Culture and Nursing Care - 2 Nursing CEs

Course Description

This course is designed to educate the nurse of how cultural differences and diversity affect patient care. Course subject matter that will be introduced includes the “Isms” of cultural diversity as well as cultural assessment and cultural communication. In addition this course will include information about the characteristics and history of immigration and refugee families. This course will also discuss how different cultural groups perceive and tolerate the pain that is often associated with disease and illness.

Course Objectives

Upon completion of this 1 hour CE course the student will be able to:

1. Define the “Isms” of cultural diversity such as: Egocentrism, Ethnocentrism, Racism, Sexism, Ageism, Sizism, and Ableism.

2. List 3 important considerations to keep in mind when performing a cultural assessment.

3. Be able to incorporate good cultural communication skills such as appropriate greetings, touching, eye contact and personal space when caring for patients.

4. Understand the characteristics history of immigration for 2 specific cultures.

5. Compare and contrast expressions of pain by culture, gender and the actual type of pain that is being felt.

Defining the "Ism's" of Cultural Diversity:

Examining what is known as the “Ism’s “ of cultural diversity is the starting point to understanding our own belief and value patterns. Consider the following definitions and how as a society we must take care to counteract such biases, discriminations and social injustices.

• Egocentrism – the assumption that oneself is superior to others.

• Ethnocentrism – the assumption that one own cultural belief’s and values are superior, best or most deserving culture.

• Racism – the assumption that the members of one race are superior to those of another race.

• Sexism – the assumption that members of one gender are superior to another.

• Heterosexism – the assumption that everyone is or should be heterosexual and that heterosexuality is superior and expectable.

• Ageism – the assumption that members of one age group are superior to those of another. Young patients and staff may not be taken as serious as those who are older.

• Adultism – the assumption that adults are superior to youths and can or should control, direct, reprimands and reward children.

• Sizism – the assumption that people of one body size are superior to others. This can have a great impact on small or overweight people

• Classism/Elitism – the assumption that certain people are superior to others because of their social and economic standing in the community.

• Ableism – the assumption that the able bodied and sound of mind are physically or developmentally superior to those who are disabled, retarded or other wise compromised.

Cultural Assessment

To complete a thorough cultural assessment on each patient that is admitted to the hospital is not only time consuming, but also nearly an impossible feat given the short amount of time a nurse is allotted to spend with each of her patients. Before you sit down to gather information from your patient, ask yourself the following questions.

Awareness

Am I aware of my biases and prejudices towards other cultural groups, as well as racism in healthcare?

Skill:

Do I have the skill of conducting a cultural assessment?

Knowledge

Am I aware about the worldviews of different cultural and ethnic groups, as well as have knowledge in the field of bicultural ecology?

Encounters

Do I seek out face-to-face interactions with individuals who are different from myself?

Desire

Do I really "want to" become culturally competent?

Once you completed your own personal assessment, you are ready to proceed. The following questions are ones you should ask your patient to help you create a plan of care that will be most beneficial to them.

• Where was the patient born? If an immigrant, how long has the patient lived in this country?

• What is the patient’s ethnic affiliation and how strong is the patient’s ethnic identity?

• Who are the patient’s major support people: family, friends or neighbors.

• Does the patient live in a blended cultural neighborhood, or in their own ethnic community?

• Is English their primary language, if not which language do they speak most often?

• How would they characterize their non-verbal communication? (Is looking into the eyes of an elder considered disrespectful etc.)

• What is the patient’s religious affiliation, and do they practice this on a daily basis?

• Does the patient have any food preferences, or are there foods that they do not eat?

• What is the patient’s economic situation and is the income of the patient adequate to meet their needs. (This is a hard but necessary question to ask)

• What are their health and illness beliefs and practices?

• Are their any specific health customs or traditions that the patient wishes to follow?

Cultural Communication

Even when nurses and patient’s speak the same language, mis-communication can occur because of differences in values and beliefs. Magnify this by the fact that the patient you are caring for has a cultural background that you are not familiar with, and the potential for mis-communication grows even greater. In addition to verbal communication, non-verbal cues that may represent different meanings can add to the communication dilemma. The following are considerations to keep in mind when conversing with a patient who is from a different culture then your own.

