Culture and Spiritually Related Health Beliefs
CULTURE AND NURSING
Culturally competent care improves patient satisfaction and patient safety (e.g., by reducing medication-related errors). To provide culturally competent care, the advanced practice registered nurse (APRN) must develop knowledge, skills, and positive attitudes about diverse cultures and work individually and within the health care system to promote care that is respectful of all cultures. If a cultural practice has an adverse effect on a patient’s health, then the nurse practitioner (NP) needs to explain to the patient in a sensitive manner the reason for not following the practice.
Example: A female patient tells the NP that her shaman/curandero “told me not to take my medicine, but to drink herbal tea instead” or “he told me not to drink water for 2 days.” The NP respectfully explains to the patient why the practice is harmful to her health.
Leininger’s Theory of Cultural Care Diversity and Universality
Madeleine Leininger is recognized as the founder of transcultural nursing and credited with the construct of “culturally congruent care.” This theory defines culture as “the specific pattern of behavior that distinguishes any society from others and gives meaning to human expressions of care” (Leininger, 2014). Leininger’s Sunrise model is likely the most frequently used to frame culturally competent nursing care and research. The Sunrise model recognizes that care is influenced by many cultural features (i.e., technology, religiosity or spirituality, kinship and social structures, cultural values and beliefs and practices, legal and political systems, economics, and education), all of which shape one’s worldview.
CULTURAL AND SPIRITUAL AWARENESS
This is defined as “being knowledgeable about one’s own thoughts, feelings, and sensations, as well as the ability to reflect on how these can affect one’s interactions with other” (Giger et al., 2007). The following cultural and religious descriptions are generalizations and oversimplifications based on traditional requirements of certain cultures and religion. Consult with the patient and family to understand their unique interpretations and practices.
African Americans often use religious coping—typically Christian (e.g., prayer, gospel music, Bible reading, engagement with faith community). Christian pastors and preachers are held in high esteem. Church congregations and religion may be important sources of emotional and 486tangible support. Some patients may feel that their illness is caused by lack of faith or by sin. Many families have a female head of household (matriarchal).
Latino families have a strong matriarchal element, and the mother is an important source of strength and solace in times of illness. People from various Latino cultures may consult folk healers. “Susto” is a cultural illness (susto means “fright”). Mal ojo (or mal de ojo), the “evil eye,” is a folk illness (usually of a baby/child). It is caused by an adult who stares with envy at the child. (This is similar to the belief in an “evil eye” among some Muslim and Mediterranean cultures.) The hex can be broken if the person staring at the child touches the child. Another way to break the hex is to pass an egg over the child (with prayers) and then place the egg under the bed overnight. In general, Hispanic families enjoy public affection. Extended family are treated like immediate family. Multigenerational households are common.
There are 562 federally recognized Indian Nations (also known as tribes, villages, bands, pueblos, rancherias, or communities) and Alaskan Native tribes in the United States (National Congress of American Indians, n.d.). These many and varied groups have differing cultural practices and beliefs, but most traditionally view illness as “punishment” by the spirits for wrongful actions. Healing is done by “shamans” using prayers, dance, fasting, smudging, and sometimes ingesting hallucinogenic plants (peyote). Smudging is the ritualistic burning of an herb (with prayer) to help cleanse a person or place. Some groups use medicine pouches, tied to the patient by a string, to help cure the illness.
East Asians (Chinese, Vietnamese, Cambodian, Korean, Japanese) highly value college education and have high regard (respect) for doctors. Listening quietly without questioning is 487considered a sign of respect. Some think that asking questions (or disagreeing) with the treatment plan shows lack of respect.
Kinship ties are very important. Several generations may live in the same household. Elderly are held in high esteem and their opinion is highly respected. Some Asian cultures have a form of “ancestor veneration” practices. In China, the male child is expected to take care of parents when they age.
May stop taking prescription medicine when symptoms resolve or may think that only one visit is needed to “cure” an illness
Often save large quantities of leftover prescription drugs
May fear blood tests and surgery because of a belief that blood loss worsens illness
May believe that Western medicine will put the body out of balance
Majority come from Asia (Cambodia, Thailand, Bhutan, Japan, Laos, Vietnam, Taiwan, Tibet, etc.)
