Chapter 6 Timby Culture & Ethnicity -
Differentiate culture, race, and ethnicity
Culture: A learned, shared, and dynamic system of values, beliefs, and practices (language, traditions, health practices) passed through generations.
Learning Objectives Answered
Race: Biological variations used to categorize people based on genetically shared physical characteristics (e.g., skin color, hair texture) considered socially significant.
Ethnicity: A sense of kinship or bonding based on common ancestry, shared language, and cultural practices from a country of birth or ancestral origin.
Discuss the factors that interfere with perceiving others as individuals
Stereotyping: Fixed, preconceived attitudes or "mental shortcuts" about groups (age, gender, sexual preference).
Ethnocentrism: Believing one's own ethnicity is superior to others, treating others as deviant or undesirable.
Ageism: Negative stereotypical thinking promoting false beliefs about older adults being impaired or burdensome.
Explain why U.S. culture is described as anglicized
U.S. culture is primarily English-based because it evolved from the language, customs, legal systems, and cultural practices of early English settlers.
List characteristics of Anglo-American culture
Use of English language; greetings via handshake; personal space of 4 to 12 ft; Christianity as the majority religion; monogamous marriage; legal equality of genders; focus on technology in healthcare; time-oriented/rigid scheduling; and use of forks/knives for eating.
List the predominant cultures present in the United States
European Americans (White), African Americans (Black), Latinos (Hispanic/Spanish Origin), Asian Americans, Native Americans/Alaska Natives, and Native Hawaiian/Pacific Islanders.
List the diversities in people according to their culture
Differences in age, sex, gender, race, health status, education, religion, occupation, economics, communication styles (eye contact, touch), hygiene practices, and dietary customs.
Describe characteristics of culturally sensitive care
It involves Awareness (recognizing biases), Attitude (analyzing belief systems), Knowledge (understanding disconnects between beliefs and behaviors), and Skills (integrating respectful communication and body language).
List ways to demonstrate cultural sensitivity
Gather data through cultural assessments, respect personal space/touch norms, use certified medical interpreters (never children), integrate helpful cultural rituals into care plans, and avoid ridiculing cultural beliefs.
Words To Know
African American: Individuals whose ancestral origin is Africa; may prefer the term "Black."
Ageism: Negative stereotypical thinking regarding older adults being physically/cognitively impaired.
Asian Americans: Individuals of Asian ancestry originating from countries like China, Japan, Korea, the Philippines, Thailand, or India.
Bilingual: Ability to communicate effectively in two different languages.
Certified Interpreter: A trained professional who facilitates communication while maintaining confidentiality and accuracy.
Cultural Shock: Bewilderment or disorientation experienced when encountering culturally unfamiliar behaviors.
Culturally Sensitive Care: Care that recognizes the need for respect and acknowledgment of the wholeness of all humans regardless of background.
Culture: Ways in which people live and express themselves; learned from birth and shared by a group.
Diversity: Differences among groups of people based on age, sex, race, religion, etc.
Ethnicity: Pride or kinship felt with a country of birth or place of ancestral origin.
Ethnocentrism: The belief that one’s own ethnicity is superior to all others.
Folk Medicine: Healthcare provided by lay providers such as curanderos, shamans, or herbalists.
Generalization: A flexible supposition that a person shares characteristics with a group, used as a springboard for further assessment.
Latino: A term for those from Mexico, Puerto Rico, Cuba, Central/South America, or other Spanish-speaking countries.
Limited English Proficiency (LEP): Inability to speak, read, write, or understand English at a level for effective interaction.
Minority: A group that coexists with a dominant group but has less political or economic power/control.
Native American: Descendants of indigenous peoples of the U.S., belonging to 574 federally recognized tribes.
Race: Categorization based on significant biological and physiological similarities.
Stereotypes: Overgeneralized beliefs that interfere with seeing people as unique individuals.
Telephonic Interpreting: Using a phone service to provide language interpretation.
