After reading this chapter, the nurse will be able to:
Describe Chinese philosophy, beliefs, and values.
Explain the ways that Chinese Americans communicate.
Describe the influences of the family system on Chinese Americans.
Explain the time concept of Chinese Americans.
Describe the illness behaviors of Chinese Americans.
Identify the biological variations of Chinese Americans.
Articulate the implications of providing effective nursing care for Chinese Americans.
Overview of China
China (the People’s Republic of China), literally “Central Kingdom,” occupies the eastern portion of Asia and is slightly larger in area than the United States ( ). In fact, China occupies roughly 3,705,386 square miles (9,596,960 square kilometers) ( ). The coastline of China is roughly a semicircle. The topography and climate of China are extremely varied. The greater part of China is mountainous; it is only in the lower portions of the Yellow and Yangtze rivers that there are any extensive low plains. The principal mountain ranges include the Tien Shan (translates as “Celestial Mountains”) in the northwest part of the country; the Kunlun chain, which runs south of the Takla Makan and Gobi deserts; the Tanggula mountain range, which connects the Kunlun chain with Tibet ( ); and the Da Xing, a mountain range in northeast China. Mount Everest on the border with Nepal is the world’s tallest peak. The major plains in China include the Northeast Plain, the Inner Mongolia Plain, the Central Plain, the lower Yangtze Plain, and the Pearl River Delta Plain.
In July of 2014, the total population of China was estimated at 1,355,692,576 ( ; ). The average annual growth was 12.79 million, or an average rate of natural increase of 0.44% ( ). The birth rate in China is 12.17 per 1000, compared with 16.3 per 1000 for the United States ( ). In 2014, the infant mortality rate in China was 14.79 per 1000, compared with 9.8 per 1000 for the United States ( ; ). The population of China makes it one of the densest countries in the world (353 people per square mile).
China has some of the largest cities in the world by population. The capital city of China is Beijing (translates as “northern capital” and was previously known as Peking ), which has an estimated population of 11,106,000. The largest city in China is Shanghai (translates as “on-the-sea”), which has an estimated population of 14,987,000. Other large cities include Tianjin (7,180,000 metro area), Guangzhou (8,829,000), Wuhan (7,243,000), and Xi’anguan (4,528,000) ( ; ).
The principal agricultural products of China include rice, wheat, potatoes, grains, tea, and cotton. In 1998, the makeup of the labor force by occupation sector was as follows: agriculture, 50%; industry, 24%; and services, 26% ( ; ). Major exports are machinery and equipment, textiles and clothing, footwear, toys and sporting goods, and mineral fuels ( ; ). In 2010, China overtook Japan as the world’s second largest economy ( ).
The president of China is Xi Jinping (2013–), and the premier is Li Keqiang (2013–). The ruling governmental authority in China is the Communist Party. The National People’s Congress is the chief legislative organ. Within the governmental hierarchy, the State Council has the executive authority. It is the Congress that elects the premier and the deputy premiers. In China, the ministries are under the auspices of the State Council headed by the premier.
According to incomplete statistics, China has 300 million religious believers. Among them, there are 14 million Christians (10 million Protestants, 4 million Catholics) and 18 million Muslims. In addition, there are 13,000 Buddhist and 1500 Taoist temples ( ).
Overview of Chinese Americans
The majority of Chinese Americans are immigrants from Taiwan, Hong Kong, and mainland China. Today, the 3,535,382 Chinese Americans constitute the largest group of Asian Americans ( ). This new figure represents a 37.9% growth rate from 1990 to 2010. This figure compares with 104.1% from 1980 to 1990. Chinese Americans residing in the United States represent 0.7% of the total U.S. population ( ). Of the number of Chinese Americans residing in this country, 52.4% live in the West, 27.0% live in the Northeast, 12.4% live in the South, and 8.1% live in the Midwest ( ). The states with the largest populations of Chinese Americans are California (704,850), New York (284,144), and Hawaii (68,804). A total of 66% of Chinese Americans live in five states: California, New York, Hawaii, Illinois, and Texas ( ; ).
Of the Chinese Americans residing in the United States before 1975, 18.5% were foreign born; of the number residing in the United States between 1975 and 1979, 11.4% were foreign born; and of those entering in 2000 or later, 29.3% were foreign born. Immigration has definitely contributed to the growth in the Chinese-American population over the past two decades. It is interesting to note, however, that the percentage of Chinese Americans who are foreign born differs considerably across time periods. The median age of Chinese Americans residing in the United States is 35.5 years, compared with 36.7 years for the general U.S. population. In addition, only 11.0% of all Asian Americans are 65 years of age or older, compared with 12.7% of the general U.S. population ( ; ).
Chinese Americans are noted for maintaining high educational standards. For example, in 2009, 81.2% of Chinese-American males and 82.8% of Chinese-American females 25 years of age or older held a high school diploma; 45.2% of Chinese American males and 49.3% of Chinese-American females held a bachelor’s degree ( ; ).
Of the number of Chinese Americans in the United States, 65.1% participate in the workforce. Chinese Americans have lower labor force participation rates than Filipinos (71.0%) and Asian Indians (72.3%). The poverty rate for Chinese Americans is 9.5%, compared with 14.3% for the general U.S. population ( . This lower rate represents the first time in a decade that the poverty rate is lower than that of the general U.S. population.