Main deity is Buddha; they believe that physical suffering is an unevitable part of life and believe in karma (“good deeds” create happiness and “bad deeds” create pain in the future) and the cycle of rebirth (reincarnation); some dying Buddhists may experience anxiety about being reborn into a lower form or less desirable life
May be vegetarian
May practice regular meditation; Buddhists value clarity of mind and may refuse narcotics or medications that alter conciousness
Traditional Chinese Medicine (TCM)
Practitioners believe life energy (chi or qi) imbalance or blockage is the cause of disease.
Yin is the female and yang is the male.
Believe acupuncture and cupping correct energy imbalance.
Cupping will create large round reddened marks or bruises on back (after 24 hours). Coining is when a coin is rubbed vigorously on skin to create welts. Both of these practices may produce lesions that may be misinterpreted as signs of abuse. The NP should question how a child received such lesions before reporting them as abuse.
Baptized Sikhs (Khalsa) and some others will obey a code of conduct that stipulates one wears five symbols of Sikh identity: uncut hair, a sword, shorts, hair comb, and iron wrist ring. These symbols should not be removed unless negotiated with the patient. Sikhs will not consume meat, alcohol, or stimulants. Adult male Sikhs may wear a large turban-like head covering (usually white color). Most come from southern or Southeast Asia, India, Canada, United Kingdom, and the United States.
Spiritual purity is of prime importance and manifested in removing shoes indoors, sprinkling water around a plate of food to symbolize purification, regular bathing, and cleaning mouth and teeth prior to eating. Food may be selected to enhance inner purity (e.g., no meat [especially beef or pork]). May wear a talisman that should not be cut or removed. Countries with highest percentage of Hindus are Nepal, India, and Mauritius.
In traditional Muslim families, Sharia law (Islamic law) is followed. Modesty is paramount; garments of adolescent females and women should cover arms, legs, and head. A hijab is a head scarf (hides hair, ears, neck) and the burqa or abaya is the full veil/robe that covers the body. The left hand is reserved for bodily functions (considered unclean). Shake the patient’s hand by using your right hand.
Clinicians of same gender preferred. Some male patients may be uncomfortable receiving health care from a female health provider. An unmarried woman needs her father’s permission to see a clinician, and a married woman needs her husband’s permission. In addition, women are not allowed to be alone or to visit with men who are not family members. If a woman is seen by a male health provider, her husband or another male family member must be present in the room. The female patient may refuse to undress (examine with the gown on).
The Qur’an (Koran) forbids drinking alcohol, eating pork, or eating meat not slaughtered in the “halal” manner. The holy month of Ramadan is observed by 30 days of fasting. It is forbidden to eat or drink fluids/water during the daytime, but one can eat or drink from sunset to before sunrise. If possible, schedule oral medications after sunset. Those who are sick may be exempted (pregnant women, physically or mentally ill people). Children are not expected to fast until puberty.
Sample Test Question
A 22-year-old Muslim woman is seen for a complaint of recurrent abdominal pain. A female NP gives the patient a paper gown with instructions for disrobing and leaves the room. When the NP returns, the patient is still clothed and refuses to undress. The NP’s best action is to:
A) Ask the patient whether she prefers to be seen by a male physician
B) Tell the patient what to expect and perform a modified physical exam
C) Instruct the patient to go to the closest ED for an abdominal sonogram
D) Lecture the patient about the importance of performing an abdominal exam without clothing
The correct answer is option B. It is an example of cultural awareness by the NP.
Orthodox Jews, such as Hasidic Jews, prefer clinicians of the same gender. Male Hasidic Jews may refuse to shake a female clinician’s hand. Shabbat (Sabbath) is observed from sundown Friday to sundown Saturday as a holy day that forbids any form of work. Some believe that electricity is a form of work and may stop using light switches or any electronic equipment during Shabbat (may have to turn on the light switch for the patient). Some observent Jews do not drive or use cell phones or other personal electronics at this time. If possible, avoid accessing unnecessary health services on the Sabbath and avoid scheduling follow-up visits or tests on the Sabbath.