• Conversational Style and Pacing - this includes tone of voice, uncomfortable periods of silences, saying “No”, being blunt and to the point or taking a more indirect approach to communication.

• Personal Space – people often assume that the personal space that is based on their own culture, is the same space requirement of others. One example is that while one culture finds it respectful to square off and face the person they are talking to, others find this very same trait to be aggressive in nature.

• Eye Contact – as with personal space, eye contact is also another area of cultural competence that most falter with. While some may view avoiding eye contact as respectful, others may view it as sneaky and dishonest.

• Touch – every culture has norms about how and when people should touch. Some cultures prohibit the touch of specific body parts, such as ones head or feet. Other cultures are more gender based in the area of touch. As the primary care provider, the nurse must be aware of any specific rules the patient may have about touch, prior to completing any type of physical assessment.

• Time orientation – in some cultures, life is based around clock time, rather than personal or subjective time. Being on time is very important to some people and in these cases, it is very important to keep the appointments you make with these patients in order to maintain trust.

Communication Barriers:

• Natural Bias – Some things are noticed but others are not.

• Generalizations – Comparing typical behavior patterns with what is actually being observed.

• Negative Bias – Some views and strengths get left out.

• Stereotypes – Seeing what is expected, and missing what is not expected. When stereotypes are negative, prejudice moves in.

• Prejudicial attitudes – Negative expectation, thoughts or emotions that ignore actual evidence.

• Discriminatory Behaviors – Treating people unfairly: the “Ism’s.

Communication with American Indian patient’s:

Major language and dialects – most American Indians speak English. Some often use anecdotes or metaphors to discuss a situation. Verbal discourse may be carefully constructed to provide precise meaning through examples.

Literacy assessment – If vocabulary is limited an interpreter may be needed.

Nonverbal communication – Respect communicated by avoiding eye contact and keeping a respectful distance is recommended.

Greeting – Light touch or handshake. Do not refer to men as chiefs or women as squaws.

Tone of voice – Tone expresses urgency, when something is imperative be direct.

Communication with African American patient’s:

Major language and dialects – Most African Americans speak English. Some use traditional dialects in the Carolinas, Alabama and Louisiana. Black English a very expressive dialect is sometimes spoken in the inner cities. People may switch from Black English to Standard English depending on the situation.

Literacy assessment – Refusal to sign documents or consent could indicate a literacy problem. Ask what level of education the patient has completed.

Nonverbal communication – African Americans are affectionate people, they hug and show affection by touching. Eye contact shows respect, and any overt silence on the part of the patient, may be a sign of distrust for the caregiver.

Greeting – African Americans prefer to be addressed as Mr., Mrs., or Miss., followed by their last name. A handshake is appropriate.

Tone of voice – When speaking to each other, conversation can get loud and animated. This may be the same if they are feeling anxious or nervous.

Communication with Arab American patient’s:

Major language and dialects – Arabic. Please note that Egyptians also speak “Egyptian Arabic”. Different Arab countries and regions use different dialects that give different words different meanings. Although their alphabet is very similar, Iranians and Arabs do not understand each other’s language.

Literacy assessment – Arab professionals speak fluent English. Though some admit to speaking and understanding English moderately, they may have difficulty understanding health professional’s explanations and directions. Arabs tend to repeat things if they feel they are not being understood so saying you understand and repeat what is being told to you will clarify this.

Nonverbal communication – Arab Americans are expressive, warm and other-oriented. They may at times present with a flat affect to protect their true feelings. They are more comfortable with closeness from the same sex. They are very polite and may not disagree openly with what is being asked of them.

Greeting – Greet using title and first name. Approach by shaking hands and acknowledging the country of origin and something personal about the patient or family.

Tone of voice – Loud voice means message is important. Anger usually is expressed in a high intense voice by patient or family members.

Communication with Chinese American patient’s:

Major languages and dialects – Cantonese and Mandarin are the most common languages spoken.

Literacy assessment – The ability to speak and read varies from individual to individual. Elderly Chinese (especially women) may not be able to read and write. Avoid yes and no questions and attempt to ascertain whether true understanding is occurring or not.

Nonverbal communication – Eye contact and touching is noted between family members, but avoiding eye contact with elderly patients is seen as a sign of respect. Keeping a respectful distance is also recommended.

