Sherwyn Hatab RN.

Assessing Culture
Assignment
• What is culture and why do we need to assess culture?
• How do culture and race differ?
• What is assimilation4
• What is subculture?
• What is ethnicity? What is Minority
• What is values?
• What is norms?
• What is ethnocentrism?
• What is stereotyping. Give example stereotyping of Filipino culture.
• Five contructs of cultural competencies
• Example of filipino cultural practices that affect health.
Wait a moment...

Take a few minutes to reflect on

what is in your mind just now.

What picture do you hold in your

mind when you think of culture?
What are the factors that you
initially think are important
 Culture
• shared system of values, beliefs, and learned patterns of behavior.
• “The totality of socially transmitted behavioral patterns, arts, beliefs,
values, customs, lifeways, and all other products of human work and
thought characteristic of a population or people that guide their
worldview and decision making.” Purnell and Paulanka (2003, p. 3)
• The particular culture defines values and norms
• Culture is learned, shared, associated with adaptation to the
environment, and it is universal
Cultural
Assimilation
• Cultural Assimilation is the
process in which a minority
group or culture comes to
resemble a dominant group
or assume the values,
behaviors, and beliefs of
another group.
Ethnocentrism.

• The perception that

one’s worldview is the
only acceptable truth
and that one’s beliefs,
values, and sanctioned
behaviors are superior to
all others.
 Stereotyping

• Many people are aware of

other cultures and their
different beliefs, values, and
accepted behaviors but do not
recognize the great variation
that can exist within any
cultural group.
• Not recognizing this variation
tends to lead to stereotyping.
Subculture
• A subculture is a group of people within a culture that
differentiates itself from the parent culture to which it
belongs, often maintaining some of its founding principles.
• Subcultures develop their own norms and values regarding
cultural, political and sexual matters.
Ethnicity

• Ethnicity, or a person’s ethnic identity, exists when the person

identifies with a “socially, culturally, and politically constructed group
of individuals that holds a common set of characteristics not shared
by others with whom its members come in contact” (Lipson, 1996, p.
8).
• Ethnicity describes subgroups that have a common history, ancestry,
or other cultural identity and may relate to geographical origin,
Race

• Race is a grouping of humans based on shared physical

or social qualities into categories generally viewed as
distinct by society.
• “originates from societal desire to separate people based
on their looks and culture . . . a vague, unscientific term
referring to a group of genetically related individuals who
share certain physical characteristics” (Bigby, 2003).
Minority

• Refers to a group who has less power or prestige within

the society, but actually means a group with smaller
population numbers.
• Can either be racial or ethnic minority
several reasons why nurses need to know about culture:

1. long history of disparity in the level of health care

received by persons from certain racial groups or
minorities
2. problems of ethnocentrism and stereotyping.
CULTURAL COMPETENCE