Jews may keep kosher dietary laws (kashrut; e.g., not mixing meat and dairy products within specified time frame, eating only meaty foods certified as kosher). Families may have two separate kitchens at home: kosher and nonkosher. Each kitchen has its own utensils, pots, and plates (not allowed to mix because the kosher items will become contaminated).
Jehovah’s Witnesses refuse to donate blood, store blood, or accept own blood (autologous transfusion) but accept nonblood plasma expanders and blood components without RBCs (albumin, cryoprecipitate, clotting factors, immunoglobulins). If a blood transfusion is needed to save the life of a child, parents may refuse (may require a court order). Believers do not celebrate civil holidays, birthdays, Christmas, Easter, and others. Health care providers should 489encourage believers to carry an advanced directive or medical release form that states their convictions; such a card is available from the church. In urban locations, a hospital liaison from the church may be available to support believers with decision making.
Believers are often vegetarian and abstain from tobacco, alcohol, and caffeinated beverages. Adventists believe the human body is a temple of God that deserves care (healthy lifestyle). They observe Sabbath (sundown Friday to sundown Saturday) as a holy day for rest from work/school and spiritual nurturing. If possible, avoid accessing unnecessary health services on the Sabbath.
Amish/Mennonites (Old Order)
Believers do not participate in Medicare or Social Security, or go to war. The individual’s community pays for health care (no health insurance). Use of folk practitioners and folk/alternative medicine is common. If surgery or an expensive test is needed, permission from church elders is required. Believers may speak German dialect. They avoid modern technology, such as telephones and electricity, and use horses and buggies for transportation. Large families, traditional roles for women, and agricultural work are characteristic. Amish prefer giving birth (using midwives) and dying at home. These closed communities have higher rates of some genetic diseases such as maple syrup urine disease, Crigler–Najjar syndrome, a type of dwarfism (Ellis–van Creed syndrome), and cystic fibrosis, as well as certain metabolic disorders.
Church of Latter-Day Saints (Mormons)
Mormon churches provide a strong social support network for the ill. The local ward bishop, elders, missionaries, home or visiting teachers, and/or lay people provide spiritual and temporal support. Patients may wear “temple garments” under hospital gown or clothing as a symbol of covenant they made in the temple. Treat such undergarments with respect.
Other Cultural Groups
Lesbian, Gay, Bisexual, Transgender (LGBT) People
Avoid assumptions regarding sexual orientation or gender identity. Facilitate disclosure while remaining respectful of an individual’s “coming out” process. Recognize and support the patient’s family of choice and use gender-neutral language on forms and during history taking (e.g., “Have you had sex with a male, female, both, or neither?”).
Conditions, such as posttraumatic stress disorder (PTSD) and traumatic brain injury, are prevalent among U.S. veterans. Military personnel are accustomed to self-protect when exposed to certain sounds or experiences (e.g., hide under bed when helicopter is overhead). They are socialized to be stoic about pain or suffering and nonquestioning of authority figures.
FACTORS THAT AFFECT HEALTH CARE
According to Healthy People 2020, health literacy is the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Office of Disease Prevention and Health Promotion, n.d.). It affects the person’s ability to learn about how to access health care, complete forms, respond 490to questions, implement recommended treatments, and so forth. It depends on communication and language, existing knowledge about health, culture, and numerical ability and skills, as well as the demands of the situation and system within which the individual presents.
Even one misunderstood or misspoken word can affect a patient’s decision making or implementation of a treatment. Strategies for communication between patients and health care providers who speak different languages include language access services (virtual, telephonic, or in-person interpreters) and handheld documents at point of service that present clinicians with patient information. Untrained staff and family members should not be used for interpretative services.
Individualistic and Collectivistic Societies
Cultures are often categorized as individualistic or collectivistic. Individualist societies value the individual above the family, organization, or group. In contrast, collectivist societies consider the rights, needs, and wishes of the family or group over those of individuals. Ways these cultural differences may be observed during clinical encounters are presented in Table 28.1.
Table 28.1 Cultural Differences in Health Care