Transcultural Nursing: Providing nursing care within the context of the client’s culture.
European American: Individuals with origins in Europe, the Middle East, or North Africa.
Introduction to Client Diversity
Individual Variance: Clients vary by age, sex, gender, race, health status, education, religion, and economic level.
Cultural Sensitivity Components:
Awareness: Understanding one's own biases.
Attitude: Actively analyzing internal beliefs.
Knowledge: Acknowledging disconnects between belief and behavior.
Skills: Integrating behavior like respectful body language and communication into daily practice.
Gerontologic Considerations:
In 2019, there were 54.1 million people aged 65+ in the U.S.
Projections: 80.8 million by 2040; 94.7 million by 2060.
Older adults may blend traditional healing with Western medicine.
Ageism can lead to shorter, less effective communication from nurses.
Concepts Related to Culture
Culture: Learned from birth, shared by members, influenced by technology, and dynamic.
Race: Classification of people based on genetically shared physical characteristics.
Minority Status: Refers to a group’s status in terms of power and control.
Ethnicity: Kinship with ancestral origin; becomes more noticeable when cultural groups interact.
Factors Affecting Perception
Stereotyping: Fixed attitudes based on age, gender, race, etc. They are unsupported by facts.
Generalization: A flexible supposition used to learn about uniqueness.
Example: Assuming a Latino patient is Roman Catholic is a generalization that must be verified by the nurse before acting.
Ethnocentrism: Treating those perceived as "different" as deviant and undesirable.
Cultures in the United States
4.1. Dominant Characteristics (Box 6-1)
Language: English is primary; regional variations in pronunciation exist.
Greetings: Handshake; 4 to 12 ft personal space for business interactions.
Apparel: Pants/jeans are standard for all genders.
Religion: Majority are Christian (Sabbath on Sunday); government separate from religion.
Marriage/Family: Individual choice of partner; monogamy standard; aging adults usually live separately.
Hygiene: Daily bathing/deodorant is standard; women often shave legs/underarms.
Healthcare: High value on technology, licensed practitioners, drugs, and surgery.
4.2. Demographics (Tables 6-2 & 6-3)
White: Origins in Europe, Middle East, or North Africa (52\% in 2022).
Hispanic/Latino: People from Latin American countries, regardless of race (15.6\% in 2022).
Black/African American: Origins in Africa, Haiti, Jamaica (10\% in 2022).
Asian: Origins in East/Southeast Asia or Indian subcontinent (5\% in 2022).
Native American: Indigenous peoples with tribal affiliation (0.9\% in 2022).
4.3. Specific Group Nuances
Asian Americans: tend to provide brief or factual answers with little elaboration due to values of simplicity and introspection. They may avoid disagreeing with authority (harmony) which can conceal potential nonadherence to treatments.
Native Americans: Often prioritize oral history; may be wary of nurses who write notes during the interview (it is better to write after). They belong to 574 recognized tribes.
African Americans: Deep mistrust exists due to historical unethical research (e.g., Tuskegee Syphilis Study). Professionalism via titles/last names and open-ended questions build trust.
Latino People: High value on physical closeness. Latino men may exhibit machismo (virility/strength mandates dealing with emotion privately), making them less likely to discuss symptoms or feelings.
Transcultural Nursing
Definition: Coined by Madeleine Leininger; providing care within the context of the client’s culture.
Cultural Assessment Areas: Language, hygiene/modesty, special clothing, religious rituals (birth/death), family roles, dietary habits, and health beliefs.
Language and Communication
6.1. Legal Rights (LEP)
Title IV Civil Rights Act (1994): Entitles LEP clients to equal healthcare access.
Joint Commission (TJC): Requires qualified interpreters. Using children or family is a civil rights violation.
6.2. Interpreters
Certified Interpreters: Rigorous professional testing; possess medical vocabulary knowledge.
Characteristics (Box 6-2): Respectful, accuracy without personal commentary, preserves emphasis/emotion, indicates cultural communication barriers.
