THE ABC’S OF TRANSCULTURAL NURSING

TRANSCULTURAL NURSING

Refers to the study and practice in nursing which is focused upon differences and similarities
among cultures with respect to human care, health and illness based upon the peoples’
cultural values, beliefs and practices and to use this knowledge to provide culturally specific
or culturally congruent nursing care.

GOAL
To provide culturally specific care.

CULTURE
Refers to norms and practices of a particular group that are learned and shared and guide
thinking, decisions and actions.

CULTURAL VALUES
Refers to the individuals’ desirable or preferred way of acting or knowing something that is
sustained over a period of time and which governs actions or decisions.

Culturally diverse nursing care

Refers to the variability of nursing approaches needed to provide culturally appropriate care
that incorporates an individual’s cultural values, beliefs and practices including sensitivity to
the environment from which the individual comes and to which the individual ultimately return.
(Leininger, 1985)

ETHNOCENTRISM
The perception that ones’ own way is best when viewing the world.

RACE
Refers to distinguishing physical features such as skin color, bone structure and blood
group.

ETHNOGRAPHY: The study of culture

WHO IS THE FILIPINO?

According to: Tomas Andres the Filipino is…

…The imponderable unity and uniqueness of diverse races, richness and

idiosyncrasies.

…The monument of the Malays, the Spaniards, the Americans, the Japanese, the Chinese,
the Hindus, the Dutch and the Englishman, all united into one.

F - aithful; Fiesta oriented

I - mitative
L - oving and tender (malambing)
I - ngenius
P - liant
I - nadequate initiative
N - o discipline
O - riented to: Kapalaran, kabuuan, kapayapaan

WHOLISTIC, NON -DUALISTIC AND SUBJECTIVE

CULTURAL COMPETENCE
Cultural competence, therefore is obtaining cultural information and then applying that
knowledge. This would require the nurse to have :

1. AN UNDERSTANDING OF OWN WORLD VIEW

2. FLEXIBILITY AND RESPECT FOR OTHERS’ VIEW POINT
3. A KNOWLEDGE OF CULTURALLY INFLUENCED HEALTH BEHAVIORS

EXAMPLES OF APPLICATIONS OF TRANSCULTURAL NURSING CONCEPTS

A – dministration of medications must take into consideration some of the patients’

beliefs and practices.

Examples:

 Catholics usually will fast on Ash Wednesday and Good Friday except for sick
patients
 Muslims will fast during Ramadan
 Jehovah’s witnesses-medications are acceptable to the extent necessary

B – e familiar with some diseases which are common in a specific race.

Examples:

• Africans - sickle cell anemia, hypertension

• Asians – osteoporosis
• Blacks – cervical cancer (female)
- prostate cancer (male)
• Jewish – breast cancer
• Whites – testicular cancer

C - ommunicate properly and be familiar with common communication practices

across cultures.

Examples:

• Asians – rarely communicate their need for analgesics since they were taught self-restraint.
• Hispanic women - discussions pertaining to the reproductive organs with male relatives or
health care providers are considered impolite
• Muslim women – prefer to talk to female doctors on matters related to reproductive
problems
D - dietary modifications must be considered when planning nursing care

Examples:

• Chinese – cold desserts (“YIN”) are served after surgery

• Europeans – main meal is served by midday and is usually followed by coffee
• Jewish – Kosher diet (no meat and dairy products at the same time)
• Muslim – Halal diet (no pork)

HISPANICS

- Present oriented society

- Most are Catholics
- Body plumpness is ideal
- Delivery of a baby is a woman’s job

MIDDLE EASTERN COMMUNITY

- Expect to receive treatment as soon as possible

- Majority are Muslims
- Emphasis on personal hygiene and a healthy diet
- Patients are told only the GOOD news about their disease
- Maybe embarrassed by questions about their sexual concerns.
- During Ramadan, many patients resist taking medications or eating during daytime.

BLACK AMERICAN COMMUNITY

- God is viewed as the source of both good health and serious illness

ASIANS

- A healthy body is a state of balance

1. Recognizing clinical differences among people of different ethnic and racial groups.
2. Communication
3. Ethics
4. Trust

Transcultural Nursing

In 1959, Madeleine Leininger, a nurse-anthropologist, used the term transcultural nursing
to define the philosophical and theoretical similarities between nursing and anthropology.

Culture specific refers to the “particularistic values, beliefs, and patterning of behavior that
tend to be special, ‘local,’ or unique to a designated culture and which do not tend to be shared
with members of other cultures” (Leininger, 1991, p. 491), whereas culture universal refers to
the commonalities of values, norms of behavior, and life patterns that are similarly held among
cultures about human behavior and lifestyles and form the bases for formulating theories for
developing cross-cultural laws of human behavior” (Leininger, 1991, p. 491).
 Leininger’s theory of culture care diversity and universality is the only one that gives
precedence to understanding the cultural dimensions of human care and caring. Leininger’s
theory is concerned with describing, explaining, and projecting nursing similarities and
differences focused primarily on human care and caring in human cultures. Leininger used
worldview, social structure, language, ethnohistory, environmental context, and the generic or
folk and professional systems to provide a comprehensive and holistic view of influences in
cultural care and well-being.

The following three models of nursing decisions and actions may be useful in providing
culturally congruent and competent care:

1. Culture care preservation and maintenance

2. Culture care accommodation and negotiation
3. Culture care repatterning and restructuring

Culture and the Formation of Values

According to Leininger (1995), value refers to a desirable or undesirable state of affairs. Values
are a universal feature of all cultures, although the types and expressions of values differ
widely. Norms are the rules by which human behavior is governed and result from the cultural
values held by the group. All societies have rules or norms that specify appropriate and
inappropriate behavior.
Individuals are rewarded or punished as they conform to or deviate from the established
norms, respectively. Values and norms, along with the acceptable and unacceptable
behaviors associated with them, are learned in childhood.