There is a bimodal distribution with regard to socioeconomic status and educational attainment in the U.S. Asian and Pacific Islander population, including Chinese Americans (U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2015; ). The median family income for Chinese Americans is $81,323 compared with $62,367 for the rest of the general U.S. population ( ). As a subgroup, the socioeconomic status and educational attainment of Chinese Americans are comparable to those of Asian Indians, Japanese, and Korean Americans but higher than those of other Asian subgroups, such as Filipinos, Vietnamese, Laotians, Cambodians, and Thais. In other words, there is a significant segment of Chinese Americans who are college-educated professionals with high income. At the same time, there are a large number of barely literate individuals of Chinese descent working in low-paying occupations ( ).
The contrasting socioeconomic characteristics of the Chinese immigrants in different historical periods determined, to a large extent, their educational attainment and their occupations. Before 1965, most Chinese immigrants had little or no education, and many were alone because their families were not allowed to immigrate with them. They were forced to immigrate for political, social, or economic reasons. The majority of them came from Guangdong Province and took up occupations such as mining, railroad construction, and farming or engaged in small family businesses, such as restaurants, laundries, and groceries. After 1965, when immigration laws changed in the United States to seek skilled labor, better educated professionals and specialists began to immigrate. Now families were also allowed to immigrate together. These immigrants came from Taiwan, mainland China, and Hong Kong. As a result, a wide cultural and linguistic diversity exists among Chinese Americans.
Chinese culture is dominated by Confucianism, which encourages individuals to pursue reciprocity, benevolence, respect for authority, self-improvement, filial piety, righteousness, modesty, integrity, and wisdom. A harmonious relationship with nature and other people is stressed, and a person is expected to accommodate rather than confront. If individual interests conflict with community interests, a person is expected to submit to the interest of the group. Public debating of conflicting views is perceived as socially unacceptable. A person is expected to be sensitive to what other people perceive and think and to be gracious toward others so as not to make them “lose face.” Self-expression and individualism are discouraged, whereas showing filial piety to parents and loyalty to family, friends, and government is highly valued. Modesty, self-control, self-reliance, self-restraint, and face-saving are taught at home and school and are indicators for maturity and consistency with the cultural norms. When they fail to follow these cultural practices and meet these expectations, many Chinese may feel shame or guilt ( ). In fact, shame is such an important concept and its influence is so prevailing in the Chinese society, Chinese culture has been termed as a “shame-oriented culture” by some scholars ( ). Consequently, the Chinese appear to be quiet, polite, pleasant, and unassertive and often suppress personal feelings such as frustration, disagreement, anger, or pain.
Reciprocation, or treating others as one would wish to be treated, is often practiced and expected in interpersonal relationships. Interpersonal interactions have a hierarchical structure, so that older or higher-status people have authority over younger or lower-status people. A person’s status is always referred to during interactions. For example, brothers address each other as “older brother” and “younger brother” in addition to the first name. Educational achievement and professional success are highly valued because pride and honor are brought to the family and the community as a result. Therefore, Chinese parents not only willingly support their children who pursue education but also frequently sacrifice, at almost any cost, to ensure a good education for their children.
The sharp contrasts between the Chinese and American cultures often cause a high level of stress among Chinese Americans during the acculturation process. Some may hold onto traditional Chinese culture, observe holidays according to the lunar calendar, and maintain Chinese customs; some may reject their traditional heritage; and some may assimilate both the Chinese culture and the American culture. Poorly adjusted individuals may not be able to perform work productively, may have low self-esteem, and may exhibit some lawless behaviors. Second- and third-generation Chinese Americans, who are already well acculturated into Western culture, may not be influenced much by traditional Chinese culture. However, they may experience an identity issue of being culturally and linguistically American, even though others perceive them as Chinese ( ). Of the number of Chinese Americans 5 years of age or older residing in the United States, 82.7% speak a language at home other than English; 46.4% speak English less than very well; and 17.3% speak only English at home ( ).
A wide cultural and linguistic diversity exists among Chinese Americans. Linguistic diversity may cause communication problems among Chinese people. Although the official Chinese language is Mandarin (Putonghūa), there are many dialects spoken that are not understood by other groups of Chinese. However, all the dialects have the same written characters and grammatical structures, which have been relatively stable for 3000 years despite having undergone great changes. This stability in the language permits all literate Chinese to be able to communicate in writing. Each Chinese character (or logogram) consists of only one syllable. Each character has its own meaning, but if one character is combined with one or more characters, the combination produces words or phrases with different concepts. There are four tones in Mandarin (as well as a neutral tone), and changes of tone produce complete changes in the meaning of a syllable or a word. For instance, ma may mean “mother” with the flat tone, “numbness” with the rising tone, “horse” with the curving tone, and “scold” or “curse” in the falling tone. Undoubtedly, the complexity arising from toning is one of the toughest challenges for any non-Chinese trying to master the spoken language. On the other hand, the Chinese language generally does not use copulas and plurals (although both exist) and has no tenses.
