A PATIENT’S BEHAVIOR is influenced in part by his cultural background.

However,
although certain attributes and attitudes are associated with particular cultural groups as
described in the following pages, not all people from the same cultural background
share the same behaviors and views.

When caring for a patient from a culture different from your own, you need to be aware
of and respect his cultural preferences and beliefs; other- wise, he may consider you
insensitive and indifferent, possibly even incompetent. But beware of assuming that all
members of any one culture act and behave in the same way; in other words, don’t
stereotype people. The best way to avoid stereotyping is to view each patient as an
individual and to find out his cultural preferences. Using a culture assessment tool or
questionnaire can help you discover these and document them for other members of
the health care team. Keeping the caveat about stereotyping in mind, let’s take a look at
how people from various cultural groups tend to perceive some common behaviors and
key health care issues.

Space and distance

People tend to regard the space immediately around them as an extension of

themselves. The amount of space they prefer between themselves and others to feel
comfortable is a culturally determined phenomenon. Most people aren’t conscious of
their personal space requirements—it’s just a feeling about what’s comfortable for them
—and you may be unaware of what people from another culture expect. For example,
one patient may perceive your sitting close to him as an expression of warmth and
caring; another may feel that you’re invading his personal space.
Research reveals that people from the United States, Canada, and Great Britain require
the most personal space between themselves and others. Those from Latin Ameri- ca,
Japan, and the Middle East need the least amount of space and feel comfortable
standing close to others. Keep these general trends in mind if a patient tends to position
himself unusually close or far from you and be sensitive to his preference when giving
nursing care.

Eye contact
Eye contact is also a culturally determined behavior. Al- though most nurses are taught
to maintain eye contact when speaking with patients, people from some cultural
backgrounds may prefer you don’t. In fact, your strong gaze may be interpreted as a
sign of disrespect among Asian, American Indian, Indo-Chinese, Arab, and Ap-
palachian patients who feel that direct eye contact is im- polite or aggressive. These
patients may avert their eyes when talking with you and others they perceive as au-
thority figures.
An American Indian patient may stare at the floor during conversations. That’s a cultural
behavior conveying respect, and it shows that he’s paying close attention to you. Like-
wise, a Hispanic patient may maintain downcast eyes in deference to someone’s age,
sex, social position, economic status, or position of authority. Being aware that whether
a person makes eye contact may reflect his cultural back- ground can help you avoid
misunderstandings and make him feel more comfortable with you.

Time and punctuality

Attitudes about time vary widely among cultures and can be a barrier to effective
communication between nurses and patients. Concepts of time and punctuality are
culturally determined, as is the concept of waiting.
In U.S. culture, we measure the passing and duration of time using clocks and watches.
For most health care providers in our culture, time and promptness are extreme- ly
important. For example, we expect patients to arrive at an exact time for an appointment
—despite the fact that they may have to wait for health care providers who are running
late.
For patients from some other cultures, however, time is a relative phenomenon, and
they may pay little attention 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 but not hours of the day. Time may also be marked according to
traditional times for meals, sleep, and other routine activities or events.
In some cultures, the “present” is of the greatest impor- tance, and time is viewed in
broad ranges rather than in terms of a fixed hour. Being flexible in regard to sched- ules
is the best way to accommodate these differences.
Value differences also may influence someone’s sense of time and priorities. For
example, responding to a fami- ly matter may be more important to a patient than meet-
ing a scheduled health care appointment. Allowing for these different values is essential
in maintaining effective nurse/patient relationships. Scolding or acting annoyed when a
patient is late would undermine his confidence in the health care system and might
result in more missed appointments or indifference to patient teaching.

Touch
The meaning people associate with touching is cultur- ally determined to a great
degree. In Hispanic and Arab cultures, male health care providers may be prohibited
from touching or examining certain parts of the female body; similarly, females may be
prohibited from caring for males. Among many Asian Americans, touching a person’s
head may be impolite because that’s where they believe the spirit resides. Before
assessing an Asian American patient’s head or evaluating a head injury, you may need
to clearly explain what you’re doing and why.
Always consider a patient’s culturally defined sense of modesty when giving nursing
care. For example, some Jewish and Islamic women believe that modesty requires
covering their head, arms, and legs with clothing. Respect their tradition and help them
remain covered while in your care.