Every society has a dominant value orientation, a basic value orientation that is shared by the
majority of its members as a result of early common experiences.

 In the United States, the dominant value orientation is reflected in the dominant cultural
group, which is made up of white, middleclass Protestants, typically those who came to
the United States at least two generations ago from Northern Europe. Members of the
dominant cultural group are sometimes referred to as white Anglo-Saxon Protestants, a
term that reflects their ancestry and religious beliefs.
 In the United States, the dominant cultural group places emphasis on educational
achievement, science, technology, individual expression, democracy, experimentation,
and informality.
 Although an assumption is sometimes made that the term white refers to a
homogeneous group of Americans, a rich diversity of ethnic variation exists among the
many groups that constitute the dominant majority. Countries of origin include those of
Eastern and Western Europe (e.g., Ireland, Poland, Italy, France, Sweden, and Russia).
The origins of people in Canada, Australia, New Zealand, and South Africa can ultimately
be traced to Western Europe. Appalachians, Amish, Cajuns, and other subgroups are
also examples of whites who have cultural roots that are recognizably different from
those of the dominant cultural group.

Five questions related to values and norms:

1. What is the character of innate human nature (human nature orientation)?
2. What is the relationship of the human to nature (person–nature orientation)?
3. What is the temporal focus (i.e., time sense) of human life (time orientation)?
4. What is the mode of human activity (activity orientation)?
5. What is the mode of human relationships (social orientation)?

Human Nature Orientation

Innate human nature may be good, evil, or a combination of good and evil. Some believe
that life is a struggle to overcome a basically evil nature; they consider human nature to
be unalterable or able
to be perfected only through great discipline and effort. For others, human nature is
perceived as fundamentally good, unalterable, and difficult or impossible to corrupt.

According to Kohls (1984), the dominant U.S. cultural group chooses to believe the best
about a person until that person proves otherwise. Concern in the United States for
prison reform, social rehabilitation, and the plight of less fortunate people around the
world is a reflective perception of the belief in the fundamental goodness of human
nature. Recent scientific advances, such as advances in stem cell research and genome
studies, have necessitated consideration of ethical quandaries regarding human nature.
Questions emerge as to whether science can or should pursue activities that could alter
the basic human orientation.

Person–Nature Orientation

The following three perspectives examine the ways in which the person–nature
relationship is perceived:
• Destiny, in which people are subjugated to nature in a fatalistic, inevitable manner
• Harmony, in which people and nature exist together as a single entity
• Mastery, in which people are intended to overcome natural forces and to put them to
use for the benefit of humankind.

Time Orientation

People can perceive time in the following three ways:

• The focus may be on the past, with traditions and ancestors playing an important role
in the client’s life. For example, many Asians, Native Americans, East Indians, and
Africans hold particular beliefs about ancestors and tend to value long-standing
traditions. In times of crisis, such as illness, individuals with a values orientation
emphasizing the past may consult with ancestors or ask for their guidance or protection
during the illness.

• The focus may be on the present, with little attention paid to the past or the future.
Individuals with this focus are concerned with the current situation, and they perceive
the future as vague or unpredictable. Nurses may have difficulty encouraging such
individuals to
prepare for the future (e.g., to participate in primary prevention measures).
 • The focus may be on the future, with progress and change highly valued. Individuals
with a future focus may express discontent with the past and present. In terms of health
care, they may inquire about the “latest treatment” and the most advanced equipment
available for a particular problem.

Activity Orientation

There are different values orientations concerning activity. Philosophers have suggested
the following three perspectives:

 Being, in which a spontaneous expression of impulses and desires is largely

nondevelopmental in nature

 Growing, in which the person is self-contained and has inner control, including the
ability to self-actualize

 Doing, in which the person actively strives to achieve and accomplish something that
is regarded highly.

The person with a doing orientation often directs the doing toward achievement of an externally
applied standard, such as a code of behavior from a religious or ethical perspective. The Ten
Commandments, Pillars of Islam, Hippocratic Oath, and Nightingale Pledge are examples of
externally applied standards.

The dominant cultural value is action oriented, with an emphasis on productivity and being busy.
As a result of this action orientation, Americans have become proficient at problem solving and
decision making. Even during leisure time and vacations, many Americans value activity.

Social Orientation

Variations in cultural values orientation are also related to the relationships that exist with others.

Relationships may be categorized in the following three ways:

 Lineal relationships: These exist by virtue of heredity and kinship ties. These relationships
follow an ordered succession and have continuity through time.
 Collateral relationships: The focus is primarily on group goals, and family orientation is
important. For example, many Asian clients describe family honor and the importance of
working together toward an achievement of the group versus a personal goal.
 Individual relationships: These refer to personal autonomy and independence. Individual
goals dominate, and group goals become secondary.

Culture and the Family

The family remains the basic social unit in the United States. Although various ways exist to
categorize families, the following are commonly recognized types of constellations in which
people live together in society:
• Nuclear (i.e., husband, wife, and child or children)
• Nuclear dyad (i.e., husband and wife alone, either childless or with no children living at home)
• Single parent (i.e., either mother or father and at least one child)
• Blended (i.e., husband, wife, and children from previous relationships)
• Extended (i.e., nuclear plus other blood relatives)
• Communal (i.e., group of men and women with or without children)
• Cohabitation (i.e., unmarried man and woman sharing a household with or without children)
• Lesbian, gay, bisexual, transgender (i.e., same-gender couples, individuals that identify with
another gender, with or without children).