• According to Campinha-Bacote (2007), there are five constructs in the

cultural competence process:
1. cultural awareness
2. cultural knowledge
3. cultural skill
4. cultural encounters
5. cultural desire
 • The motivation to engage in
intercultural encounters and acquire
cultural competence.
• Campinha-Bacote’s model is based
on the assumption that the starting
Cultural Desire point of cultural competence is
cultural desire.
• The nurse must also seek repeated
encounters with people of the
culture so that awareness,
knowledge, and skill continually
increase.
 Cultural Awareness
• Cultural awareness is the “deliberate,
cognitive process in which the healthcare
provider becomes appreciative and
sensitive to the values, beliefs, life ways,
practices and problem solving strategies
of a client’s culture” (Campinha-Bacote,
1998).
• cultural awareness involves “self-
examination and in-depth exploration of
one’s own cultural background”
(Campinha-Bacote, 2003).
 1. Unconscious incompetence: not
aware that one lacks cultural
knowledge; not aware that cultural
The stages of differences exist.
2. Conscious incompetence: aware that
cultural one lacks knowledge about another
culture; aware that cultural
awareness differences exist but not knowing
what they are or how to
communicate effectively with clients
from different cultures
 3. Conscious competence: consciously
learning about the client’s culture and
providing culturally relevant
interventions; aware of differences;
The stages of able to have effective transcultural
interactions
cultural 4. Unconscious competence: able to
automatically provide culturally
awareness congruent care to clients from a
different culture; having much
experience with a variety of cultural
groups and having an intuitive grasp of
how to communicate effectively in
transcultural encounters
 • Cultural knowledge is “the process of
seeking and obtaining a sound
educational foundation concerning the
various worldviews of different
cultures” (Campinha-Bacote, 1998).
Cultural • The client’s worldview is the basis for
Knowledge his or her behaviors and
interpretations of the world.
• These characteristics based on
worldview, along with biological
variations, comprise the content of
cultural knowledge useful for the
nurse assessing a client from a
different culture.
 • Cultural skill is “the ability to
collect relevant cultural data
regarding the client’s health
history and presenting
Cultural Skill problem as well as
accurately performing a
physical assessment”
(Campinha-Bacote, 1998).
 • A cultural encounter is “the process
that allows the healthcare provider
to engage directly in face-to-face
Cultural interactions with clients from
culturally diverse backgrounds”
Encounters (Campinha- Bacote, 1998).
• Repeated face-to-face encounters
help to refine or modify the nurse’s
knowledge of the culture.
 • Giger & Davidhizar TRANSCULTURAL
ASSESSMENT MODEL
THEORITICAL • This model was developed in 1988 in
response to the need for nursing students
BASES FOR in an undergraduate program to assess
TRANSCULTU and provide care for patients that were
RAL Nursing culturally diverse.
• According to Giger & Davidhizar, although
all cultures are not the same, all cultures
have the same basic organizational factors
 • Six cultural phenomena that vary
among cultural groups and affect
Giger & health care.
Davidhizar 1. Communication
TRANSCULTU 2. Space
RAL 3. Social organization
ASSESSMENT 4. Time orientation
MODEL
5. Environmental control
6. Biological variations
Communication

Communication is the means by which culture is transmitted and

preserved.

Both verbal and nonverbal communications are learned in one’s

culture

Verbal and nonverbal patterns of communication vary across

cultures.
Communication
• If nurses do not understand the client’s cultural rules in
communication:
1. The client’s acceptance of a treatment plan may be
compromised.
2. Accurate diagnosis and treatment is impossible if the health-
care professional cannot understand the patient
3. Will put the patient in a state of isolation from the health
care team
An assessment of communication should
consider the following:

DIALECT STYLE VOLUME, INCLUDING TOUCH EMOTIONAL TONE

SILENCE

KINETICS (INCLUDING
GESTURES, POSTURE,
AND EYE BEHAVIOR)
Knowing what the norm within
the culture will facilitate
understanding and lessen
miscommunication
 Space

• Space refers to the distance

between individuals when they
interact
• All communication occurs in the
context of space
There are four distinct zones
of interpersonal space:

