After reading this chapter the nurse will be able to:
Describe methods a nurse can use to enhance communication with a Puerto Rican.
Explain the importance of personal space to some Puerto Rican women.
Describe the importance of family relationships for Puerto Ricans.
Discuss the effect of time orientation on health promotion activities for Puerto Ricans.
Identify the role of folk and spiritual healers for some Puerto Ricans.
Discuss biological variations that may be found in Puerto Ricans.
Overview of Puerto Rico
The commonwealth of Puerto Rico is located in the Caribbean Sea about 1000 miles east-southeast of Miami. Puerto Rico is to the east of Haiti and the Dominican Republic (La Hispaniola) and to the west of the Virgin Islands. With a land area of 3425 square miles, Puerto Rico is approximately three times the size of Rhode Island ( ). Its territory includes the islands of Culebra, Vieques, Descecheo, and Mona. Puerto Rico has a high central mountain range, dry and fertile northern coastal plains, low eastern mountains, and the El Yunque rain forest ( ).
In the fifteenth century, some 50,000 indigenous Taino Indians inhabited the territory and called the island Boriken or Borinquen, which means “the great land of the valiant and noble Lord” or “land of the great lords” ( ). This word is still used to designate the people and island of Puerto Rico. When Christopher Columbus arrived in 1493 and claimed the island for Spain, the Taino Indians lived in small villages, organized in clans, and were led by a chief. The Taino lived off the tropical crops, including pineapples, cassava, and sweet potatoes, supplemented by seafood. Spanish colonizers who arrived in 1508 were welcomed by the Taino, who offered these colonizers gold nuggets they picked out of the river. The seaside port, which later was named San Juan and today is the capital, quickly became Spain’s most important military outpost in the Caribbean. The Spaniards constructed a wall around San Juan. A massive fort on the harbor, San Felipe del Morro Castel, was erected to protect the city with garrisoned troops. The Spaniards also established gold-mining operations, which lasted until 1570, when the gold stores were depleted.
Under the rule of Juan Ponce de León, the governor appointed by the Spanish crown, the first repartimiento (colonial forced labor system) of Puerto Rico was established. Indians were offered to officials and colonists as wage-free, forced labor. When several priests protested the treatment of the Indians, the Spanish crown instituted the encomienda, which required the Indians be taught the Catholic religion and be paid for their labor. However, the Indians continued to be treated as slaves, and those who resisted were killed, which resulted in the annihilation of much of the male population. Only a few Indians escaped into the remote mountains of the island. Many of the remaining women were taken by the Spanish settlers for mates, and their offspring become known as jibaros. With industrialization and migration to the cities, few jibaros remain today ( ). African slaves were brought to the island as sugarcane was introduced, with slavery continuing until 1873 ( ). The slaves imported from Africa came from Sudan, Congo, Senegal, Guinea, Sierra Leone, the Ivory Coast, and the Gold Coast, adding further diversity to the island’s racial mix. Furthermore, some French families from both Louisiana and Haiti, Scottish and Irish farmers escaping depressed economies, Italians, Germans, and even Lebanese people moved to Puerto Rico and contributed to the cultural and racial mix that makes the Puerto Rican culture unlike any other. This historic intermingling has resulted in an island where racial problems are minimal ( ).
Over the centuries, the Spaniards fought off attempts by the French, Dutch, and British to capture control of the island. Nevertheless, after the Spanish-American War, in 1898, the Treaty of Paris ceded Puerto Rico to the United States, thus adding American influence to the culture. In 1917 Puerto Ricans were given U.S. citizenship.