Culture and Socioeconomic Factors

No single indicator can adequately capture all facets of economic status for entire populations,
but measures such as median or average annual income, employment rate, poverty rate, and
net worth are most often used. The economic status of most individuals, especially children,
is better reflected by the pooled resources of family or household members than by their
individual earnings or incomes. Socioeconomic status (SES) is a composite of the economic
status of a family or unrelated individuals based on income, wealth, occupation, educational
attainment, and power. It is a means of measuring inequalities based on economic differences
and the manner in which families live as a result of their economic well-being. Most families
with racially or ethnically diverse backgrounds have a lower SES than the population at large,
with a few exceptions (e.g., Cuban Americans and subgroups of Asian Americans).

Culture and Nutrition

Long after assimilation into U.S. culture has occurred, many members of various ethnic groups
continue to follow culturally based dietary practices and eat ethnic foods. Often, neighborhood
food markets and ethnic restaurants are established soon after the arrival of a new group of
immigrants to the United States. The ethnic restaurant is commonly a place for members of a
cultural group to meet and mingle, and customers from the dominant cultural group may be of
secondary interest.

Food is an integral part of cultural identity that extends beyond dietary preferences.

Nutrition Assessment of Culturally Diverse Groups

Factors that must be considered in a nutrition assessment include the cultural definition of food,
frequency and number of meals eaten away from home, form and content of ceremonial meals,
amount and types of food eaten, and regularity of food consumption. Twenty-four-hour dietary
recalls or 3-day food records traditionally used for assessment may be inadequate when
dealing with clients from culturally diverse backgrounds. Standard dietary handbooks may fail
to provide culture-specific diet information, because nutritional content and exchange tables
are usually based on Western diets. Another source of error may originate from the cultural
patterns of eating. For example, among low-income urban African American families, elaborate
weekend meals are frequent, whereas weekday dietary patterns are markedly more moderate
(Giger, 2017).

Although community health nurses may assume that food is a culture universal term, they may
need to clarify its meaning with the client. For example, certain Latin American groups do not
consider greens, an important source of vitamins, to be food and fail to list intake of these
vegetables on daily records. Among Vietnamese refugees, dietary intake of calcium may
appear inadequate because low consumption rates of dairy products are common among
members of this group. However, they commonly consume pork bones and shells, providing
adequate quantities of calcium to meet daily requirements (Giger, 2017).

Food is only one part of eating. In some cultures, social contacts during meals are restricted
to members of the immediate or extended family. For example, in some Middle Eastern
cultures, men and women eat meals separately, or women are permitted to eat with their
husbands but not with other males. Among some Hispanic groups, the male breadwinner is
served first, then the women and children eat. Etiquette during meals, use of hands, type of
eating utensils (e.g., chopsticks or special flatware), and protocols governing the order in
which food is consumed during a meal all
vary cross-culturally.

Dietary Practices of Selected Cultural Groups

Cultural stereotyping is the tendency to view individuals of common cultural backgrounds

similarly and according to a preconceived notion of how they behave. However, not all Chinese
like rice, not all Italians like spaghetti, and not all Mexicans like tortillas. Nevertheless,
aggregate dietary preferences among people from certain cultural groups can be considered
(e.g., characteristic ethnic dishes and methods of food preparation, including use of cooking
oils); the reader is referred to nutrition texts on the topic for detailed information about culture-
specific diets and the nutritional value of ethnic foods.

Religion and Diet

Cultural food preferences are often interrelated with religious dietary beliefs and practices. As
indicated in Table, many religions have proscriptive dietary practices, and some use food as
symbols in celebrations and rituals. Knowing the client’s religious practice as it relates to food
makes it possible to suggest improvements or modifications that will not conflict with religious
dietary laws.

Dietary Practices of Selected Religious Groups

Fasting and other religious observations may limit a person’s food or liquid intake during
specified times. For example, many Catholics fast or abstain from meat on Ash Wednesday,
and each Friday during the season of Lent, Muslims refrain from eating during the daytime
hours for the month of Ramadan but are permitted to eat after sunset, and Mormons refrain
from ingesting all solid foods and liquids on the first Sunday of each month.

Culture and Religion

Although the nurse cannot be an expert on each of the estimated 1200 religions practiced in
the United States, knowledge of health-related beliefs and practices and general information
about religious observances are important in providing culturally competent nursing care. For
example,
when planning home visits or scheduling clinic visits for members of a specific religious group,
the nurse should consult the group’s religious calendar and work around designated holy days.
The nurse should also know the customary days of religious worship observed by members
of the religion. Most Protestants worship on Sundays, whereas Muslims’ holy day of worship
extends from sunset on Thursday to sunset on Friday, and Jews and Seventh-Day Adventists’
holy day extends from sunset on Friday to sunset on Saturday. Roman Catholics may worship
in the late
afternoon or evening of Saturday or all day Sunday. Some religions may meet more than once
weekly.

As an integral component of the individual’s culture, religious beliefs may influence the client’s
explanation of the cause of illness, perception of its severity, and choice of healer. In times of
crisis, such as serious illness and impending death, religion may be a source of consolation
for the client
and family and may influence the course of action believed to be appropriate.

