CULTURAL DIVERSITY IN NURSING PRACTICE

With increasing ethnocultural diversity among health care clients and staff, health care providers must increase their sensitivity to and knowledge of cultural concepts, be aware of both similarities and differences in values and beliefs that exist across cultures, and know how this may affect health care delivery. Important objectives are to increase respect and sensitivity for diversity in order to minimize potential for transgressing cultural norms, and to provide culturally conscious health-care and working relationships among clients and staff from dissimilar cultures.

The purpose of this section is to provide a framework/ structure for assessing, planning, and implementing culturally conscious interventions.

We have selected 10 essential areas as guidelines for assessing cultural characteristics that have implications for health and health care: communication, family roles, biocultural ecology, high-risk health behaviors, nutrition, pregnancy and childbearing practices, death rituals, spirituality, health care practices, and health care practitioners.

1. Communication
1. Language
1. What is the usual volume and tone of speech?
1. Guidelines: use interpreters (to provide meaning behind words) rather than translators (who just restate words); avoid use of relatives and children; use interpreters of same age and gender when possible. Select the words you use carefully, avoiding buzz words and jargon. Speak clearly, pacing yourself to be neither too fast nor too slow. Words that are slurred, have many syllables in them, or are too technical make communication more difficult. Speaking too fast may overload the client and make it difficult for the client to follow. Speaking too slowly may lose the client’s attention.
1. Select the gestures you use with care, using your nonverbal behavior to underscore your words and your actions. The proper use of gestures can clarify a message, and drawings can sometimes be helpful. Be careful, however; not all gestures mean the same thing in all cultures.
2. Cultural communication patterns
1. Willingness to share their thoughts and feelings.
2. Use and meaning of touch between family, friends, same sex, opposite sex, with health-care provider.
3. Personal space: meaning of distance and physical proximity.
4. Eye contact: special meaning for staring (rude, “evil eye”); for avoidance of eye contact (e.g., not caring, not listening, not trustworthy); variation of eye contact among family, friends, strangers, and socioeconomic groups.
5. Facial expression: how emotions are shown (or not) in facial expressions; use and meaning of smiles.
6. Standing greeting strangers: what is acceptable.
3. Concept of time: past, present or future oriented; social time vs. clock time.
4. Names: expected greetings by health-care providers.


2. Family roles
1. Gender roles: patriarchal or egalitarian; change in perceived head of household during different life stages; male/female norms (e.g., stoic, modest)
2. Prescriptive (should do), restrictive (should not do), taboo behaviors for children and adolescents
1. Prescriptive: e.g., “Fat children are healthy.”
2. Restrictive practices: e.g., silence, not anger, at parents.
3. Taboo: e.g., discussion of sexuality.
3. Family roles and priorities
1. Family goals and priorities (family needs may have priority over individual health needs).
2. Developmental tasks.
3. Aged: status and role.
4. Extended family (biologic and nonbiologic): role and importance.
5. How social status is gained: through heritage? Educational accomplishments?
4. Alternative lifestyles
1. Nontraditional families: single parents, blended families, communal families, same sex families.


3. Biocultural ecology
1. Variations in color of skin and biologic variations
1. Skin color: special problems/concerns: assessment of jaundice, mongolian spots, and blood/oxygenation levels in dark skin. Considerations for health care:
1. Assessment of anemia: examine oral mucosa and nail bed capillary refill.
2. Assessment of jaundice (e.g., in Asian people): look at sclera.
3. Get a baseline of skin color from family, d. Use direct sunlight.
4. Look at areas with least amount of pigmentation.
5. Rashes: palpate.
6. Compare skin in corresponding areas.
2. Biologic variations in body, size, shape, and structure: long bones, width of hips and shoulders, flat nose bridges (relevance for fitting eyeglasses), shorter builds (at variance with normative growth curves); mandibular and palatine dimensions (relevance for fitting dentures); teeth (peg, extra, natal, large size); ears (free, floppy, attached); eyelids (epicanthic folds).
3. Diseases and health conditions:
1. Specific risk factors related to climate, topography (e.g., air pollution, mosquito infested tropical areas).
2. At-risk groups for endemic diseases (those that occur continuously in a specific ethnic group): e.g., malaria, liver and renal impairment, infectious blindness and scleral infections, otitis media, respiratory diseases (e.g., tuberculosis, coccidiomycosis).
3. Increased genetic susceptibility for diseases and health conditions (e.g., diabetes, dwarfism, muscular dystrophy, cystic fibrosis, myopia, keloid formation, gout, cancer of stomach is more prevalent in blood type O, sickle cell anemia, Tay-Sachs).
4. Variations in drug metabolism: e.g., cardiovascular effects of propranolol in Chinese; peripheral neuropathy in Native Americans in isoniazid.
5. Variations in blood groups, e.g., Native Americans usually are type O and no type B; Rh negative nonexistent in Eskimos, more often in Whites; twinning (dizygote) is highest among African-Americans.


