Culture, race, ethnicity, and minority status

The 2001 Surgeon General’s report discussed culture, race, and ethnicity in relation to minority groups (USDHHS, 2001). Although the definitions of these terms distinguish them from one another, they are related.

Minority status is connected more with economic and social standing in society than with cultural identity; however, many cultural, racial, and ethnic minority groups are also economically and socially disadvantaged groups.

Culture comprises the shared beliefs, values, and practices that guide a group’s members in patterned ways of thinking and acting. Culture can also be viewed as a blueprint for guiding actions that impact care, health, and well-being (Leininger & McFarland, 2006). Culture is more than ethnicity and social norms; it includes religious, geographic, socioeconomic, occupational, ability- or disability-related, and sexual orientation–related beliefs and behaviors. Each group has cultural beliefs, values, and practices that guide its members in ways of thinking and acting. Cultural norms help members of the group make sense of the world around them and make decisions about appropriate ways to relate and behave. Because cultural norms prescribe what is “normal” and “abnormal,” culture helps develop concepts of mental health and illness.

Ethnic groups have a common heritage and history (ethnicity). These groups share a worldview, a system for thinking about how the world works and how people should act, especially in relationship to one another. From this worldview, they develop beliefs, values, and practices that guide members of the group in how they should think and act in different situations.

Acknowledging the inadequacy of describing minority groups according to a single biological race, the U.S. Census Bureau used the 2000 census combined race-ethnicity categorization system for the 2010 census. Respondents are first asked whether they are of Hispanic, Latino, or Spanish origin; if not, they are asked to further identify their race. Federally defined racial groups were expanded from six categories in 2000 to fifteen in 2010 (U.S. Census Bureau, 2010). Respondents who do not identify with any of the predefined categories are encouraged to use blank spaces provided to classify their race (Figure 5-1).

The purpose of categorizing individuals according to racial-ethnic descriptions is to help the government understand the needs of its citizens. The Surgeon General used data from the 2000 census classification system to identify disparities in mental health care along racial-ethnic lines. Recording these classifications also helps to determine when and how the health care needs of these populations are being met.

Despite the benefits, this convention of classifying groups of people can be confusing, confounding, and offensive. Consider the following:

Categorizing people according to a racial-ethnic system carries inherent problems. In psychiatric mental health nursing, we can assess patients further and make better decisions on their behalf if our focus is on culture rather than race.

Demographic shifts in the united states

In 2043, the United States population is projected for the first time to become a majority-minority nation; that is, no one group will make up the majority (U.S. Census Bureau, 2012). Non-Hispanic whites will continue to remain the largest single group. A comparison of projected population composition in 2012 and 2060 is provided in Table 5-1.

These changing demographics mean that psychiatric nurses will likely be caring for culturally diverse patients. We need to know how to provide culturally relevant care and help reduce the problem of mental health disparities among culturally diverse populations.

Worldviews and psychiatric mental health nursing

Nursing theories, psychological theories, and the understanding of mental health and illness used by nurses in the United States have all grown out of a Western philosophical and scientific framework, which is in turn based on Western cultural ideals, beliefs, and values. Because psychiatric mental health nursing is grounded in Western culture, nurses should consider how their core assumptions about personality development, emotional expression, ego boundaries, and interpersonal relationships affect the nursing care of any patient.

A long history of Western science and European-American norms for mental health has shaped present-day American beliefs and values about people. Our understanding of how a person relates to the world and to other people is based on Greek, Roman, and Judeo-Christian thought. Other Western scientists and philosophers, such as Descartes (credited with the Western concept of body-mind dualism), have contributed to the Western scientific tradition. Nursing knowledge of psychology, development, and mental health and illness is based on this tradition.

However, a vast number of people throughout the world have very different philosophical histories and traditions from those of Western cultures (Table 5-2). The Eastern cultures of Asia are based on the philosophical thought of Chinese and Indian philosophers and the spiritual traditions of Confucianism, Buddhism, and Taoism. Diverse cultures found among Native Americans, African tribes, Australian and New Zealand aborigines, and tribal peoples on other continents frequently include rich cultural traditions based on deep personal connections to the natural world and the tribe.

In the Western tradition, one’s identity is found in one’s individuality, which inspires the valuing of autonomy, independence, and self-reliance. Mind and body are seen as two separate entities, so different practitioners treat disorders of the body and the mind. Disease is considered to have a specific, measurable, and observable cause, and treatment is aimed at eliminating the cause. Time is seen as linear, always moving forward, and waiting for no one. Success in life is obtained by preparing for the future.