Style, Volume, and Touch
The Chinese value silence and avoid disagreeing or criticizing, especially in public. Disagreements are not verbalized so that harmonious relationships will be maintained, at least outwardly. To raise one’s voice to make a point, a common behavior for some Americans, is viewed by many Chinese as being associated with anger and a sign of loss of self-control. To avoid confrontation and subsequent “loss of face,” a direct “no” is rarely used. On the other hand, the word “yes” with or without nodding may merely mean “I heard you” and may not indicate agreement or consent. In some circumstances, “yes” can even mean “no” or “perhaps.” Hesitancy, ambiguity, subtlety, and implicitness are dominant features in Chinese communication ( ). Understanding nonverbal cues and contextual meanings is also necessary to communicate effectively with some Chinese Americans.
Touching and touching different parts of the body have different meanings that are largely defined culturally. Chinese people do not ordinarily touch each other during conversation ( ). Touching someone’s head indicates a serious breach of etiquette, particularly when the involved person is elderly or of higher social status. Touching during an argument indicates shameful loss of self-control. In the same respect, putting one’s feet on a desk, table, or chair is regarded as impolite and disrespectful. On the other hand, public displays of affection toward a person of the same sex are quite permissible in the Chinese culture. Unlike the American culture, however, public displays between the opposite sexes are considered socially unacceptable ( ). The Chinese are often viewed as polite but reserved, shy, cold, unassertive, or uninterested ( ; ; ).
Communication among the Chinese is high-context, in contrast to communication among mainstream Americans. A high-context communication is one in which most of the information is either in the physical context or internalized in the persons involved, whereas very little is in the coded, explicit, transmitted message. A low-context communication is just the opposite; that is, the mass of the information is vested in the explicit code ( ).
The Chinese people tend to perceive, value, and rely on nonverbal and contextual cues during communication and do not communicate explicitly ( ). For example, facial expressions, tensions, movements, pace of speech, and location of interactions are perceived during interactions to formulate specific meanings. They expect others to figure out the underlying meanings of communicated words ( ; ). Again, it cannot be overemphasized that understanding nonverbal cues and contextual meaning is necessary for effective communication with the Chinese people.
In the past, Chinese people greeted others by bowing. It is more commonplace now to greet people with “Have you had your breakfast [lunch, dinner]?” The greeting person is not really interested in the question literally. Instead, it is merely a culturally determined format of greeting other people. Nodding the head may indicate “yes,” whereas shaking the head may indicate “no.” To answer a question such as “Haven’t you had anything to eat?” is problematic for many Chinese Americans. They may be confused about whether to answer affirmatively or negatively: “Yes, I haven’t had anything,” or “No, I would like something.”
Many Chinese Americans experience feelings of shame and embarrassment when they cannot communicate well. Some apologize frequently and repeatedly for their linguistic inadequacies because they think they are inconveniencing others. Although most Chinese Americans will often refrain from expressing their emotions openly, some may narrow their eyes to express anger and disgust ( ). In general, Chinese Americans tend to have less eye contact than other Americans have because, in the Chinese culture, excessive eye contact may indicate impoliteness and rudeness ( ); it may also be perceived as threatening ( ).
Chinese Americans, like other immigrants, experience a great amount of stress when they are in health care facilities. The language barrier and their different cultural background often cause confusion, depression, frustration, helplessness, and powerlessness ( ; ). However, they tend not to discuss their concerns or express their emotional problems with health care professionals ( ; ; ; ). Some Chinese Americans believe that emotional problems are personal issues and are often embarrassed to ask questions when no health care workers speak their language. These emotional experiences are often not orally expressed but may be indicated by nonverbal cues. Frequently, observing nonverbal behaviors and encouraging clients to verbalize will help identify these psychological problems.
Implications for Nursing Care
It is important for the nurse to remember that there are diverse Chinese dialects that are not comprehensible to other Chinese groups. If the client needs a translator in the health care setting, the nurse must first find out which dialect the client speaks and then find a translator who can speak that dialect.
Because the Chinese language is quite different from English, the nurse must remember that when Chinese Americans communicate in English, they often experience a high level of stress ( ; ; ; ). The nurse may observe and validate its associated symptoms and help the client control and lower the stress level. Because Chinese Americans tend to be “good patients”—quiet and polite, with few requests, with a tendency to suppress feelings such as anxiety, fear, depression, or pain—it is important for the nurse to recognize nonverbal cues and their cultural meanings to develop culturally appropriate nursing care plans. The nurse can never assume that a Chinese patient has no unmet need if he or she does not request anything.
Some Chinese Americans hesitate to ask questions when they do not understand; therefore, after rapport has been established, the nurse should elicit and encourage Chinese Americans to verbalize their feelings and ask questions. Because of culturally determined communication patterns, the nurse would do best to validate the patient’s understanding by asking questions or having the patient do a return demonstration, instead of relying solely on the patient’s verbal and nonverbal responses. In addition, the nurse should avoid using negative questions to elicit responses because negative questions are comprehended differently in the Chinese language.
In addition, because some Chinese Americans do not ordinarily touch another person during conversation, it is important for the nurse to explain the necessity of touching for therapeutic purposes. Showing respect, demonstrating empathy, and being nonjudgmental can help establish rapport with Chinese-American patients. The nurse can communicate better with Chinese Americans by understanding their cultural norms, values, and practices and unique communication styles. Therapeutic communication techniques can also be used to promote conversations to help Chinese-American patients express thoughts and feelings and to ensure mutual understanding, especially when the nurse believes that the patient is experiencing anxiety, fear, depression, or pain.