Alternative Methods: Telephonic/video interpreting, voice-to-text apps, and picture communication boards.
6.3. Communication Expectations
Eye Contact:
European Americans: Value direct contact throughout interactions.
Asian/Native Americans: May view lingering eye contact as an invasion of privacy or disrespectful.
Arab Culture: Strong eye contact can indicate honesty, but Arab women may avoid eye contact with men to prevent misinterpretation as flirtation.
Space & Distance:
Asian American clients: May prefer nurses to remain at more than an arm's length away.
Touch:
Southeast Asia: The head is sacred (permission required). The area between a female’s waist and knees is intensely private; avoid male-to-female touch if possible.
Emotional Expression:
European/African Americans: Freely express feelings.
East Asian backgrounds: May be stoic and not vary facial expressions even with high pain intensity.
Dietary Customs and Religious Beliefs
7.1. Religious Practices (Table 6-4)
Judaism: Sabbath (Friday sundown to Saturday sundown). Kosher laws (no shellfish; meat and dairy not mixed). Burial within 24 hours.
Catholicism: Birth control/abortion forbidden. Baptism necessary for salvation; any baptized Christian can perform it in emergencies.
Jehovah’s Witnesses: Refuse blood transfusions (blood is the soul).
Seventh Day Adventist: Strict dietary laws (vegetarian/no caffeine). Saturday is Sabbath.
Christian Scientist: Prayer is the antidote for illness; practitioners assist with healing.
Amish: Reluctant to spend unnecessarily on healthcare. Formal education to 8th grade. Photos not permitted.
Hinduism: Modesty/hygiene valued (daily bath). Vegetarianism; beef forbidden. Religious forehead mark (pundra) should not be removed.
Islam (Muslim): Prayer 5 times a day facing Mecca. Pork and alcohol forbidden. Only relatives touch/wash the body after death.
7.2. Nutrition & Acculturation
Dietary Acculturation: People move and change eating behaviors. Often leads to increased fat/sugar (Typical American Diet) and decreased fruits/fiber.
Specific Foods:
Mexican American: Atole (traditional cornmeal drink) used for comfort and recovery post-delivery (la cuarentena).
African American: Southern roots include greens, grits, cornbread, and fatty meats.
Asian: Southeast/Northeast diets may be high in sodium (soy sauce) and Southeast/South diets lack fresh fruit.
Muslim: Seek halal meat slaughtered according to ritual.
Health Beliefs & Biologic Variations
8.1. Illness Perspectives
Biomedical/Scientific: Based on research, microorganisms, and data.
Naturalistic/Holistic: Balance between humans and nature. Includes Yin/Yang (balanced forces) and Hot/Cold theory (common in Latino/Caribbean cultures).
Magico-religious: Supernatural forces, faith healing, and African Diaspora religions (Vodou/Voodoo).
8.2. Biologic Variations
Concept Mastery: Always incorporate beliefs (e.g., inviting a tribal leader/medicine person for Native Americans).
Skin Assessment on People of Color:
Use natural or bright artificial light.
Best inspection sites: Palms of hands, feet, and abdomen (least pigmentation).
Observe for absence of underlying red tones.
Enzymatic Variations:
Lactase deficiency: Difficulty digesting milk (high in African/Asian/Native Americans).
G-6-PD: Affects RBC stability (Mediterranean/African).
ADH: Affects alcohol metabolism.
Introduction to Client Diversity
Individual Variance: Clients vary by age, sex, gender, race, health status, education, religion, and economic level.
Cultural Sensitivity Components:
Awareness: Understanding one's own biases.
Attitude: Actively analyzing internal beliefs.
Knowledge: Acknowledging disconnects between belief and behavior.
Skills: Integrating behavior like respectful body language and communication into daily practice.
Gerontologic Considerations:
In 2019, there were 54.1 million people aged 65+ in the U.S.
Projections: 80.8 million by 2040; 94.7 million by 2060.