Religion and Spirituality

Religious concerns evolve from, and respond to, the mysteries of life and death, good and
evil, and pain and suffering. Nurses frequently encounter clients who find themselves
searching for a spiritual meaning to help explain illness or disability. Some nurses find spiritual
assessment difficult because the topic is abstract and personal, whereas others feel
comfortable discussing spiritual matters. Comfort with personal spiritual beliefs is the
foundation for effective assessment of spiritual needs in clients.
Although religions offer various interpretations of many of life’s mysteries, most people seek
a personal understanding and interpretation at some time in their lives. Ultimately, this
personal search becomes a pursuit to discover a supreme being (e.g., Allah, God, Yahweh,
or Jehovah) or some unifying truth that will render meaning, purpose, and integrity to
existence.
An important distinction must be made between religion and spirituality. Religion refers to an
organized system of beliefs concerning the cause, nature, and purpose of the universe,
especially belief in or the worship of a god or gods. As already stated, more than 1200 religions
are practiced
in the United States. Spirituality, in contrast, is born out of the individual’s unique life
experience and personal effort to find purpose and meaning in life.

Religion may influence decisions regarding prolongation of life, euthanasia, autopsy, donation
of a body for research, disposal of a body and body parts including fetus, and type of burial.
The nurse should use discretion in asking clients and their families about these issues and
gather data only when the clinical situation necessitates that the information be obtained. The
nurse should encourage clients and families to discuss these issues with their religious
representative when necessary. Before dealing with potentially sensitive issues, the nurse
should establish rapport with the client and family by gaining their trust and confidence in less
sensitive areas.

Methods of Assessing Spiritual Needs in Culturally Diverse Clients

Environment

• Does the client have religious objects in the environment?

• Does the client wear outer garments or undergarments that have religious significance?

• Are get-well greeting cards religious in nature or from a representative of the client’s
religious institution?

• Does the client receive flowers or bulletins from a church or other religious institution?

Behavior

• Does the client appear to pray at certain times of the day or before meals?

• Does the client make special dietary requests (e.g., kosher diet; vegetarian diet; or diet
free from caffeine, pork, shellfish, or other specific food items)?

• Does the client read religious magazines or books?

Verbalization

• Does the client mention a Supreme Being (e.g., God, Allah, Buddha, or Yahweh), prayer,
faith, church, or religious topics?

• Does the client request a visit by a clergy member or other religious representative?

• Does the client express anxiety or fear about pain, suffering, or death?

Interpersonal Relationships

• Who visits the client? How does the client respond to visitors?

• Does a church representative visit?

• How does the client relate to nursing staff and roommates?

• Does the client prefer to interact with others or remain alone?

Culture and Aging

Values held by the dominant U.S. culture, such as emphasis on independence, self-reliance,
and productivity, influence aging members of society. Americans define people 65 years and
older as “old” and limit their work. In some other cultures, people are first recognized as being
unable to work and then identified as being old. In some cultures the wisdom, not the
productivity, of the older adult is valued; the diminution of one’s activity level and the reduction
of physical stamina associated with growing old are accepted more readily without loss of
status among culture members. Retirement is also culturally defined, with some older adults
working as long as physical health continues and others continuing to be active but assuming
less physically demanding jobs.

The main task of older adults in the dominant culture is to achieve a sense of integrity in
accepting responsibility for their own lives and having a sense of accomplishment. Individuals
who achieve integrity consider aging a positive experience, make adjustments in their personal
space
and social relationships, maintain a sense of usefulness, and begin closure and life review.

Not all cultures value accepting responsibility for an individual’s own life. For example, among
Hispanics, Asians, Arabs, and other groups, older adults are often cared for by family
members who welcome them into their homes when they are no longer able to live alone. The
concept of placing an older family member in an institutional setting to be cared for by
strangers is perceived as an uncaring, impersonal, and culturally unacceptable practice by
many cultural groups (Andrews and Boyle, 2016; Giger, 2017).

Older adults may develop their own means of coping with illness through self-care, assistance
from family members, and social group support systems. Some cultures have developed
attitudes and specific behaviors for older adults that include humanistic care and identification
of family
members as care providers. Older adults may have special family responsibilities (e.g., the
older Amish adults provide hospitality to visitors, and older Filipino adults spend considerable
time teaching the youth skills learned during a lifetime of experience).
Older adult immigrants who have made major lifestyle adjustments in the move from their
homeland to the United States or from a rural to an urban area, or vice versa, may need
information about health care alternatives, preventive programs, health care benefits, and
screening programs
for which they are eligible. These individuals may also be in various stages of culture shock,
the state of disorientation or inability to respond to the behavior of a different cultural group
because it holds sudden strangeness, unfamiliarity, and incompatibility for the newcomer’s
perceptions and expectations (Leininger and McFarland, 2002).

Several examples of how being an elderly immigrant influences health can be found in the
nursing literature. Wilmoth and Chen (2003) studied living arrangements and symptoms of
depression among middle-aged and older immigrants and concluded that immigrants had
significantly more depressive symptoms than nonimmigrants. Furthermore, immigrants who
lived alone or with family had more depressive symptoms than those who lived with a spouse.

Cross-Cultural Communication

Verbal communication and nonverbal communication are important in community health

nursing and are influenced by the cultural background of the nurse and client. Cross-cultural,
or intercultural, communication refers to the communication process between a nurse and a
client with different cultural backgrounds as each attempts to understand the other’s point of
view from a cultural perspective.
Nurse–Client Relationship

From the introduction of the nurse to the client through termination of the relationship,
communication is a continuous process for the community health nurse. First impressions are
important in all human relationships; therefore cross-cultural considerations concerning
introductions warrant a few brief remarks. To ensure a mutually respectful and trusting
relationship, the nurse should introduce himself or herself and indicate how the client should
refer to the nurse (i.e., by first name, last name, or title). Having done so, the nurse should ask
the client to do the same. This enables the nurse to address the client in a manner that is
culturally appropriate, thereby avoiding potential embarrassment.
For example, some Asian and European cultures write the last name first; confusion can be
avoided in an area of sensitivity (i.e., the client’s
name).