In studying human spatial relationships, divided humans into two groups: contact and noncontact. People from a contact group interact with each other by facing each other more directly, being closer, touching more, making more eye contact, and speaking more loudly than members of a noncontact group. People from a contact group may perceive people from a noncontact group as being shy, uninterested, cold, and impolite. Conversely, people from a noncontact group may view people from a contact group as being pushy, aggressive, obnoxious, and impolite ( ). Both Chinese Americans and most middle-class mainstream Americans are categorized as noncontact individuals. However, from the Asian person’s point of view, Americans face each other more, touch more, and have more visual contact than Asians do. Chinese people feel more comfortable in a side-by-side or right-angle arrangement and may feel uncomfortable when placed in a face-to-face situation. Americans prefer to sit face to face or at right angles to each other. In the Asian culture, the person of higher status has the prerogative of sitting as proximally as desired; thus the burden of correct behavior is on the person of lesser status ( ; ).
Implications for Nursing Care
Because Chinese Americans are categorized as noncontact, it is important for the nurse to remember that some Chinese Americans may be erroneously perceived as being extremely shy or withdrawn. It is equally important for the nurse to remember that some Chinese Americans may view tasks that are associated with closeness, increased eye contact, and touch as being impolite or offensive. The nurse can reduce these misunderstandings by providing explanations when performing these tasks. Because some Chinese Americans feel uncomfortable with face-to-face arrangements, the nurse may seek the client’s input in terms of comfortable seating arrangements and remain alert and sensitive to the patient’s comfort level of personal space.
Effect of Immigration on Social Organization
Many early Chinese immigrants came to this country as contract laborers or with money that was borrowed from various Chinese-American organizations. These organizations assumed a supervisory role for these early immigrants once they arrived in the United States. The Chinese immigrants were similar to immigrants from other ethnic and cultural groups in that most of them were unfamiliar with the language and the culture of the United States. Therefore, many of the early Chinese immigrants worked as laborers in gangs. Although many of these individuals were physically smaller than those in other ethnic or cultural groups in the United States, they were hard workers. Historically, Chinese Americans helped build the United States by constructing railroads and working at other equally taxing jobs. Early Chinese immigrants worked cheaply and saved money by living frugally. These virtues made many of the early Chinese immigrants employable, but they were feared and hated as competitors by American workers ( ; ).
By 1851, there were 25,000 Chinese Americans living in California alone ( ). By 1870, the number of Chinese immigrants in the United States had increased to 63,000. In 1880, approximately 6000 Chinese persons entered the United States. Nearly twice as many entered the United States in 1881, and nearly five times as many entered in 1882 ( ). However, in 1882 an exclusionary immigration law reduced the inflow of Chinese immigrants to less than 1000 until the year 1890. Because of this law, the initial Chinese immigration was almost exclusively male. The immigration of Chinese men to the United States was believed to be a tentative rather than a permanent move, and during the 1880s the number of Chinese persons leaving the United States was greater than the number entering.
In addition to the Chinese Exclusion Act of 1882, other laws that severely curtailed not only immigration but also the possibility of a Chinese person’s becoming a naturalized citizen were enacted in the United States. Furthermore, some of these laws were specific enough to require citizenship as a prerequisite for entering many occupations and for owning land ( ). From 1854 to 1874, there were laws that prevented Chinese people from testifying in court against White men ( ). Some historians believe that such laws in effect made it possible to declare “open season” on Chinese Americans because many of these individuals had no legal recourse when robbed or assaulted. The almost total exclusion of Chinese immigration from 1882 to 1890 had devastating long-range effects on Chinese Americans that are still evident. Because the early Chinese immigrants were almost exclusively male, there was little hope for a normal social or family life. Many of these early male immigrants had wives and children in China, whom they would not see for many years, if at all. Because of the severe restrictions on economic opportunities, it was impossible to earn enough money to book passage to China.
Over the years, the few Chinese women who had managed to immigrate to the United States were able to produce a small number of first-generation children. When these children grew up, there was a slight ease in the serious shortage of women that remained characteristic of Chinese Americans from the early immigration period until World War II. In addition, an unknown number of Chinese women were smuggled into the United States for the specific purpose of prostitution ( ). As recently as the 1960s, many illegal aliens from China entered the United States to pursue a better life. As a result, many Chinese residents deliberately avoided census takers.
Despite the fact that economic opportunities for early Chinese immigrants were highly restricted, many Chinatown communities took care of their own indigents. This fact may explain why even during such disasters as the San Francisco earthquake in 1906 and the Great Depression of the 1930s, many Chinese Americans did not seek or receive federal aid.
In 1943, the Chinese Exclusion Act of 1882 was repealed, and that repeal did help ease the imbalance of the male-to-female ratio and permitted a more normal family life to develop among a very family-oriented people. After the repeal of the Chinese Exclusion Act of 1882, the bulk of the new Chinese immigrants were female ( ). The labor shortages of World War II opened many new job opportunities that were not previously available to Chinese Americans. Thus many Chinese Americans abandoned traditional Chinatown occupations to move into these new jobs ( ).