Older adults may blend traditional healing with Western medicine.
Ageism can lead to shorter, less effective communication from nurses.
Characteristics of Anglo-American Culture
Language: English is primary; regional variations exist.
Greetings: Handshake; 4 to 12 ft personal space for business.
Religion: Majority are Christian (Sabbath on Sunday); government separate from religion.
Marriage/Family: Individual choice of partner; aging adults usually live separately.
Hygiene: Daily bathing/deodorant is standard; women often shave legs/underarms.
Healthcare: High value on technology, licensed practitioners, drugs, and surgery.
Cultural Group Nuances in the United States
African Americans: Deep mistrust exists due to historical unethical research (e.g., Tuskegee Syphilis Study). Professionalism via titles/last names and open-ended questions build trust.
Latino People: High value on physical closeness. Latino men may exhibit machismo (virility/strength mandates dealing with emotion privately), making them less likely to discuss symptoms.
Asian Americans: Tend to provide brief answers with little elaboration. They value harmony and may avoid disagreeing with authority, which can conceal nonadherence.
Native Americans: Prioritize oral history; may be wary of note-taking during interviews. Belongs to 574 recognized tribes.
Health Beliefs and Practices
Perspectives on Illness:
Biomedical/Scientific: Based on research, microorganisms, and data.
Naturalistic/Holistic: Balance between humans and nature. Includes Yin/Yang and Hot/Cold theory (common in Latino/Caribbean cultures).
Magico-religious: Supernatural forces, faith healing, and African Diaspora religions (Vodou/Voodoo).
Folk Medicine: Traditions outside mainstream practice provided by lay providers (curanderos, medicine people, herbalists).
Complementary and Alternative Medicine (CAM):
Homeopathy: Uses diluted substances to trigger symptoms similar to the illness to trigger healing.
Naturopathy: Uses botanicals, nutrition, and acupuncture to restore balance.
Chiropractic Medicine: Focuses on spinal misalignment and joint manipulation.
Environmental Medicine: Proposes that environmental allergies affect health; advocates reducing chemical exposure.
Acupuncture: Traditional Chinese medicine used commonly for pain and stress management.
Language and Communication
Legal Rights (LEP): Title IV Civil Rights Act (1994) entitles LEP clients to equal access. The Joint Commission (TJC) requires qualified interpreters.
Interpreters: Certified professionals who preserve accuracy and confidentiality. Children or family members should never be used as interpreters.
Eye Contact:
European Americans: Value direct contact.
Asian/Native Americans: May view lingering eye contact as disrespectful or an invasion of privacy.
Arab Culture: Eye contact indicates honesty, but women may avoid it with men to prevent misinterpretation.
Touch and Space:
Southeast Asia: The head is sacred; permission is required to touch. Areas between the waist and knees are intensely private.
Biologic Variations & Skin Assessment
Skin Assessment on People of Color:
Use natural or bright artificial light.
Best inspection sites: Palms of hands, feet, and abdomen.
Washcloth Discoloration: Nurses should not misinterpret brown discoloration on a washcloth as poor hygiene; it is the normal shedding of pigmented dead skin cells.
Pigmentation Conditions:
Hypopigmentation: Skin lacks uniform color; damaged skin may show temporary redness fading to a lighter hue.
Vitiligo: Irregular white patches due to absence of melanin; causes no physical symptoms but potential emotional distress.
Congenital Dermal Melanocytosis (CDM): Dark blue hyperpigmented areas on the lower back/abdomen in children with dark skin. These are not bruises; they are painless upon pressure and usually fade by age 5.
Hair Characteristics: Texture results from protein molecules. Wide-toothed combs, moisturizing creams, and wetting hair before grooming help manage curly hair textures.
Enzymatic Variations
Lactase Deficiency: Absence of the enzyme that converts lactose into glucose and galactose. Prevalent in African, Latino, and Chinese ancestry.