• Intimate distance extends from 0 to 1 ½

feet
• Personal distance extends from 1 ½ to 4
feet
• Social distance extends from 4 to 12 feet
• Public distance extends 12 feet or more
• Rules concerning personal distance vary
from culture to culture.
• Comfort level is related to personal
space
 Social organization
• Social organization refers to the social group
organizations with which clients and families
may identify
• Family structure and organization, religious
values and beliefs and role assignments may all
relate to ethnicity and culture.
• The social environment in which people grow
up and live plays an essential role in their
cultural development and identification
• Children learn their culture’s responses to life
events from the family and its ethno-religious
group
Time Orientation
• Time is an important
aspect of interpersonal
communication
• Some cultures are
considered future
oriented, others present
oriented, and still others
past oriented
Future Oriented Societies
• Future-oriented societies have a great deal of optimism about the
future. They think they understand it and can shape it through their
actions. They view management as a matter of planning, doing and
controlling.
• Future-oriented societies are concerned with long-range goals and
with health-care measures in the present to prevent the occurrence
of illness in the future
 • Past-oriented societies
are concerned with
traditional values and
ways of doing things.
• As a result those that
are past-oriented tend
to be conservative in
management and slow
to change those things
that are tied to the
past.
Past Oriented Societies
Present Oriented Societies
• Present-oriented societies see the past as
passed and the future as uncertain.
• They consequently prefer short-term
benefits and immediate results.
Environmental control
• Environmental control refers to the ability of the person to control
nature and to plan and direct factors in the environment that affect
them.
• If persons come from a cultural group in which there is less belief in
internal control and more in external control, there may be a fatalistic
view in which seeking health care is viewed as useless.
Biological variations • Biological variations are:
1. Body structure
2. Skin colour
3. Other visible physical
characteristics
4. Enzymatic and genetic
variations
5. Elelectrocardiographic patterns
6. Susceptibility to disease
7. Nutritional preferences and
deficiencies
8. Psychological characteristics
 • The Giger and Davidhizar Transcultural
Application Assessment Model provides a process for
assessing clients from differing cultures in
of the Model order to be aware of differences and to plan
appropriate strategies
• It was used to identify cultural beliefs from
the six cultural phenomena previously
described by Giger and Davidhizar
• his Model, which also included interview
questions and observational guidelines, was
used for structural interviews
• The model can enable the nurse in assessing
individuals who are culturally diverse in
order to provide culturally competent care
 • Cultural assessment can mean adding
elements of cultural assessment to the
health assessment, or it can mean
CULTURAL completing an entire cultural assessment.
• Two main belief categories are included in a
ASSESSME cultural assessment: those that affect the
NT client approaching the health care system
and provider and those that affect the
disease, illness, or health state.
Cultural 1. Beliefs about what causes disease
2. Beliefs about health
Beliefs and
3. Beliefs about who serves in the role
Values About of healer
Health and 4. what practices bring about healing
Illness
 1. Ethnicity (assimilation)
Factors 2. Education level and communication
Affecting 3. Religion
Approach to 4. Occupation and income level

Providers 5. Time dimensions

6. Space
 MICRO ASPECTS OF THE PURNELL
MODEL of Cultural Competence
12 CULTURAL DOMAINS Affecting Disease, Illness, Health State
1. Overview/Heritage
2. Communication
3. Family roles and organization
4. Workforce issues
5. Bicultural ecology
6. High-risk behaviors
7. Nutrition
8. Pregnancy and childbearing
9. Death rituals
10. Spirituality
11. Health care practices
12. Health care practitioner Sherwyn U. Hatab
 • The Purnell Model for Cultural Competence, developed
The Purnell in 1995, provides a constructive framework for culturally
Model for assessing a person (Purnell, 2011). Twelve domains make
up this model that is common to all cultures prevalent
Cultural among people. The domains are all interconnected
Competence (Purnell, 2012)
 • All communication is culturally based.
• Verbal communication can have many variations
based on both language differences and usual tone
of voice.
Culturally • For instance, a harsh tone of voice may be normal in
some cultures and thought to be rude in others.
Competent • Nonverbal communication has the most often
Interview misinterpreted variations. These variations include
patterns of space, eye contact, body language and
hand gestures, silence, and touch.
• Time is also interpreted to be a form of
communication when two people from different
cultures perceive time differently.
 • Dietary considerations in cultural assessment
include:
1. The meaning of food to the individual
2. Common foods eaten
3. Rituals surrounding the eating
Diet and 4. The distribution of food throughout a 24-
Nutrition hour day
5. Religious beliefs about foods
6. Nutritional deficiencies associated with the
ethnic group.
7. Religious beliefs affect what can and
cannot be eaten.
 • As noted by Purnell and Paulanka (2003),
Death death rituals include views of death,
euthanasia, and rituals for dying, burial, and
Rituals bereavement, and are unlikely to vary from
the original ethnic group’s practices.
 • Practices that affect health care include:
1. customs as ritual washing of the body
2. the number of family members present at
the death of a family member

