Communication

Communication occurs verbally and nonverbally. Nurses must be alert to different types of communication styles among patients to provide culturally competent care.

Space

The amount of space around a person’s body is an important psychological consideration. Americans may desire a great deal of personal space. In some other cultures, population density may dictate limited personal space. Patients who are used to dense living quarters may feel insecure in a hospital room. It is important that the nurse have frequent contact with these patients and allow significant members of the social group to remain with the patient as much as possible.

A major challenge in caring for patients is the use of touch and the protection of modesty. Although nurses must touch patients to administer care, all cultures have taboos regarding touch. There are added considerations when the patient is of a different gender than the nurse. This is a particularly sensitive issue for groups within the Muslim, Orthodox Jewish, Amish, and Roma communities. For example, a Muslim woman may prefer to be cared for by a female nurse rather than a male nurse. Nurses should consider inquiring about patients’ preferences regarding touch before implementing nursing care. It may be best to have a family member of the same gender as the patient present during procedures, if possible. There may also be apparent paradoxes within cultures; for example, persons of Hispanic descent may value human contact but also value modesty.

Social Organization

Families are basic social units. The definition of family and the criteria for inclusion varies among individuals and among cultures. Americans of western European descent may have small, nuclear families, whereas other cultural groups living in the United States may have larger, extended families. Delivery of nursing care can be enhanced by including family whenever appropriate; nurses are in a position to advocate for inclusion of family in health care settings. Limiting the amount of time a patient can visit with members of the social group is a long-standing practice in American health care settings, but in some other countries, such as the Philippines, it is expected that family members will stay by the patient’s bedside and participate in his or her care.

Time

Nurses and their patients may have different perceptions of time. Time moves slowly for a patient who is anxious or in pain but moves quickly for a nurse who has a demanding workload. The use of vague terms to denote time may also cause a disparity between nurses’ and patients’ perceptions of time. Words like now, soon, or later may have vastly different nuances among individuals and groups.

Adding to the complexity of time perception are the concepts of linear time and circular time. When time is perceived as linear, the present flows into the future and is irretrievably lost. Viewing time as linear is likely to prompt thinking such as “I must do this now.” When time is perceived as circular, the present has more stability and the need to do things at the moment has less urgency. Viewing time as circular is likely to prompt thinking such as, “I will have the opportunity to do this later.”

The cultural aspect of time perception has a profound effect on pharmacotherapeutic adherence. All cultures have a concept of time as it is related to the past, present, and future. All humans are acutely aware that the present is here and now and in real time; it is the relative importance placed on the past, present, and future that directs the use of time.

People of western European descent may exhibit a great deal of future orientation. This can lead to health practices perceived to prevent illness, such as adhering to a low-fat diet to prevent higher cholesterol or wearing a condom during sex to prevent disease. Concern for the future also serves as motivation to take steps to control chronic illness, which is likely to lead to greater adherence to long-term pharmacotherapy. Explanations for these phenomena are that people of western European descent have historically experienced longevity and expect to have a lengthy future, and that their economic and social lives have revolved around calendars and clocks for centuries.

Non-European cultural groups such as those of African, Asian, Native American, or Latin American descent have exhibited less dependence on strict time schedules for economic and social activities. These groups’ perception of time may be rooted in agrarian cultures that use daily and seasonal rhythms of the earth and the sun to direct activities. This could result in emphasis being placed on the present; measures to ease the discomfort of a current illness may take precedence over measures to promote long-term wellness or treat a chronic illness. Patients with a present-oriented perception of time are more likely to discontinue mainstream prescriptive therapies when they feel well. It must be noted, however, that with the shrinking of agrarian cultures and the spreading of European-style practices, this treatment of time is changing. The nurse must therefore assess the patient’s degree of acculturation or assimilation.

Cultural groups that are steeped in traditional practices or perceive that their cultural identities are threatened are likely to have a past orientation of time, which may lead to the use of traditional health practices over mainstream health practices. Health behaviors of individuals are also influenced by the quantity and quality of past experiences with the health care system.