Symptoms: Cramps, gas, and diarrhea 30 minutes to 2 hours after dairy ingestion.
Teaching for Lactose Elimination:
Avoid packaged foods with dry milk solids or whey.
Use non-dairy creamers or Acidophilus milk.
Use Lactaid or Kosher (Pareve) foods.
Alternative calcium sources: Green leafy vegetables, sardines/salmon with bones, dates, and whole grains.
G-6-PD Deficiency: Red blood cells lack an enzyme for glucose metabolism, making them vulnerable to destruction during stress (anemia). Sex-linked (males affected).
Triggers: Aspirin (Acetylsalicylic\ acid), NSAIDs (Ibuprofen, Naproxen), and Sulfonamides (Bactrim).
Alcohol Dehydrogenase (ADH) Deficiency: Often seen in Asian and Native American populations. Results in vascular flushing and rapid heart rate due to toxic acetaldehyde metabolites remaining in the system.
Disease Prevalence and Mortality
Leading Causes of Death (2019):
Heart Disease: #1 for All Americans, Black/African Americans, Hispanic/Latino, and Native Americans.
Cancer: #1 for Asian/Pacific Islanders; #2 for all other major groups.
Social Factors: Homicide is a top 10 cause for African Americans. Suicide is a top 10 cause for Native Americans, Latinos, and Asians.
Liver Disease/Cirrhosis: Ranked #4 for Native American populations.
Pharmacologic Considerations: Genetic variations influence medication outcomes. Drugs for depression/schizophrenia may be more effective for those of African or Asian descent.
Socioeconomic Impact: Poverty leads to limited access to preventive care, resulting in higher mortality for underserved communities.
Culturally Sensitive Nursing Care
Foundational Step: Accepting that the United States is multicultural and recognizing the existence of health care disparities.
Key Recommendations:
Interaction Techniques: Use culturally sensitive techniques such as sitting in the client’s comfort zone and making appropriate eye contact.
Knowledge of Differences: Become familiar with physical differences among racial groups to perform accurate assessments.
Assessment Skills: Learn to perform physical assessments (especially of the skin) using techniques that yield valid data for different populations.
Collaborative Planning: Consult clients about their beliefs regarding health, illness, and techniques for healing. Consult the client on ways to solve health problems.
Non-Judgmental Attitude: Never ridicule cultural beliefs or practices, verbally or nonverbally.
Integration: Integrate helpful or harmless cultural practices (like "smudging" or specific symbols) into the care plan. Guide clients in modifying only unsafe practices.
Symbolic Items: Avoid removing religious clothes or items (e.g., safety pins, amulets). If removal is necessary for safety, keep them secure and replace them as soon as possible.
Food & Rituals: Provide cultural food preferences when possible. Facilitate rituals by healers identified within the client's belief system.
Advocacy: Advocate for routine screening for diseases to which certain clients are genetically prone (e.g., G-6-PD, Sickle Cell).
Professional Growth: Apologize for violations of traditions and consider learning a second language to bridge gaps.
Clinical Applications & NCLEX-Style Review Notes
Priority in Teaching: When teaching a Latino client about dietary changes (e.g., for diabetes), the first step is to determine the client’s food likes and dislikes before providing specific meal plans.
Assessment Positioning: For cultural assessments, the best technique is to position oneself just beyond an arm's length away to respect personal space while remaining engaged.
Skin Assessment in Infants: A nurse observing a bluish area on an African American infant’s buttocks should document it as a normal finding (CDM) rather than reporting abuse.
Harmless Rituals: If a client uses "smudging" to cleanse negative energy, the nurse should suggest that the client include the ritual alongside the physician’s treatment rather than discouraging it.
Dietary Restrictions (Orthodox Judaism): Appropriate menu choices include Tuna filet and Baked chicken; Pork chops, Crab salad, and Bacon are forbidden.
Home Health Planning: For non-English speaking clients, a nurse prepares by arranging for a certified medical interpreter and researching the client's specific cultural background.