4. High-risk behaviors
1. Use of alcohol, tobacco, recreational drugs
2. Level of physical activity; increased calorie consumption
3. Use of safety measures (e.g., seat belts and helmets and safe driving practices)
4. Self-care using folk and magico-religious practices before seeking professional care


5. Nutrition
1. Meaning of food: symbolic, socialization role; denotes caring and closeness and kinship, and expression of love and anger
2. Common foods and rituals
1. Major ingredients commonly used (high sodium, fat, spices).
2. Preparation practices, e.g., Kosher does not mix meat with dairy (cooking, eating, serving).
3. Afternoon tea (British), morning coffee (American).
4. Fasting (e.g., Muslims, Catholics, Jews).
5. Foods not allowed (e.g., no shell fish or pork in kosher diet).
3. Nutritional deficiencies and food limitations
1. Enzyme deficiencies (e.g., in glucose-6phosphate dehydrogenase deficiency, fava bean can cause hemolysis and acute anemic crisis).
2. Food intolerances (e.g., lactose deficiency).
3. Significant nutritional deficiencies, such as calcium (Southeast Asian immigrants).
4. Native food limitations that may cause special health difficulties, such as poor intake of lysine and other amino acids (Hindu).
4. Use of food for health promotion, to treat illness, and in disease prevention
5. “Hot and cold” theories.
6. Pregnancy and childbearing practices
1. Fertility and views toward pregnancy, contraception, and abortion
2. Prescriptive, restrictive, and taboo practices related to pregnancy, birthing practices, and postpartum period
1. Pregnancy: foods, exercise, intercourse, and avoiding weather-related conditions.
2. Birthing process: reactions during labor, presence of men, position for delivery, preferred types of health-care practitioners, place for delivery.
3. Postpartum period: bathing, cord care, exercise, foods, role of men.


7. Death rituals
1. Death rituals and expectations
1. Cultural expectations of response to death and grief.
2. Meaning of death, dying, and afterlife.
1. Euthanasia.
2. Autopsies.
2. Purpose of death rituals and mourning practices
3. Specific burial practices (e.g., cremation)


8. Spirituality
1. Use of prayer, meditation or symbols
2. Meaning of life and individual sources of strength
3. Relationship between spiritual beliefs and health practices


9. Health care practices
1. Health-seeking beliefs and behaviors
1. Beliefs that influence health-care practices.
1. Perception of illness (e.g., punishment for sin, work of malevolent persons).
2. Health promotion and prevention practices.
1. Acupuncture.
2. Yin and yang.
1. Increased yin results in nervous, digestive disorders.
2. Increased yang results in dehydration, fever, irritability.
2. Responsibility for health care
1. Acute care: curative or fatalistic.
2. Who assumes responsibility for health care?
3. Role of health insurance.
4. Use of over-the-counter medications.
3. Folklore practices
1. Combination of folklore, magico-religious beliefs, and traditional beliefs that influence health-care behaviors.
4. Barriers to health care (e.g., language, economics, geography)
5. Cultural responses to health and illness
1. Beliefs and responses to pain that influence interventions.
1. Special meaning of pain.
2. Beliefs and views about mental illness/mental health care.
1. Therapies must include extended families as opposed to individuals or nuclear families.
2. Cultural and racial as well as individual components must be considered when assessing precipitating or predisposing causes of illness (e.g., need to atone for sins).
3. Values may conflict: for example, individualism versus concern for family or social interactions; self-actualization versus survival needs.
4. Some ethnic groups do not value or possess qualities required for some psychiatric therapies, such as verbal skills, introspection, ability to delay gratification, ability to discuss personal problems with strangers.
5. Therapy resources may not be accessible or considered useful or relevant for members of some ethnic groups.
6. Common feelings and behavior patterns may be shared by many “minority” groups:
1. Feelings of inferiority and inadequacy, often a result of prejudice and racism.
2. Incompetent behavior as an outcome of feeling inferior and inadequate.
3. Suppressed anger, resulting in displaced hostility and paranoid ideas.
4. Withholding and withdrawal; not comfortable with sharing feelings or experiences.
5. Selective inattention; may block out or deny frustration or insults.
6. Overcompensation in some areas to make up for denied opportunities in other areas.
3. Different perception of mentally and physically handicapped.
4. Beliefs and practices related to chronic illness and rehabilitation.
5. Cultural perceptions of the sick role.
6. Acceptance of blood transfusions and organ donation


10. Health care practitioners
1. Traditional vs. biomedical care
1. Does the age of practitioner matter?
2. Does the gender of practitioner matter?
2. Status of health-care provider
1. How different members of health-care practice see each other.