In 1952 the people voted in favor of commonwealth status. As a commonwealth, Puerto Rico is a self-governing part of the United States. Puerto Rico’s executive power resides in the governor and a bicameral legislature made up of a Chamber of Representatives of 53 members and a Senate of 27 members, who have control over the internal affairs of Puerto Rico. Puerto Rico is divided into 78 municipalities, each of which has an elected mayor and municipal assembly ( ). Puerto Rico has one resident commissioner with a voice but no vote in the Congress of the United States. As U.S. citizens, Puerto Ricans are subject to military service and most federal laws, and they have free movement in and out of the United States. However, as residents of the commonwealth, they pay no federal income tax on locally generated earnings, nor can electoral votes be cast by Puerto Rico in the U.S. presidential elections.
Currently, Puerto Ricans are divided over whether to request the United States for statehood or to remain a commonwealth ( ). A view of the Internet version of the Puerto Rico Herald ( www.puertorico-herald.org ) indicates numerous articles related to the political future of Puerto Rico, including one titled, “What should the U.S. Congress do about Puerto Rico’s political status?”
Puerto Rico is a strategic location for the U.S. military in the Caribbean. This setting gives the U.S. military access to North, Central, and South America, and Puerto Rico is a center for U.S. military training, surveillance, and weapons testing ( ). Since the closure of U.S. bases in Panama in 1999, Puerto Rico has provided the home for military forces in Latin America and for the U.S. Army South.
With a population of 3,620,897 (July 2014 estimate) and density of 1057.5 people per square mile (2014 estimate), Puerto Rico is one of the most densely populated islands in the world and is more densely populated than any of the other states ( ; ). Some 71% of the population lives in urban areas. Approximately one third of the population is concentrated in the San Juan-Carolina-Bayamon metropolitan area; 75.8% are White, 12.4% are Black, 0.4% Amerindian, 0.2% Asian, and 10.8% are mixed and other ( ; ). A total of 98.8% of the population considers themselves Hispanic ( ). According to 2014 estimates, the birthrate is 10.90 per 1000 live births, the average annual rate of growth is 0.65%, the infant mortality rate is 7.73 per 1000 live births, and the life expectancy at birth is 79.09 years (75.46 years for males and 82.80 years for females) ( ; ; ).
Puerto Rico is a major hub of Caribbean commerce and tourism, boasting a diversity of attractions in an unvarying climate that ranges year round from 75° to 85° F ( ). San Juan provides one of the world’s busiest cruise ship ports and is among the most dynamic cities in the West Indies ( ). Romantic resorts, private villas, and remote offshore islands offer attractive honeymoon destinations. The chief crops of Puerto Rico include coffee, plantains, pineapples, tomatoes, sugarcane, bananas, mangos, and ornamental plants. Chief industries are pharmaceuticals, manufacturing of electronics and apparel, and tourism. Some 19% of the labor force is employed by the government. In spite of marked success in Puerto Rico’s developmental efforts, the per capita median income (2009 estimate) of $14,905 is low by U.S. standards, but high by the World Bank estimates that considers high-income countries as having a gross national income per capita of $16,300 (2014 estimate) ( ). The unemployment rate of 16% (2015) means some persons live off public assistance ( ). The median family income is $27,017 (U.S.) compared with the rest of the general U.S. population at $52,029 ( ). In 2008, it was estimated that some 48.8% of the total population of people in Puerto Rico lived below the poverty level, which is defined by Health and Human Services for a family of three at $15,670 per year and for a family of four at $18,240 ( ).
Immigration to the United States
The open borders allow migration of Puerto Ricans to the United States. As American citizens, they are neither immigrants nor aliens ( ). Initial settlements of Puerto Ricans were in New York. In the 1950s, an average of 40,000 Puerto Ricans migrated yearly, so that by 1970 more than 1.4 million Puerto Ricans lived in regions across the United States. When the economy in the United States declined in the 1970s, thousands returned to Puerto Rico. When the Puerto Rican economy declined, social programs from the U.S. government were provided.
In mainland United States, Puerto Ricans make up the second largest Hispanic subgroup in the United States and represent 9.7% of the country’s Hispanic population ( ; ). Today, nearly 4.6 million Puerto Ricans reside in mainland United States, predominantly in the Northeast, with large numbers in New York and metropolitan New Jersey ( ; ).