Space, Distance, and Intimacy

Sense of spatial distance is significant because culturally appropriate distance zones vary
widely.

For example, the nurse may back away from clients of Hispanic, East Indian, or Middle Eastern
origin who invade personal space with regularity in an attempt to bring the nurse closer into
the space that is comfortable to them. Although the nurse is uncomfortable with clients’ close
physical
proximity, clients are perplexed by the nurse’s distancing behaviors and may perceive the

community health nurse as aloof and unfriendly. summarizes the four distance zones identified
for the functional use of space that are embraced by the dominant cultural group in the United
States, including most nurses.

Nonverbal Communication

Unless the nurse makes an effort to understand the client’s nonverbal behavior, he or she may
overlook important information such as that conveyed by facial expressions, silence, eye
contact, touch, and other body language. Communication patterns vary widely cross-culturally,
even for seemingly “innocent” behaviors such as smiling and shaking hands.
 For example, among many Hispanic clients, smiling and shaking hands are considered an
integral part of sincere interaction and essential to establishing trust, whereas a Russian client
may perceive the same behavior from the nurse as insolent and frivolous (Giger, 2017).

Gender issues also become significant. For example, among some groups of Middle Eastern
origin, men and women do not shake hands or touch each other in any manner outside the
marital relationship. However, if the nurse and client are both female, a handshake is usually
acceptable
(Andrews and Boyle, 2016).

Wide cultural variation exists in the interpretation of silence. Some individuals find silence
extremely uncomfortable and make every effort to fill conversational lags with words. In
contrast, Native Americans consider silence essential to understanding and respecting the
other person. A
pause after a question signifies that what the speaker has 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. The English and Arabs may use silence out of respect for another person’s privacy,
whereas the French, Spanish, and Russians may interpret it as a sign of agreement. Asian
cultures often use silence to demonstrate respect for elders (Giger, 2017).

Eye contact is among the most culturally variable nonverbal behaviors. Although most nurses
have been taught to maintain eye contact while talking with clients, individuals from culturally
diverse backgrounds may misconstrue this behavior. Asian, Native American, Indochinese,
Arab,
and Appalachian clients may consider direct eye contact impolite or aggressive, and they may
avert their own eyes during the conversation. Native American clients often stare at the floor
when the nurse is talking. This culturally appropriate behavior indicates that the listener is
paying close attention to the speaker (Giger, 2017; Andrews and Boyle, 2016).
In some cultures, modesty for women is interrelated with eye contact. For a Muslim woman,
modesty is achieved in part by avoiding eye contact with men, except for her husband, and
keeping the eyes downcast when encountering members of the opposite sex in public
situations. In many
cultures, the only women who smile and establish eye contact with men in public are
prostitutes (Giger, 2017). Hasidic Jewish men also have culturally based norms concerning
eye contact with women. Such a man may avoid direct eye contact and turn his head in the
opposite direction when walking past or speaking to a woman. It is important to understand
that the preceding examples are intended to be illustrative and are not exhaustive, nor do they
represent values, actions, and beliefs of all members of the cultural groups described.

Language

To assess non–English-speaking clients, the nurse may need the help of an interpreter.
Interviewing a non–English-speaking person requires a bilingual interpreter for full
communication. Even the person from another culture or country who has a basic command
of English may need an interpreter when faced with the anxiety-provoking situation of
becoming ill; encountering a strange symptom; or discussing sensitive topics such as birth
control, gynecological concerns, and urological problems. The nurse may be tempted to ask
a relative or friend of another client to interpret because this person is readily available and is
anxious to help.
However, doing so is disadvantageous because it violates confidentiality for the client, who
may not want personal information shared with another. Furthermore, the friend or relative,
although fluent in ordinary language, is likely to be unfamiliar with medical terminology, clinical
procedures, and medical ethics. Whenever possible, the nurse should use a bilingual team
member or trained medical interpreter.

This person knows interpreting techniques, has a health care background, and understands
clients’ rights. The trained interpreter is also knowledgeable about cultural beliefs and health
practices, can help bridge the cultural gap, and can provide advice concerning the cultural
appropriateness of recommendations.

Although the nurse is in charge of the client–nurse interaction, the interpreter is an important
member of the health care team. Whenever feasible, the nurse should ask the interpreter to
meet the client before the visit to establish rapport and learn about the client’s age, occupation,
educational level, and attitude toward health care. This knowledge enables the interpreter to
communicate on the client’s level.

The nurse should allow more time for visits with culturally diverse clients who require an
interpreter. With the third person repeating everything, it can take considerably longer than
interviewing English-speaking clients. The nurse will need to focus on the major points and
prioritize data.

Line by line and summarization are interpretation styles. Translation line by line ensures
accuracy, but it takes more time. The nurse and client should speak only a sentence or two
and then allow the interpreter time to interpret. The nurse should use simple language, not
medical jargon
that the interpreter must simplify before translating. Summary translation is faster and useful
for teaching relatively simple health techniques with which the interpreter is already familiar.
The nurse should be alert for nonverbal cues as the client talks because they can give valuable
data. A
good interpreter will also note nonverbal messages and communicate those to the community
health nurse.