In 1940, only 3% of Chinese Americans in California had jobs that were considered “professional,” compared with 8% of the White population. By 1950, the percentage of Chinese Americans in professional fields had doubled to 6%. Over the next decade the percentage of Chinese Americans working in professional fields tripled and for the first time passed the percentage of Whites working in professional fields. By 1970 it was reported that Chinese Americans in general had a higher income or higher occupational status than most other Americans. In 1970 at least one fourth of all employed Chinese Americans were working in scientific or professional fields. Many Chinese Americans are in the science and engineering fields ( ). The Chinese Student Protection Act in 1992 allowed many students from the People’s Republic of China to apply for permanent resident visas, which led to an increased number of Chinese Americans in the science and engineering fields.
The Chinese family can be classified into five categories: old immigrant families, professional immigrant families, American-born Chinese families, new working-class immigrant families, and biracial/bicultural Chinese families ( ). The socioeconomic, educational, or acculturation status of these families varies. The old immigrant families may own small grocery stores or restaurants, speak limited English, and hold onto traditional Chinese values. The parents of professional immigrant families mostly came to the United States as international students and have professional jobs after graduation. They may sponsor their parents for immigration to the United States and form an extended family. The American-born Chinese families may have children ranging from first generation to fifth generation. The children of these families may be well acculturated, receive college degrees, and have high occupational status and income. However, the children of the working-class immigrant families may not acculturate well. Both parents may be employed in the labor-intensive market (such as tourist shops, restaurants, and garment sweatshops) with an enclave economy. Because of their work schedule, they have little time with their children. The biracial Chinese families happen mostly among the U.S.-born population. The children of these families may identify themselves as Chinese and another race.
Chinese, like other Asian Americans, have a culture of collectivism. This culture of collectivism emphasizes loyalty to family and devotion to tradition and de-emphasizes individual feelings ( ). The Chinese are willing to submit individual interests to those of the family to maintain a strong and cohesive bond. In return, the family is expected to take care of its members, both immediate and extended. Doing so brings honor to the family; not doing so brings shame.
The Chinese family generally has a hierarchical structure. The older children have authority over the younger children, and the younger children must show deference to authority figures, usually the elderly male in the household ( ). Boys may be more valued than girls. Husbands may have more authority over their wives. Wives may be expected to be obedient to parents and parents-in-law ( ); failure to do so causes shame for the family. The authority figure has more influence on decision making. In most cases, decisions are made on the basis of consensus rather than majority rule. The individual learns to submit to prevailing opinion rather than disagree ( ). However, the values of the Chinese-American family erode in the acculturation process. Many youngsters do not show respect to the elderly. Youngsters who embrace individualism are more likely to engage in misconduct ( ). On the other hand, youngsters who hold traditional Chinese family values (filial piety) and do not exert early individualism have less misconduct ( ). Elderly Chinese Americans who are dissatisfied with support from family members have a high risk of depression ( ).
Because of the early Chinese Exclusion Act in the United States, there was a disproportionately large number of Chinese men compared with Chinese women. Many of the early unmarried Chinese men who came to the United States had virtually no opportunity to marry; thus in 1890 only 26.1% of the total number of Chinese-American men were married. The percentage of married Chinese-American women from 1890 to 1950 ranged from 57.4% to 69.1%. During this time there appeared to be a lower percentage of single Chinese women who immigrated, which was partially accounted for by the Chinese tradition of females marrying at a younger age. Chinese Americans divorce less frequently than their American counterparts ( ).
Today, Chinese Americans remain family-oriented. Married couples may experience conflicts but will avoid divorce or separation, which may be viewed as a shame. According to the 2000 census, 60.1% of Chinese Americans are married, 29.7% have never married, 1.1% are separated, 4.6% are widowed, and 4.5% are divorced ( ; U.S. Department of Commerce, Bureau of the Census, American Community Survey, 2015).
There are four primary religions in China: Buddhism, Taoism, Islam, and Christianity (Catholicism and Protestantism). Of these four primary religions, Buddhism has the largest number of professed followers while Taoism has the smallest number. Among Chinese and Chinese Americans, Christianity is regarded as a newcomer; nevertheless, its effects are pronounced. Christianity is viewed as being partially responsible for the introduction of Western culture into China as well as to Chinese Americans. Many Chinese Americans convert to Christianity after they come to the United States ( ). The number of Chinese Roman Catholics has increased rapidly, particularly among foreign-born Chinese Americans ( ; ; ).
Implications for Nursing Care
It is important for the nurse to remember that Chinese Americans are a family-oriented people who normally put family commitments before personal interests. In addition, the Chinese-American family has traditionally had a hierarchical structure. By assessing the client’s kinship relationship and identifying the authoritative family member, the nurse can effectively use the influential family members to achieve the therapeutic goals. Chinese Americans believe that they have a major responsibility in taking care of family members and relatives. Therefore, family members may view the hospitalization or health care needs of a family member as a personal concern. The nurse needs to understand this sense of responsibility and be sensitive to the family’s needs. Opinions and ideas of the family members should be incorporated into the plan of care. Also, it is important to provide health care education to all family members, not just the client, when procedures are to be done. However, parents of the ill child may not want the siblings to know about the illness to avoid unnecessary worry. The nurse should assess the family situation to avoid disclosing information to inappropriate family members ( ). A rule of thumb with regard to caring for Chinese Americans is to involve the family to the highest possible extent. Otherwise, the family may take away the health professional’s access to the patient. The notion that an individual has rights independent of his or her family is alien to many Chinese and Chinese Americans. In addition, Chinese-American women may be very uncomfortable and uneasy when examined by male health professionals. Therefore, a female nurse should be present and assist in the examination.