As citizens, Puerto Ricans do not require a work visa to live or work in the United States, significantly simplifying travel back and forth. However, while travel can be done without difficulty, problems with the English language, lack of financial resources, and health problems present significant acculturation problems that require assistance from culturally competent professionals ( ). Among the Puerto Rican population in the United States, 25.7% live in poverty, compared with 14.3% of the total population ( ). As an ethnic group and minority, Puerto Ricans in the mainland United States may encounter prejudice not experienced on an island where racial diversity is the norm.
For many years Spanish and English were both designated as the official languages of Puerto Rico. Even though few Puerto Ricans spoke English, English was the official language of instruction, and children were forced to learn English in school ( ). In 1991, in response to pleas from the people, the Puerto Rican legislature passed a bill that made Spanish the island’s official language. However, in 1993 the governor restored equal status to Spanish and English ( ). Today, Spanish tends to be used at home and in schools, the mass media, and business, whereas English is used for all federal matters, is spoken in all major tourist areas, and in most schools is taught as the second language. Puerto Ricans from large cities are most likely to be able to read, understand, and speak at least some English ( ).
It is important for the nurse to appreciate that the Spanish spoken by Puerto Ricans may differ significantly from the Spanish spoken by individuals from other Hispanic cultures. An example of this is found in the use of Escala de Inteligencia para Ninos, which is a translation of the Wechsler Intelligence Scale for Children developed in Puerto Rico but used widely for testing with many Spanish-speaking children. When Christine tried to use this test with Aymara children in Bolivia who were bilingual in Spanish and Aymara, a number of overt and covert problems were identified. The language presented overt problems, and differences in cultural heritage between the two groups taking the test presented covert problems. When a word was taken from American English to Puerto Rican Spanish to Bolivian Spanish and from White middle-class children in the United States to Puerto Rico to the poor rural American Indian children in Bolivia, both the word and the meaning changed.
Puerto Ricans are sensitive people and are quick to express feelings of love and affection, or carinosos . They are known for their hospitality and desire warm and smooth interpersonal relationships, or simpaticos ( ). Gratitude and respect are often expressed to others, including health care providers, by gifts of homemade food. Since showing respect properly is highly valued in the culture, rejection of a gift can be interpreted as an insult.
Puerto Ricans are fond of fiestas (celebrations) and celebrate not only U.S. federal holidays but also many holidays unique to Puerto Rico, including Three Kings Day (January 6), the Discovery of Puerto Rico Day (November 19), and Constitution Day (July 25). Tourists can easily find festivals and carnivals to add to their holiday itinerary when visiting Puerto Rico ( ). Many Puerto Ricans living in the United States continue to celebrate Puerto Rican holidays.
Tone of voice is important in communication for Puerto Ricans; their tone is typically melodic and peaceable ( ). A Puerto Rican may misinterpret the nurse’s use of high pitch and voice inflection as confrontational when this is not intended.
Puerto Ricans are generally accustomed to shaking hands when greeting people. Close friends may grasp shoulders and kiss each other on the cheek. While women may kiss women or men in this way, men do not greet other men with a kiss. However, a man may embrace a good friend or relative ( compadre ) with a hug after a long absence. It is common for females to touch each other with their hands during communication. In greeting, more traditional Puerto Ricans may avoid eye contact as a sign of respect. Avoidance of eye contact may also be practiced when greeting the elderly as a sign of respect.
For most Puerto Ricans, self-respect is communicated by pride in personal appearance, particularly by what is worn in public. In Puerto Rico, parties and social gatherings are occasions where formal dress is expected, with shirts and ties for men and dresses or skirts and blouses for women. Sloppy, overly casual, or revealing dress is not considered appropriate. The traditional clothing once associated with Puerto Rico is no longer worn, but Espiritistas or faith healers may wear white outfits, hats, and handkerchiefs on selected days.