Although use of an interpreter is ideal, the nurse may find himself or herself in a situation with
a non–English-speaking client in which no interpreter is available.
 Overcoming Language Barriers: Use of an Interpreter
• Before locating an interpreter, the nurse should know what language the client speaks at
home because it may be different from the language spoken publicly (e.g., French is
sometimes spoken by aristocratic or well-educated people from certain Asian or Middle
Eastern cultures).
• The nurse should 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).
• The nurse should be aware of the gender difference between the interpreter and client to
avoid violation of cultural mores related to modesty.
• The nurse should be aware of the age difference between the interpreter and client.
• The nurse should be aware of socioeconomic differences between the interpreter and
client.
• The nurse should ask the interpreter to translate as closely to verbatim as possible.
• An interpreter who is not a relative may seek compensation for services rendered.
 Overcoming Language Barriers when an Interpreter is not
available
• The nurse should be polite and formal.
• The nurse should greet the client using his or her last or complete
name. The nurse should gesture to himself or herself and say his or
her name. The nurse should offer a handshake, nod, or smile.
• The nurse should proceed in an unhurried manner. The nurse
should pay attention to efforts by the client or family to communicate.
• The nurse should speak in a low, moderate voice. The nurse should
remember that he or she may have a tendency to raise the volume
and pitch of his or her voice when the listener appears not to
understand, and the listener may perceive that the nurse is shouting
or angry.
• The nurse should use words that he or she may know in the client’s
language. Doing so indicates that the nurse is aware of and respects
the client’s culture.
• The nurse should use simple words, such as “pain” instead of
“discomfort.” The nurse should avoid medical jargon and slang. He
or she should avoid using contractions such as “don’t,” “can’t,” and
“won’t.” The nurse should use nouns repeatedly instead of pronouns.
For example, the nurse should say, “Do you take medicine?” instead
of “You have been taking your medicine, haven’t you?”
• The nurse should pantomime words and simple actions while
verbalizing them.
• The nurse should give instructions in the proper sequence. For
example, he or she should say, “First, wash the bottle. Second, rinse
the bottle,” instead of “Before you rinse the bottle, sterilize it.”
• The nurse should discuss one topic at a time. He or she should
avoid use of conjunctions. For example, the nurse should ask, “Are
you cold [while pantomiming]?” and then “Are you in pain?” instead
of, “Are you cold and in pain?”
• The nurse should determine whether the client understands by
having the client repeat instructions, demonstrate the procedure, or
act out the meaning.
• The nurse should write out several short sentences in English and
determine the client’s ability to read them.
 • The nurse should try a third language. Many Indo-Chinese people
speak French. Europeans often know three or four languages. The
nurse should try Latin words or phrases.
• The nurse should ask who among the client’s family and friends
could serve as an interpreter.
• The nurse should 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
suitable interpreters.

Touch

Touching the client is a necessary component of a comprehensive assessment. Although

benefits exist in establishing rapport with clients through touch, including the promotion of
healing through therapeutic touch, physical contact with clients conveys various meanings
cross-culturally. In many cultures (e.g., Arab and Hispanic), male health care providers may
be prohibited from touching or examining all or certain parts of the female body. During
pregnancy, the client may prefer female
health care providers and may refuse to be examined by a man. The nurse should be aware
that the client’s significant other also might exert pressure on health care providers by
enforcing these culturally meaningful norms in the health care setting.

Touching children may also have variable meanings cross-culturally. For example, Hispanic
clients may believe in mal ojo (evil eye), in which an individual becomes ill as a result of
excessive admiration by another. Many Asians believe that personal strength resides in the
head and consider touching the head disrespectful. The nurse should approach palpation of
the fontanelle of an infant of Southeast Asian descent with sensitivity. The nurse may need to
rely on alternative sources of information (e.g., assessing for clinical manifestations of
increased intracranial pressure or signs of premature fontanelle closure). Although it is the
least desirable option, the nurse may need to omit this part of the assessment (Giger, 2017).

Gender

Violating norms related to appropriate male–female relationships among various cultures may
jeopardize the therapeutic nurse–client relationship. Among Arab Americans, a man is never
alone with a woman, except his wife, and is usually accompanied by one or more other men
when interacting with women. This behavior is culturally significant, and failure to adhere to
the cultural code (i.e., set of rules or norms of behavior used by a cultural group to guide their
behavior and interpret situations) is viewed as a serious transgression, often one in which the
lone male will be accused of sexual impropriety. The best way to ensure that cultural variables
have been considered is to ask the client about culturally relevant aspects of male–female
relationships, preferably at the beginning of the interaction before an opportunity arises to
violate culturally based practices.
Health-Related Beliefs and Practices

One of the major aspects of a comprehensive cultural assessment concerns the collection of
data related to culturally based beliefs and practices about health and illness. Before
determining whether cultural practices are helpful, harmful, or neutral, the nurse must first
understand the logic of the belief system underlying the practice and then be sure to grasp
fully the nature and meaning of the practice from the client’s cultural perspective.

Health and Culture

The first step in understanding the health care needs of clients is to understand personal
culturally based values, beliefs, attitudes, and practices. Sometimes this step requires
considerable introspection and may necessitate that the nurse confront his or her own biases,
preconceptions, and prejudices about specific racial, ethnic, religious, sexual, or
socioeconomic groups. The next step is to identify the meaning of health to the client,
remembering that concepts are derived, in part, from the way in which members of their
cultural group define health.