Environmental Control

A major aspect of culture is the desire to control nature to facilitate the needs of human beings. The concept of “nature” may include otherworldly forces or beings, such as deities and spirits. Illness may be attributed to cosmic forces and believed to be cured or ameliorated by persons who possess special abilities. Traditional healers are thought to have influence over otherworldly forces.

Healers and spiritual advisors can be beneficial in health care settings; examples include the practice of clergy (e.g., minister, priest, rabbi) visiting ill members of a congregation or the inclusion of a traditional healer in the plan of care.

The Indian Health Service is a federal agency within the U.S. Department of Health and Human Services that oversees the health care of approximately 2 million Native Americans who belong to federally recognized tribes. Similarly, the Canadian health care system has developed many initiatives to improve the health care of its indigenous peoples, known as First Nation, Inuit, and Metis. In both systems, the use of traditional healers and spiritual guides is incorporated into mainstream prescriptive therapies.

Biologic Variations

Through the work of the Human Genome Project, an international collaborative research program, the field of pharmacogenomics is rapidly expanding. In the United States, the project is managed by the National Human Genome Research Institute, which is part of the National Institutes of Health (NIH). Pharmacogenomics refers to the general study of all the different genes that determine drug behavior. An example of a significant finding of pharmacogenomics is the effect of the Cytochrome P-450 (CYP) enzymes on drug response, drug-drug interactions, and adverse drug events, which are described later in the chapter.

The Genographic Project has performed DNA testing on populations all over the world. Findings reveal that human beings are 99.9% genetically identical; this implies that there are not multiple races but multiple genotypes (an individual’s genetic identity).

To illustrate the significance of these findings to the patient care setting, it is necessary to review additional terms used in the fields of pharmacogenomics and pharmacogenetics. Genomes are a complete set of chromosomes and make up a cell’s DNA. Polymorphisms are DNA variants that occur within a specific population at a frequency greater than 1%. A substrate is a substance that binds to and is metabolized by one or more enzymes. Drugs are chemical substances and a type of substrate. The Cytochrome P-450 enzyme system either induces or inhibits the action of substrates. Induction or inhibition of a substrate accounts for the variations in drug metabolism in individuals and groups. The Division of Clinical Pharmacology at Indiana University Department of Medicine continually updates a clinically relevant table of drug interactions caused by the Cytochrome P-450 system.

Human migration around the world has been so vast over such a long period that most people have a variety of genetic markers. The study of pharmacogenetics can pave the way for pharmacotherapy that yields greater therapeutic benefits and causes fewer adverse reactions. The application of pharmacogenetics should be approached with caution. A person who is dark-skinned and appears to be of African descent is likely to have some European genetic markers.

Certain classifications of medications have different effects in individuals whose genetic markers are predominantly characteristic of a certain biologic group. For example, in the United States, Caucasian people are more likely than people of Asian or African heritage to have abnormally low levels of the CYP2D6 enzyme that metabolizes drugs belonging to a variety of therapeutic areas, such as antidepressants, antipsychotics, and beta blockers.

African Americans respond poorly to several classes of antihypertensive agents (beta blockers and angiotensin-converting enzyme inhibitors). Differences in skin structure and physiology can affect response to dermatologic and topically applied products. Clinical trials have demonstrated lower responses to interferon-alpha used in the treatment of hepatitis C among African Americans compared with other racial subgroups.

As another example, the U.S. Food and Drug Administration has entered into an agreement with the manufacturers of drugs containing carbamazepine (Tegretol) to include product labeling recommending that patients of Asian ancestry be genetically tested before starting on this agent. There is a strong association between serious skin reactions and an inherited variant of the H 1502LA-B gene found in Asians.

These intrinsic biologic factors must be considered along with extrinsic factors such as diet and environmental and sociocultural issues to prescribe effective therapies and provide holistic health care.

Researchers conducting clinical trials for development of new drugs are now required to obtain genetic testing of the participants in the study. Issues to be resolved before widespread testing are the cost-versus-benefit ratio and ethical considerations. Genetic testing is expensive and generally not covered by third-party payers. Genetic information can affect employment, insurability, and family relationships.