When addressing others in formal situations, Puerto Ricans may use titles to show respect. A Puerto Rican may use a title recognizing the person’s profession alone or in combination with a surname. It is most respectful to address an older person by combining the title with the person’s first name.
Implications for Nursing Care
Lack of ability to speak English has been related to lack of adequate treatment for Puerto Ricans in the United States. While Spanish literature for teaching may be available, the literacy level of the patient may not allow the literature to be understood. When a Spanish-speaking translator is available, the dialect of the translator may be so different that the Puerto Rican patient does not clearly understand what is being explained. noted that translators can make many errors in translating a language even when they are familiar with that language. When a translator lacks the cultural and linguistic background to recognize words in a language that may change meaning from one culture to the next, the translation can lack accuracy ( ).
When interpreters are used, it is important to consider the topic to be discussed and the gender of the interpreter. If the topic carries a stigma such as acquired immunodeficiency syndrome, tuberculosis, or sexual behavior, a patient may be more likely to express concerns to an interpreter than to a family member and to express concerns to the interpreter that they do not want this information disclosed to the health care provider. Thus, it is necessary to convey to the patient that no information should be communicated to the interpreter that the patient does not want the health care provider to know. For some topics related to sexual matters, same-sex family members will be more effective translators than an interpreter of the opposite sex.
noted that when dealing with Puerto Rican patients who have come from an agrarian society, even if the care provider or interpreter speaks Spanish, the patient may have difficulty with good control of the Spanish language. Additionally, in contrast with other Hispanic persons, it is essential to understand the nonverbal communication and symbolism that Puerto Ricans convey with hand gestures and facial expressions, which are critical to understanding the patient’s communication.
It is important for the nurse to appreciate that a Puerto Rican patient may be very hesitant to use a bedside commode or bedpan and may refrain from having a bowel movement during hospitalization because of embarrassment. The nurse may be able to provide adequate privacy that enables a patient on bed rest to use a bedpan by being aware of the stress this causes the patient. Even when a Puerto Rican is sick, self-care for personal needs or care by a family member of the same sex may be preferred over having care provided by medical care providers. The nurse should be flexible and adapt care to be culturally appropriate.
The nurse must appreciate the value that Puerto Ricans place on saving face. For example, a patient who has limited grasp of the English language may be hesitant to ask a nurse to slow down or repeat what is said. The importance of respect in verbal and nonverbal communications should be recognized and accepted with cultural understanding, for example, accepting a patient’s gift of homemade food to show appreciation and respect. Because Puerto Ricans are particularly sensitive to feeling slighted, the nurse should be attentive to actions that may be interpreted as rejection ( ).
Puerto Ricans are accustomed to standing close together when talking. A Puerto Rican may feel insulted if the other individual in a social or professional interaction moves away even slightly during the conversation ( ). On the other hand, personal space can be a significant issue for some Puerto Rican women, who are conscious of maintaining a reasonable distance with persons of the opposite sex. Younger Puerto Ricans may relate distance to being stereotyped as nonassertive.
Implications for Nursing Care
Since spacial needs and interpretations vary, it is important to assess each individual in relation to spacial needs. Spatial needs will vary with sex, age, and position.
The family, including both nuclear and extended members, is highly valued in the Puerto Rican culture. In fact, in most Puerto Rican families all activities, decisions, and social and cultural standards occur in the context of the family ( ).
In Puerto Rico, the total fertility rate is 1.64 (2014 estimate), and 70% of Puerto Rican women report use of contraception to control family size. The average family size in Puerto Rico is 3.6 people. The marriage rate is 9.2 per 1000 persons, with a divorce rate of 4.47 per 1000 ( ; ). Older Puerto Ricans are often rejecting of nonheterosexual preferences, and subsequently gay and lesbian choices may not be revealed to older family members ( ).