Chinese Americans vary widely in educational background and socioeconomic status, have varied cultural and religious values and practices, and have different levels of acculturation. For example, some Chinese Americans speak English very poorly, whereas others can communicate in English without any problem. Some have medical insurance, whereas others do not. Some use herbal medicine, whereas others do not. Language deficiency is one of the primary barriers to health care access and utilization for Chinese Americans ( ). If the client has a language barrier, a translator is needed and can usually be found in the local Chinese community. Visual displays, flip charts, or exhibits can be used to facilitate the client’s understanding. Recently, more credible and reliable patient education materials in Chinese are available (e.g., National Diabetes Education Program: ndep.nih.gov.easyaccess1.lib.cuhk.edu.hk/index.aspx , MedlinePlus’ Health Information in Chinese: www.nlm.nih.gov.easyaccess1.lib.cuhk.edu.hk/medlineplus/languages/chinesetraditional.html , and National Library of Medicine’s Materials in Asian Languages—Chinese: asianamericanhealth.nlm.nih.gov.easyaccess1.lib.cuhk.edu.hk/Alchinese.html ). The nurse can refer the patient to these Web sites and use information in these Web sites to provide patient education.
The Chinese have a different perception and experience regarding time; it is not past, present, or future oriented. Some Chinese Americans perceive time as a dynamic wheel with circular movements and the present as a reflection of the eternal. This metaphoric wheel continually turns in an unforeseeable direction, and individuals are expected to adjust to the present, which surrounds the rotating wheel, and seek a harmonious relationship with their surroundings ( ).
has described the time concept of Asians as polychronic and that of Westerners as monochronic. An individual with a polychronic time orientation adheres less rigidly to time as a distinct and linear entity, focuses on the completion of the present, and often implements more than one activity simultaneously. On the other hand, an individual with a monochronic orientation to time emphasizes schedules, promptness, standardization of activities, and synchronization with clocks.
When making decisions regarding current and future events, some Chinese people may be affected by traditions and customs. Before making decisions, they may seek symbols, correlations, and intuitive understanding, as well as consider significance, consequences, future situations, and present factors. They do not make decisions according to an individual’s own benefit ( ).
Implications for Nursing Care
Because Chinese Americans are perceived as being polychronic, it is important for the nurse to remember that some Chinese Americans may not adhere to fixed schedules. Polychronic individuals may arrive late for appointments; may insist on completing a task before moving on to a new one, even though the new task may be time sensitive and more urgent; and may implement more than one task at a time. It is important for the nurse to recognize that when some Chinese Americans make important decisions related to current events, they may appear hesitant and request time for deliberation because of the need to consider as many variables as possible, including consultation with family members.
Many Chinese Americans, especially the first generation, may not believe that they have control over nature because they subscribe to a belief in fatalism and may view people as adjusting to the physical world, not controlling or changing the environment ( ). In traditional Chinese philosophy, a harmonious relationship with nature is stressed ( ). Ancient Chinese philosophers believed that qi (or chi ) was the vital life energy flowing around the universe and differentiated qi into two forces, yin and yang. While yin and yang are opposites, they exist only by virtue of each other. Yin and yang regulate the universe, including the body and food. Yang represents the positive, active, or “male” force, and yin represents the negative, inactive, or “female” force. Accordingly, body organs are categorized into yin and yang groups. For example, the liver, heart, spleen, lungs, and kidneys are yin, whereas the gallbladder, stomach, large intestine, small intestine, bladder, and lymphatic system are yang. The yin forces store the strength of life, while the yang forces protect the body from outside invasions. Many Chinese Americans believe that an imbalance between yin and yang will result in illness, whereas a balance between the two maintains and enhances health ( ).
Likewise, food is divided into yin (cold) and yang (hot) groups and is considered to be either the cause or the treatment of illnesses. A person with leukemia may believe that too many “cold” foods have been consumed. Diseases with excessive yin forces, such as cancer, postpartum psychosis, menstruation, or lactation, are treated with foods with yang qualities, such as beef, chicken, eggs, fried foods, spicy foods, hot foods, vinegar, and wine. Diseases or conditions with excessive yang forces, such as infection, fever, hypertension, sore throat, or toothache, require foods with yin properties, such as bean curd, honey, carrots, turnips, green vegetables, fruits, cold foods, and duck ( ). In addition, Chinese Americans often use tea, honey, prunes, or vegetables such as bok choy to treat constipation; they use chrysanthemum, crystal (preserved ginger), ginseng, or other herbal decoctions to treat indigestion ( ).