Eastern tradition, however, sees the family as the basis for one’s identity, so that family interdependence and group decision making are the norm. Body-mind-spirit are seen as a single entity; there is no sense of separation between a physical illness and a psychological one (Chan et al., 2006). Time is seen as circular and recurring, as in the belief in reincarnation. One is born into an unchangeable fate, with which one has a duty to comply. For the Chinese, disease is caused by fluctuations in opposing forces—the yin-yang energies.

The term indigenous culture refers to those people who have inhabited a country for thousands of years and includes such groups as New Zealand Maoris, Australian aborigines, American natives, and native Hawaiians. These groups place special significance on the place of humans in the natural world and frequently manifest a more dramatic difference from Western views (Cunningham & Stanley, 2003). Frequently, the basis of one’s identity is the tribe. There may be no concept of person; instead, a person is an entity only in relation to others. The holism of body-mind-spirit may be so complete that there may be no adequate words in the language to describe them as separate entities. Disease is frequently seen as a lack of harmony of the individual with others or the environment.

Psychiatric mental health nursing theories and methods are themselves part of a cultural tradition and our nursing care is a culturally derived set of interventions designed to promote the verbalization of feelings, teach individually focused coping skills, and assist patients with behavioral and emotional self-control—all consistent with Western cultural ideals. When nurses understand that many of the concepts and methods found in psychiatric mental health nursing are based on different assumptions than those of our patients, the process of becoming culturally competent begins.

Culture and mental health

Diverse cultures have evolved from the three broad categories of worldview described in the previous section. Cultures developed norms consistent with their worldviews and adapted to their own historical experiences and the influences of the “outside” world. Cultures are not static; they change and adjust, although usually very slowly. Each culture has different patterns of nonverbal communication (Table 5-3), etiquette norms (Box 5-1), beliefs and values that shape the culture (Table 5-4), and beliefs, values, and practices that influence how the culture understands health and illness (Table 5-5). For instance, in American culture, eye contact is a sign of respectful attention, but in many other cultures, it may be considered arrogant and intrusive. In Western culture, emotional expressiveness is valued, but in many other cultures, it may be a sign of immaturity. In American culture, independence and self-reliance are encouraged, and the family interdependence valued by other cultures may be seen as a symbiotic relationship or a pathological enmeshment.

TABLE 5-5   

CULTURAL BELIEFS AND VALUES ABOUT HEALTH AND ILLNESS

This table contrasts the views typically held by Western nurses and the views about health and illness their patients from diverse cultures may hold.
	WESTERN BIOMEDICAL PERSPECTIVE	PERSPECTIVE OF VARIOUS OTHER CULTURES
Health	Absence of disease Ability to function at a high level	Being in a state of balance Being in a state of harmony Ability to perform family roles
Disease causation	Measurable, observable cause that leads to measurable, observable effect Pathogens, mutant cells, toxins, poor diet	Frequently intangible, immeasurable cause Lack of balance (yin and yang) Lack of harmony with environment
Location of disorder	Body Mind	Whole entity: mind, body, and spirit are completely merged Disorder causing disease in the person may be in the family or environment
Decisions about care	Made by patient or holder of power of attorney Goals are autonomy and confidentiality Truth telling required so patient has information to make decisions	Made by the whole family or family head Goals are protection and support of patient Hope should be preserved; patient should be protected from painful truth
Sick role	Sick people should be as independent and self-reliant as possible Self-care is encouraged; one gets better by “getting up and getting going”	Sick people should be as passive as possible Family members should “take care of” and “do for” the sick person Passivity stimulates recovery
Best treatments	Physician-prescribed drugs and treatments Advanced medical technology	Regaining of lost balance or harmony by counteracting negative forces with positive ones and vice versa Treatment by folk healers and traditional remedies
Pain	Stoicism valued Pain described quantitatively Able to pinpoint location of pain In cultures in which negative feelings are not expressed freely, pain is kept as silent as possible: Northern European, Asian, Native American	Pain expressed vocally and dramatically Use of quantitative scales to measure pain is difficult Pain experienced globally In cultures in which emotional expression is encouraged, more dramatic pain expression is expected: Southern European, African, Middle Eastern
Ethics	Based on bioethical principles of autonomy, beneficence, justice, and confidentiality Informed consent requires truthfulness	Based on virtue or community needs Hope should be preserved, painful truth hidden Support and care should be provided Emphasis is on greatest good for the greatest number

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