Greeting – Chinese people are often shy in an unfamiliar environment. Address elders with Mr./Mrs. and their last name. Use of the first name when initial contact is made can be viewed as disrespectful.

Tone of voice – The Chinese language is very expressive and sometimes loud. Often this loudness is interpreted as abrupt.

Communication with Filipino American patient’s:

Major language and dialects – Filipino (Tagalog) is the national language. There are however more then 85 languages and dialects spoken. Most Filipinos do speak English as a second language.

Literacy assessments – Most Filipinos speak and understand English. Using simple medical terms will assist them in understanding.

Nonverbal communication – Typically shy and affectionate. They are sometimes awkward in unfamiliar surroundings and want family members to share their space for comfort and support.

Greeting – A smile or facial expression is frequently used as a greeting, a handshake is not commonly practiced. Family members show elders respect by kissing their hand forehead or cheek.

Tone of voice – Filipino language as a practical language is not very rich. Changing the tone of their voice is done often to evoke emotion and romanticize the language.

Communication with Korean American patient’s:

Major language and dialects – older generations speak Korean, though younger generations most often speak English.

Literacy assessment – Elders may have learned to understand English from younger generation, but still may not be able to read or write English. Understanding health care terminology may require an interpreter.

Nonverbal communication – When in the comfort of friends and family, touching and hugging is acceptable. With strangers, touching is considered disrespectful except in the case of a physical examination. Personal space is frequently shared with each other but not with strangers. Silence is viewed as a tranquil, peaceful time that can be used for prayer and meditation. When conversing with each other, Korean’s are very excitable animated in communication.

Greeting – The use of Mr./Mrs./Miss and the last name unless the patient requests otherwise. Respect towards elders and authority is constantly demonstrated.

Tone of voice – Tone has a wide variety of pitches with emphasized loudness depending on what the speaker feels is important. Commands are given differently dependant on whether they are intended for an elder or a child.

Communication with Mexican American patient’s:

Major language and dialects – Some speak Spanish exclusively but the majority are bilingual and speak English as well. There are many indigenous languages in Mexico that give different meanings to different words depending on the region that one lives.

Literacy assessment – There is a great diversity in educational levels. First generation females who do not work outside of the home tend to be less likely to speak English. Younger Mexicans are more likely to not only speak English, but also read and write English. It is important to assess reading/writing skills and provide simple verbal and visual aids as appropriate.

Nonverbal communication – Respect strongly influences the use of nonverbal communication. Direct eye contact is frequently avoided when one is considered an authority. Family members may stand when someone enters the room as a form of respect. Silence sometimes shows a lack of agreement. Touch by strangers can be perceived as disrespectful and can be very stressful.

Greeting – Using formal names is considered respectful. Formal greetings should be used with elders and women. As time passes and increased comfort with caregiver is perceived, a less formal greeting is required.

Tone of voice – A respectful and polite tone is usually used. Mexican American’s are very warm and expressive. They can be noted to be reserved and quiet in an unfamiliar setting.

Communication with Vietnamese American patient’s:

Language and dialects – The three major languages spoken by the Vietnamese are Vietnamese, French and Chinese. Many have adopted English as their second language, but the ability to read/write English must be assessed.

Literacy assessment – If patient is unable to read or write English there is usually a family member present at all times who can assist them with this.

Nonverbal communication – A gentle touch may be appropriate when conversing with younger generations, but with elders and more traditional Vietnamese people touching is limited. Avoiding eye contact with those of higher standing shows respect. Slightly bowing head is a way to show respect.

Greeting – In a formal setting, the family name (which is the last name mentioned first) is the name of choice. In a more casual setting, using the given or first name is acceptable. Vietnamese greet with smile and bow rather than a handshake. Caregivers should not shake a woman’s hand unless she extends it first.

Tone of voice – typically soft spoken. Raising the tone of voice and pointing a finger are a sign of great disrespect. Indirectness and restraint rather that confrontation are the preferred method of communication.

Characteristics of Immigrant and Refugee Families:

The United States is known as a “melting pot” because except for the American Indians, we are all immigrants. Some came to the United States by choice, some were deposited here, some were sold into slavery and others were just looking for a safe haven and did not care what country that haven was to be found. In considering a care plan for your patient, understanding how and why they got here, will assist in care that brings positive outcomes. The following are some characteristics of immigrant and refugee families that should be taken into consideration:

• Traditional family values are evident when the role of the man and woman is specifically defined. For example, the woman stays at home and the man is considered the head of household.