Communication
In some aspects of care, the perspectives of health care providers, patients, and
families may be in con- flict. One example is the issue of informed consent and full
disclosure. For example, you may feel that each patient has the right to full disclosure
about his disease and prognosis and advocate that he be in- formed. But his family,
coming from another culture may believe they’re responsible for protecting and sparing
him from knowledge about a serious illness. Similarly, patients may not want to know
about their condition, expecting their relatives to “take the bur- den” of that knowledge
and related decision making. If so, you need to respect their beliefs; don’t just de- cide
that they’re wrong and inform the patient on your own.
You may face similar dilemmas when a patient refus- es pain medication or treatment
because of cultural or religious beliefs about pain or his belief in divine inter- vention or
faith healing. You may not agree with his choice, but competent adults have the legal
right to refuse treatment, regardless of the reason. Thinking about your beliefs and
recognizing your cultural bias and world view will help you understand differences and
resolve cultural and ethical conflicts you may face. But while caring for this patient,
promote open dia- logue and work with him, his family, and health care providers to
reach a culturally appropriate solution.
For example, a patient who refuses a routine blood transfusion might accept an
autologous one.

Holidays
People from all cultures celebrate civil and religious holidays. Get familiar with major
holidays for the cul- tural groups your facility serves. You can find out more about
various celebrations from religious orga- nizations, hospital chaplains, and patients
themselves. Expect to schedule routine health appointments, diag- nostic tests, surgery,
and other major procedures to avoid such holidays. If their holiday rituals aren’t
contradicted in the health care setting, try to accom- modate them.

Diet
The cultural meanings associated with food vary widely. For example, sharing meals
may be associated with solidifying social or business ties, celebrating life events,
expressing appreciation, recognizing accom- plishment, expressing wealth or social
status, and val- idating social, cultural, or religious ceremonial func- tions. Culture
determines which foods are served and when, the number and frequency of meals, who
eats with whom, and who gets the choicest portions. Cul- ture also determines how
foods are prepared and served, how they’re eaten (with chopsticks, fingers, or forks),
and where people shop for their favorite food.
Religious practices may include fasting, abstaining from selected foods at particular
times, and avoiding certain medications, such as pork-derived insulin. Practices may
also include the ritualistic use of food and beverages. (See Prohibited Foods and
Beverages of Selected Religious Groups.)
Many groups tend to feast, often with family and friends, on selected holidays. For
example, many Christians eat large dinners on Christmas and Easter and traditionally
consume certain high-calorie, high-fat foods, such as sea- sonal cookies, pastries, and
candies. These culturally based dietary practices are especially significant when caring
for patients with diabetes, hypertension, gastrointestinal disor- ders, and other
conditions in which dietary modifications are important parts of the treatment regimen.

Biologic variations
Along with psychosocial adaptations, you also need to consider culture’s physiologic
impact on how patients respond to treatment, particularly medications. Data have been
collected for many years regarding different effects some medications have on persons
of diverse ethnic or cultural origins. For example, because of ge- netic predisposition,
patients may metabolize drugs in different ways or at different rates. For one patient, a
“normal dose” of a medication may trigger an adverse reaction; for another, it might not
work at all. (Think of how antihypertensive drugs don’t work as well for African
Americans as they do for white ones.) Cultur- ally competent medication administration
requires you to consider ethnicity and related factors—including values and beliefs
about herbal supplements, dietary intake, and genetic factors that can affect how effec-
tive a treatment is and how well patients adhere to the treatment plan.

Environmental variations
Various cultural groups have wide-ranging beliefs about man’s relationship with the
environment. A patient’s attitude toward his treatment and prognosis is influ- enced by
whether he generally believes that man has some control over events or whether he’s
more fatal- istic and believes that chance and luck determine what will happen. If your
patient holds the former view, you’re likely to see good cooperation with health care
regimens; he’ll see the benefit of develop- ing behavior that could improve his health.
Some American Indians and Asian Americans are likely to fall into this category.
In contrast, Hispanic and Appalachian patients tend to be more fatalistic about nature,
health, and death, feeling that they can’t control these things. Patients who believe that
they can’t do much to improve their health through their actions may need more
teaching

Recipe for success

Clearly, you can’t take a “cookbook” approach to car- ing for patients based on their
cultural heritage or background. Transcultural nursing means being sensi- tive to
cultural differences as you focus on individual patients, their needs, and their
preferences. Show your patients your respect for their culture by asking them about it,
their beliefs, and related health care practices. They’ll respond to your honesty and
inter- est, and most will be happy to tell you more about their culture.