or appreciation; recognition of achievement or accomplishment; validation of social, cultural, or religious ceremonial functions; facilitation of business negotiations; and expression of affluence, wealth, or social status. Culture determines which foods are served and when they are served, the number and frequency of meals, who eats with whom, and who is given the choicest portions. Culture also determines how foods are prepared and served; how they are eaten (with chopsticks, hands, or fork, knife, and spoon); and where people shop for their favorite food items (eg, ethnic grocery stores, specialty food markets). Religious practices may include fasting (eg, Mormons, Catholics, Buddhists, Jews, Muslims), abstaining from selected foods at particular times (eg, Catholics abstain from meat on Ash Wednesday and on Fridays during Lent), and considerations for medications (eg, Muslims may prefer to use non-pork-derived insulin). Practices may also include the ritualistic use of food and beverages (eg, Passover dinner, consumption of bread and wine during religious ceremonies). Many groups tend to feast, often in the company of family and friends, on selected holidays. For example, many Christians eat large dinners on Christmas and Easter and consume other traditional high-calorie, high-fat foods, such as seasonal cookies, pastries, and candies. These culturally-based dietary practices are especially significant in the care of patients with diabetes, hypertension, gastrointestinal disorders, and other conditions in which diet plays a key role in the treatment and health maintenance regimen.
  8. BIOLOGIC VARIATIONS. Along with psychosocial adaptations, nurses must also consider the physiologic impact of culture on patient response to treatment, particularly medications. Data have been collected for many years regarding differences in the effect some medications have on persons of diverse ethnic or cultural origins. Genetic predispositions to different rates of metabolism cause some patients to be prone to overdose reactions to the “normal dose” of a medication, while other patients are likely to experience a greatly reduced benefit from the standard dose of the medication. An antihypertensive agent, for example, may work well for a white male client within a 4-week time span but may take much longer to work or not work at all for an African-American male patient with hypertension. General polymorphism—variation in response to medications resulting from patient age, gender, size, and body composition—has long been acknowledged by the health care community. Culturally competent medication administration requires that consideration of ethnicity and related factors such as values and beliefs regarding the use of herbal supplements, dietary intake, and genetic factors can affect the effectiveness of treatment and compliance with the treatment regimen.



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