Death 3. religious practices required during or after

dying
Rituals 4. acceptance of life- or death-prolonging
treatments
5. beliefs about withdrawing life support
6. beliefs about autopsy.
 • Responses to death and grief vary. Some
cultures expect loud wailing in grief with
Death death (e.g., Latins, African Americans), while
others expect solemn, quiet grief (e.g.,
Rituals Hindus). In addition, the expected duration
of grief varies with culture.
 • “More traditional, folk, and
magicoreligious beliefs surround fertility
control, pregnancy, childbearing, and
Pregnancy postpartum practices in this cultural
domain than in any other” Purnell and
and Paulanka (2003)
Childbearing • Fertility control varies by culture and
religion. Use of sterilization is accepted
by some, rejected by others, and
forcibly used in other cultures.
• Rituals to restrict sexuality are used in
some cultures, including female
circumcision.
 • Other cultures have pregnancy taboos such
as having the mother avoid reaching over
Pregnancy her head to prevent the umbilical cord from
going around the baby’s neck, not buying
and baby clothes before birth, not permitting the
father to see the mother or baby until the
Childbearing baby is cleaned (Belize and Panama), and
many other beliefs (Purnell & Paulanka,
2003, p. 31).
 Culture-Based
Treatments
• Some of the more common Asian
treatments:
• Cupping, often used to treat back
pain, involves placing heated glass
jars on the skin. Cooling causes
suction that leaves redness and
bruising.
Culture-Based
Treatments
• Coining involves rubbing ointment
into the skin with a spoon or coin.
It leaves bruises or red marks but
does not cause pain. It is used for
“wind illness”, fever, and stress-
related illnesses such as
headache.
Culture-Based Treatments
• Moxibustion is the attachment of
smoldering herbs to the end of
acupuncture needles or placing
the herbs on the skin; this causes
scars that look like cigarette burns.
It is used to strengthen one’s
blood and the flow of energy, and
generally to maintain good health
 Culture-Bound Syndromes

• Culture-bound syndromes are conditions

that are specific to various cultures and
occur as a combination of psychiatric or
psychological and physical symptoms.
• Many of the culture-bound syndromes
are based on different beliefs in what
causes disease. Some of the culturally
based beliefs about disease causation
include yin/yang out of balance, hot/cold
imbalanced, and spirit possession
Health Care Practices
• Purnell and Paulanka (2003) divide the assessment of health care
practices into six categories:
1. Health-Seeking Beliefs and Behaviors
2. Responsibility for Health Care
3. Folklore Practices
4. Barriers to Health Care
5. Cultural Responses to Health Illness
6. Blood Transfusion and Organ Donation
 • In general, chronic diseases predominate in
developed countries and infectious diseases
Geographical predominate in third world countries.
and Ethnic • Vascular diseases tend to be higher in
African Americans and populations with
Disease larger body size and lifestyle habits such as
Variation smoking
• Osteoporosis is more prevalent in small-
framed people such as Asians
 • Filipino men and women have the highest
Geographical prevalence of hypertension characterized by
sodium sensitivity (Garde, Spangler, &
and Ethnic Miranda, 1994). High incidence of
hyperuricemia is attributed to a shift from a
Disease Filipino to an American diet (McBride,
Variation Mariola, & Yeo, 1995)
Geographical • The major public health concerns in the Arab
and Ethnic world include trauma related to motor
Disease vehicle accidents, maternal child health, and
control of communicable diseases
Variation
Geographical • The three leading causes of death in Japan
and Ethnic are malignant neoplasms, heart diseases,
Disease and cerebrovascular diseases. These account
for over 50 percent of deaths in both sexes
Variation