Considerable research has been conducted on the various definitions of health that may be
held by various groups. For example, Jamaicans define health as having a good appetite,
feeling strong and energetic, performing activities of daily living without difficulty, and being
sexually active and fertile. For traditional Italian women, health means the ability to interact
socially and perform routine tasks such as cooking, cleaning, and caring for oneself and
others. Individuals may define themselves or others in their group as healthy even though the
nurse identifies symptoms of
disease (Spector, 2017).

Cross-Cultural Perspectives on Causes of Illness

For clients, symptom labeling and diagnosis depend on the extent of the difference between
the individual’s behaviors and those the group defines as normal. Other issues that the nurse
should consider include the client’s beliefs about the causation of illness, level of stigma
attached to a particular set of symptoms, prevalence of the disease, and meaning of the illness
to the individual and family.

Throughout history, humankind has attempted to understand the cause of illness and disease.
Theories of causation have been formulated on the basis of religious beliefs, social
circumstances, philosophical perspectives, and level of knowledge. Disease causation may
be viewed from them following three major perspectives: biomedical (i.e., sometimes used
synonymously with the term scientific), naturalistic (i.e., sometimes used synonymously with
the term holistic), and magicoreligious (i.e., metaphysical or supernatural belief).

Biomedical Perspective

The biomedical (i.e., scientific) theory of illness causation is based on the following beliefs:
1. All events in life have a cause and effect.
2. The human body functions more or less mechanically (i.e., the functioning of the human
body is analogous to the functioning of an automobile).
3. All life can be reduced or divided into smaller parts (e.g., the human person can be reduced
into body, mind, and spirit).
4. All of reality can be observed and measured (e.g., with intelligence tests and psychometric
measures of behavior).
Among the biomedical explanations for disease is the germ theory, which posits that
microscopic organisms such as bacteria and viruses are responsible for many specific disease
conditions. Most educational programs for nurses and other health care providers embrace
biomedical, or scientific, theories that explain the causes of physical and psychological
illnesses.

Naturalistic Perspective

Another way in which clients may explain the cause of illness is from the naturalistic (i.e.,
holistic) perspective. This viewpoint is found most frequently among Native Americans,
Asians, and others who believe that human life is only one aspect of nature and a part of the
general order of the cosmos. Individuals from these groups believe that the forces of nature
must be kept in natural balance or harmony to maintain health and well-being. A combination
of worldviews is possible, and many clients are likely to offer more than one explanation for
the cause of their illness. As a profession, nursing largely embraces the biomedical-scientific
worldview, but some aspects of holism have begun to gain popularity. These include a wide
variety of techniques for management of chronic pain (e.g., hypnosis, therapeutic touch, and
biofeedback). Many nurses hold a belief in spiritual power and readily credit supernatural
forces with various unexplained phenomena related to clients’ health and illness states.
Numerous Asians subscribe to the yin-yang theory, in which health is believed to exist when
all aspects of the person are in perfect balance. Rooted in the ancient Chinese philosophy of
Tao, the yin-yang theory states that all organisms and objects in the universe consist of yin or
yang energy forces. The origin of the energy forces is within the autonomic nervous system,
where balance between the opposing forces is maintained during health. Yin energy
represents the female and negative forces (e.g., emptiness, darkness, and cold), whereas
yang forces are male and positive, emitting fullness, light, and warmth. Foods are classified
as hot and cold in this theory and are transformed into yin and yang energy when metabolized
by the body. Yin foods are cold, and yang
foods are hot. Cold foods are eaten when one has a hot illness, and hot foods are eaten when
one has a cold illness. The yin-yang theory is the basis for Eastern or Chinese medicine.

The naturalistic perspective posits that the laws of nature create imbalance, chaos, and
disease.
Individuals embracing the naturalistic view use metaphors such as the healing power of
nature, and they may call the earth “Mother.” For example, from the perspective of the
Chinese, illness is seen not as an intruding agent but rather as a part of life’s rhythmic course
and an outward sign of the disharmony that exists within. Many Hispanic, Arab, African
American, and Asian groups embrace a hot-cold theory of health
and illness, an explanatory model with its origin in the ancient Greek humoral theory. Blood,
phlegm, black bile, and yellow bile, the four humors of the body, regulate basic bodily functions
and are described in terms of temperature, dryness, and moisture. The treatment of disease
consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the
humors.

Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to
their perceived effects on the body, not on their physical characteristics. Illnesses believed to
be caused by cold entering the body include earache, chest cramps, paralysis, gastrointestinal
discomfort, rheumatism, and tuberculosis. Illnesses believed to be caused by overheating
include abscessed teeth, sore throats, rashes, and kidney disorders.
According to the hot-cold theory, the individual as a whole, rather than a specific ailment, is
significant. Those who embrace the hot-cold theory maintain that health consists of a positive
state of total well-being, including physical, psychological, spiritual, and social aspects of the
person.

Paradoxically, the language used to describe this artificial dissection of the body into parts is
a reflection of the biomedical-scientific perspective, not a naturalistic or holistic one.

Magicoreligious Perspective

Another way in which people explain the causation of illness is from a magicoreligious
perspective. The basic premise of this explanatory model is that the world is seen as an arena
in which supernatural forces dominate. The fate of the world and those in it depends on the
action of
supernatural forces for good or evil. Examples of magical causes of illness include the belief
in voodoo or witchcraft among some African Americans and others from circum-Caribbean
countries.
Faith healing is based on religious beliefs and is most prevalent among selected Christian
religions, including Christian Scientists. Various healing rituals (prayer, anointing, exorcism,
laying of hands, etc.) may be found in many religions—Roman Catholicism, Mormonism (i.e.,
Church of Jesus Christ of Latter-day Saints), and others (Hanson and Andrews, 2016).