Feng shui (translated literally to mean “wind [and] water”), which some Chinese Americans subscribe to, is the art of spatial arrangement of physical structures to achieve proper harmony and balance with nature ( ). Positive feng shui is believed to ward off evil spirits and promote good health and prosperity. Shapes of objects, buildings, and so on take on significance for some Chinese Americans and are thought to be correlated with good or bad luck. For example, a triangular building is considered to lead to bad luck and would not usually be used by Chinese Americans for house construction. Likewise, it is believed that doors should not open to direct traffic because this would allow evil spirits ready access into the home. Similarly, it is believed that the best location for a building is directly facing water while its rear is backed by mountains. Such an arrangement encourages prosperity while offering protection.
Some Chinese Americans hold beliefs related to colors and numbers that may take on significance to health and health care. For example, the number 4 ( sì ), because it is pronounced the same as the word for “death” in Mandarin, is considered bad luck ( ), whereas the number 8 ( ba ), which sounds like the word for “prosperity” in Cantonese, is considered good luck. On the other hand, the color white is considered bad luck because it is a color of mourning, whereas the color red is considered good luck and is associated with happiness and celebration. Thus a person born on 8/8/88 would be considered to be extremely fortunate or lucky, whereas a person born on 4/4/44 would be considered to be extremely unlucky. It is conceivable that a Chinese American subscribing to these beliefs might have considerable difficulty going for diagnostic testing in a triangular building that was located at 444 Fourth Street, where all the personnel wear white laboratory coats ( ).
Illness and Wellness Behaviors
Cultural differences, language barriers, and financial status play a major role in the utilization of health services by Chinese Americans. found that income, language ability, and citizenship status are associated with health care access and utilization in Chinese Americans. In addition, cultural norms and social stigma are major barriers associated with low utilization of mental health services ( ).
Many Chinese Americans underutilize health services because of their socioeconomic status, associated high cost, and perceived cultural insensitivity of the health care system ( ). Although unemployment rates for Chinese Americans are lower than for the general U.S. population, underemployment rate among Chinese Americans is much higher; underemployment is evidenced by a shorter work week, a mismatch between education and employment, and longer working hours for the same pay. In addition, at least 14.0% of Chinese Americans live at or below the poverty level. Many elderly Chinese Americans live alone with a fixed income, and this may be a direct result of early discriminatory immigration laws that barred reunion with wives. Chinese immigrant families may have no health insurance because they may not believe in insuring health or may be unable to afford it ( ). In fact, factors such as marital status, length of residence in the United States, education, employment, and average household income were associated with health insurance coverage among Chinese Americans ( ). In addition, income, language ability, and citizenship are associated with health care access and utilization among Chinese Americans ( ). Chinese Americans may fear medical institutions because of language barriers and unfamiliarity with the U.S. health care system. As a result, some Chinese Americans may not access or comply with medical treatments. Cultural beliefs and practices such as those regarding mental health also underscore such underutilization.
Many diagnostic tests, such as amniocentesis, glucose tolerance testing, ultrasonography, or drawing blood, are often perceived as being dangerous and unnecessary ( ). For instance, the invasive procedure of drawing blood on a daily basis not only is perceived as unnecessary but also is tolerated poorly by Chinese Americans because blood is believed to be part of the irreplaceable vital energy of the body and the belief in the intactness of the body (wholism) ( ). There was a report that a department store in Beijing had to resort to a lottery to determine whose turn it was to give blood “voluntarily,” even with a bonus equivalent to a 2-month salary and 15 days of vacation ( ). In addition, many Chinese Americans have a tendency to self-medicate with over-the-counter drugs, herbal remedies, tranquilizers, and antibiotics ( ). In this regard, some Chinese Americans may save part of a prescribed medicine and take it at their own discretion at a later time ( ).
Many Chinese Americans use Western and Chinese health providers simultaneously ( ; ), often failing to inform either. The failure to inform either Chinese or Western health providers when using both Chinese medicines and Western medicines at the same time can lead to unnecessarily increased safety risks and even tragedies ( ; ). Because some herbal and Western medicines have similar effects, using both can create problems. For example, ginseng is a tonic stimulant and an antihypertensive medicine. A client may overmedicate by taking antihypertensive drugs and ginseng at the same time.
Typically, Chinese Americans seek opinions and treatments of minor or chronic illnesses first within the informal health care system (family members, relatives, and friends) and try to manage on their own. If unsuccessful, they tend to consult with and seek treatment from Chinese medical providers. Western physicians tend to be the last option. However, Western physicians may be the first choice if the conditions are acute or serious ( ). The delay for treatment is especially common among Chinese-American psychiatric clients because of the sociocultural stigma associated with mental illnesses ( ). This practice also accounts for the observed phenomenon that admitted Chinese patients tend to be sicker and more symptomatic ( ).
The preparation and administration of Chinese medicines are unique. Chinese herbal medicines are boiled in a specified amount of water over low heat for an extended time until the desired concentration is reached. The medicines are then taken as a single dose. If the client does not feel better after the initial dose, the client may need to return to the herbalist. Because of this tradition, some Chinese Americans are unfamiliar with the Western practice of continuing to take medications such as antibiotics over the entire prescribed duration even when feeling better ( ). In addition, the Western practice of taking multiple drugs in tablet or capsule form at various times and over several days or weeks is inconvenient and can be confusing.