• Families tend to be extended, if not all living in one house, they usually live in very close (often walking distance) proximity.

• Many immigrants and refugees are poor and struggle to earn an adequate income. Often men in refugee communities have been professionals in their home country but are unable to be employed in the same capacity in this country.

• Refugees may be fleeing war and political persecution. Many may experience depression, anxiety and post trauma disorders.

• Traditional health and illness beliefs may contribute or interfere with traditional Western Medical approaches. The need to incorporate herbs and homemade remedies may need to be considered.

• Language is a significant barrier for the first few years of an immigrant’s life. Children tend to learn English more quickly and acculturate faster then their parents.

Vietnamese Americans – From 1975-1977 a variety of well educated professional migrated to the U.S. From 1980-1986 this second wave of immigrants were known as the “boat people” or refugees. This group escaped on their own to seek freedom from persecution. Many spent time in refugee camps.

Expressions of pain:

Pain, which is a universally recognized phenomenon, is a very important area for a nurse to consider when taking care of multi-cultural patients. Being able to understand not only how pain is perceived, but also how it is expressed will have a significant impact on the nursing interventions. In terms of pain measurement, it is not only necessary to assess the pain threshold and individual tolerance, but also the cultural norms and influence that surround the issue of pain. The following list discusses specific cultures and how they perceive and express feelings of pain or discomfort.

American Indians – Pain is generally under treated with American Indians because in this culture is usually not specific to what is hurting them. Often statements such as “I don’t feel well”, or “something isn’t right” are expressions that will be used to describe pain. American Indian patients may complain to a trusted family members about specific pain, so in when assessing for pain, the nurse may find it beneficial to interview family members.

African Americans – Expressions of pain are generally open and public, but can as with all individuals tend to vary in degree. Using a 1-10 pain scale with this group is most effective. Of important note, some African Americans are hesitant to take pain medication for fear of becoming addicted. As the nurse it is important to educate the patient to the addiction risks of pain medication when treating severe pain.

Arab Americans – This cultural group is very vocal and expressive about pain, particularly if other family members are present. Pain is feared and sometimes causes panic when it occurs. The goal for this group is to do whatever is necessary to avoid pain altogether. If this cultural group understands the cause and prognosis for the pain, they are much more likely to deal with it appropriately. As the nurse, when dealing with African American patients who are suffering in pain, begin patient education regarding pain as soon as possible.

Chinese Americans – This cultural group most likely will not complain of pain. It is important to be aware of non-verbal cues when assessing for pain. Offering pain medication rather than waiting for the patient to request it will assist with proper pain management. Acupuncture and acupressure are alternatives that this group may use to control pain.

Filipino Americans – Stoic is the term that best describes this group when it comes to pain. As with the Chinese Americans offering pain medication rather than waiting for the patient to request it will assist with proper pain management.
Some Filipino Americans have a high pain tolerance and this might also be a reason why they do not request pain medication. “Moaning” is the most notable sign that pain is being felt. This population prefers PO or IV routes of medication and are sometimes fearful of medication that is given IM.

Korean Americans – “Ah-poom nida” means much pain and “chegesso” or “chegetta” are terms that mean “I think I might die”. For the very stoic of this population, a pain scale may be not be tangible. Instead ask “how bad is the pain” in order to get a better idea for treatment. For those who are more dramatic in expressing pain, moaning and flailing around is not unusual. Fear of addiction and/or complications makes pain management for this group sometimes difficult.

Mexican Americans – Verbalization of pain is not common but non-verbal cues are often used. For some (especially men) showing outward signs of pain is viewed as being weak. In women expression of pain is more acceptable. Using a pain scale is effective with this patient population.

Vietnamese Americans – “Dau” means pain in Vietnamese. This patient population tends to be stoic about pain. Offering pain medication rather then waiting for the patient to request it will assist with proper pain management. Some may understand a numerical pain scale if not, use facial expression of pain and then ask “how severe is it”. Fear of addiction and/or complication with this patient population as well can make pain management difficult.