Folk Healers

All cultures have their own recognized symptoms of ill health, acceptable sick-role behavior,
and treatments. In addition to seeking help from the nurse as a biomedical-scientific health
care provider, clients from many groups may seek help from folk or religious healers.
Numerous types of folk healers exist, each with a unique scope of practice. Hispanic clients
may turn to a curandero (male folk healer) or curandera (female folk healer), spiritualist, yerbo
(herbalist), or sabador (healer who manipulates muscles and bones). In many instances,
people from diverse cultures combine folk healing and biomedicine. Among the main reasons
for seeking care from folk healers is the perception that biomedical practitioners (e.g.,
physicians and nurses) fail to provide
holistic care and use medicines that are not natural (Andrews and Boyle 2016).

Some African American clients may mention having received assistance from a hougan
(voodoo priest or priestess), spiritualist, or “old lady” (an older woman who has successfully
raised a family and specializes in child care and folk remedies). Likewise, Native American
clients may seek
assistance from a shaman or a medicine man or woman. Clients of Asian descent may
mention that they have visited herbalists, acupuncturists, or bone setters (Giger, 2017).

Each culture has its own healers, most of whom speak the native tongue of the client, make
house calls, and cost significantly less than healers practicing in the biomedical-scientific
health care system. In addition to folk healers, many cultures rely on lay midwives (e.g.,
parteras for Hispanic women) or other health care providers to meet the needs of pregnant
women.

In some religions, spiritual healers may be found among the ranks of the ordained or official
religious hierarchy ranks and are called priest, bishop, elder, deacon, rabbi, brother, or sister.
Other religions have a separate category of healer (e.g., Christian Science “nurses” [not
licensed by states] or practitioners) (Hanson and Andrews, 2016).

The nurse should be aware of alternative practices and folk healers that are used by the
groups for which they care. The nurse should also be aware that most indigenous healing
practices are innocuous, regardless of whether they are effective.

Cultural Expressions of Illness

A wide cultural variation exists in the manner in which certain symptoms and disease
conditions are perceived, diagnosed, labeled, and treated. The disease that is grounds for
social ostracism in one culture may be reason for increased status in another.

Bodily symptoms are also perceived and reported in a variety of ways. For example,
individuals of Mediterranean descent tend to report common physical symptoms more often
than people of Northern European or Asian heritage. To express emotion, East Asian clients
sometimes somaticize
their symptoms. For example, a client may complain of cardiac symptoms because the center
of emotion in the Chinese culture is the heart. If the client has experienced a loss through
death or divorce and is grieving, he or she may describe the loss in terms of a pain in the
heart. Although
some biomedical-scientific clinicians may refer to this pain as a psychosomatic illness, others
will recognize it as a culturally acceptable somatic expression of emotional disharmony
(Andrews and Boyle, 2016; Giger, 2017).

Cultural Expression of Pain

Pain, an extensively studied symptom, is used here to illustrate the manner in which symptom
expression may reflect the client’s cultural background. Pain is a universally recognized
phenomenon and an important aspect of assessment for clients of various ages. It is also a
private, subjective experience that is greatly influenced by cultural heritage. Expectations,
manifestations, and pain management are all embedded in a cultural context. The definition
of pain, like that of health or illness, is culturally determined.
The term pain is derived from the Greek word for penalty, a fact that helps explain the long
association between pain and punishment in Judeo-Christian thought. The meaning of painful
stimuli for individuals, the way people define their situation, and the influence of personal
experience combine to determine the experience of pain. Much cross-cultural research has
been conducted on pain (Campbell and Edwards, 2012; Ludwig-Beymer, 2008; Zborowski,
1969). Pain has been found to be a highly personal experience that depends on cultural
learning, the meaning of the situation, and other factors unique to the individual (Campbell
and Edwards, 2012). Health care professionals have identified silent suffering
as the most valued response to pain. The majority of nurses have been socialized to believe
that in virtually any situation, self-control is better than open displays of strong feelings.

Studies of health care providers’ attitudes toward pain reveal that the ethnic background of
clients is relevant to the assessment of physical and psychological pain (Campbell and
Edwards, 2012). Nurses view Jewish and Spanish clients as experiencing suffering the most
and Anglo-Saxon
Germanic clients as experiencing suffering the least. In addition, nurses who infer relatively
greater client pain tended to report their own experiences as more painful. In general, nurses
with an Eastern or Southern European or African background tend to infer greater suffering
than do nurses of Northern European background. Years of experience, current position, and
area of clinical practice are unrelated to inferences of suffering (Ludwig-Beymer, 2008).

In addition to expecting variations in pain perception and tolerance, a nurse should expect
variations in the expression of pain. Individuals turn to their social environments for validation
and comparison. A first important comparison group is the family, which transmits cultural
norms to its children.

Culture-Bound Syndromes

Clients may have a condition that is culturally defined, known as a culture-bound syndrome.
Some of these conditions have no equal from a biomedical or scientific perspective, but others,
such as anorexia nervosa and bulimia, are examples of health problems found primarily
among members of the dominant U.S. cultural group.

Cultural Negotiation

Cultural negotiation refers to the process in which messages, instructions, and belief systems
are manipulated, linked, or processed between the professional and lay models of health
problems and preferred treatment. In each act, the nurse gives attention to eliciting the client’s
views regarding a health-related experience (e.g., pregnancy, complications of pregnancy, or
illness of an infant).