Traditionally, Chinese Americans as a group are health-conscious and believe in preventive health practices, frequently incorporating health promotion activities such as walking into their daily lives. Confucianism mandates that one should treat one’s own physical well-being as an expression and duty of filial piety ( ). For this reason, many Chinese Americans are reluctant to take medications unless absolutely necessary because they believe every medication has side effects. Some Chinese people respond to pain stoically because they fear addiction to analgesics and because of the cultural value on self-control and the belief that suffering is inherent in life ( ).
Death and Dying Issues and Practices
Like birth, death is an important life event. However, it is a cultural taboo for Chinese Americans to talk about death and related issues for fear of bringing bad luck or even jinxing their lives ( ; ; ). Euphemisms are used when death or dying has to be dealt with ( ). Therefore, it is unlikely that Chinese Americans will have a living will and power of attorney at hospital admission, especially for first-generation Chinese immigrants. Talk or even mention of death is to be avoided during daily conversation, especially when illness strikes ( ). Although life is mortal, Chinese Americans believe in “natural and peaceful death” ( shou zhong zheng qin ). It is essential for the health care professional to remember that for most Chinese Americans, dying at home surrounded by family members is more desirable than dying at a health care facility ( ). It is also important to remember that euthanasia and suicide in general are inconsistent with Chinese bioethics. In addition, according to traditional Chinese teaching, life is given by one’s parents, and, moreover, it is the extension of one’s family life ( ); therefore, one has no right to take it away. This belief may serve as a protective factor against suicide at the cultural level.
For Chinese Americans, the rituals surrounding death can be very elaborate, with the primary purpose to help the dead live a comfortable and rich afterlife. Upon death, the body is washed and clean clothes are put on. Among Chinese Americans, burial in the ground is preferred, signifying that the body returns to where it came from (nature). Food offerings and burning of fake paper money at burial time, as well as annual visitations in the spring at the Qing Ming Festival, are commonly practiced so that the dead will not be hungry and poor in the afterlife ( ). Many of these rituals are symbolic, with no practical reasons for the dead, but they serve the important purpose of comforting and relieving the burden of the living. Organ donation is inconsistent with the Chinese belief in wholism, which mandates that the body must remain intact, even after death ( ).
Folklore and Folk Practices
Maintaining the balance of yin and yang is the fundamental principle of Chinese medicine ( ). Chinese medical practice includes acupuncture, herbal medicines, moxibustion, massage, coining, cupping, and so forth. Acupuncture involves the insertion of fine, sterile, metal needles through specific body points to treat or cure illnesses such as pain, stroke, or asthma. Herbal medicines are also categorized according to their yin-yang properties and their therapeutic functions and are prescribed on the basis of the yin-yang nature of the particular illness. Moxibustion involves heat treatment of illnesses such as mumps or convulsions. When moxibustion is used as a modality, the ignited moxa plants are placed near specific areas of the body. After moxibustion, tiny craters about 1 cm in diameter can be observed on the skin. Massage is used to stimulate the circulation, increase the flexibility of the joints, and improve the body’s resistance to illnesses. Massage is a useful technique to relieve tension and stress. Coining involves applying a special oil to a symptomatic area and rubbing the area with the edge of a coin in a firm, downward motion. This treatment is used to treat cold, heatstroke, headache, and indigestion. Linear multiple bruises may be observed on the skin as a result of this process. Cupping is used to treat headaches, arthritis, and abdominal pain. A vacuum is created inside a glass jar by burning a special material. Then the inverted jar is placed immediately on the selected area and kept there over a designated duration until it is removed. Circular, ecchymotic marks 2 inches in diameter can be observed on the skin after this treatment ( ; ).
Implications for Nursing Care
Because Chinese Americans often believe that they do not have control over nature and maintain a fatalistic outlook on life, they may be hesitant about seeking health care treatment. In addition, because some Chinese Americans subscribe to the theory of yin and yang, such individuals are more likely to engage in self-treatment. Therefore, the nurse must be able to distinguish between practices that could be harmful, neutral, or beneficial to the client’s particular medical problem. For example, some Chinese Americans from Southeast Asia or rural areas in China may practice native healing processes in which they may tie a string around the wrist, burn incense, or make food offerings to the spirits. As long as these practices are not harmful and pose no safety hazards, the nurse should respect them and allow them to continue. In addition, the nurse who observes that a Chinese American client is taking herbal medicine concurrently with prescribed Western medications should inform the attending physician and caution the client about the possibility of overmedicating and the possible side effects of drug interactions. For those Chinese Americans who subscribe to the theory of yin and yang and believe that food has yin and yang qualities, the nurse should assist the clients to select the appropriate foods accordingly. Finally, the nurse should encourage the family of a Chinese-American client to bring familiar and more tasteful foods from home if (1) the client wishes and (2) there is no contraindication. For dying Chinese-American patients, home hospice is more culturally congruent because the dying is often surrounded by family members in a familiar and intimate environment to achieve a dignified death. The nurse should allow and make adaptation to the request for death rituals if safety and health risks are nonissues or can be minimized. Being empathetic, sensitive, and supportive is the key to meeting the family needs at this critical and trying time.