Puerto Ricans tend to rely on older adults and elder family when making decisions. In some families, the oldest son or daughter is the one with final decision-making authority over health matters ( ). When a health-related decision is to be made, a wife will typically consult her husband. Even in an emergency situation, the nurse should be sure to ask a Puerto Rican woman if her husband needs to be consulted regarding consent for treatment of a Puerto Rican male. This may be also the case if another family member is to be included in the decision-making process. In some situations, an older woman in the family will have authority and a respected role in decision making. For younger families it will usually be the man who takes responsibility for decisions. Since generational differences may exist as well as differences related to generation of migration to the United States, the nurse must be sensitive and assess each patient for decision-making responsibility within the family. Sick individuals are expected to assume a passive role in terms of care responsibilities and allow themselves to be taken care of by a family member. Family members generally prefer to provide support for individuals needing care in the home themselves rather than involving home care or homemaking services; for example, an elder daughter or son may assume care responsibilities for an elderly parent and a wife for the husband rather than involving an outside caregiver.
It is important to avoid stereotyping individuals who are Hispanic since many differences exist between Hispanic cultures. For example, investigated family structure in relation to alcohol and drug use among Mexican, Puerto Rican, and Cuban-American adolescents. Whereas Mexican-American adolescents in female-headed households had higher rates of drinking, drug use, and overall risk-taking behavior, Puerto Rican adolescents in female-headed households had higher rates of overall risk-taking behaviors, and Cuban-American adolescents’ behavior did not show any relationship to family structure. Thus, relationships and influences within the family structure vary among different Hispanic groups.
Children are highly valued members of the Puerto Rican culture and represent a significant portion of the population: 18.1% of the population of Puerto Rico is 0 to 14 years of age, while 65.4% is 15 to 64 years of age and 12.2% is 65 years and over ( ). Mothers assume the greater role in physical care of children, and a father’s role is for financial needs. The socioeconomic environment of some Puerto Rican families places children at higher risk for health problems. reported that high rates of poverty, poor housing, violence, and high rates of mental illness in adults place children in Puerto Rican families at higher risk for both health problems and acquired disability, such as head trauma, lead poisoning, and spinal injury. Research has provided data that suggest values of Puerto Rican parents may hamper optimal functioning of children with disabilities. investigated sociocultural influences on disability status in Puerto Rican children. These investigators conclude that Puerto Rican values of interdependence, anonar (pampering or nurturing behaviors), and sobre protective (overprotectiveness) influence parental expectations for the capacity of children with disabilities and need to be taken into account when evaluating scores on the Pediatric Evaluation of Disability Inventory and in establishing plans of care.
When a family member is sick, it is expected that close and distant family members, as well as neighbors and friends, will visit to provide support. The nurse should attempt to accommodate the need of some Puerto Rican families to have someone with a hospitalized patient on an ongoing basis.
Attitude toward victims of child sexual abuse varies among cultures and has been found to be more positive in Puerto Rican families. found that Puerto Rican adults evaluated victims more positively than did Cuban-American adults and thus are less likely to stigmatize the child.
Pregnancy is a time for indulgence for many Puerto Rican women. Men are supportive and tolerant of pregnant women. Although most Puerto Rican women follow a diet, exercise is viewed as inappropriate. Therefore, it is helpful for the nurse to encourage exercise and good nutrition in order to avoid excessive weight gain. During labor, fathers generally assume a passive supportive role, and many prefer not to be in attendance at the delivery. Vaginal delivery is preferred since there is some stigma that a cesarean section suggests a “weak woman” ( ). Many women from rural areas prefer breastfeeding; women who work may combine breastfeeding with formula. A tradition for the first meal after delivery for some Puerto Ricans is homemade fresh chicken soup. Some Puerto Rican women’s birth recuperation includes avoiding housework and hair washing for 40 days. Male babies are traditionally circumcised at birth.
Researchers conducted a study to investigate the cultural differences in the relationship between maternal sensitivity, emotional expression, and control strategies during the first year of life, comparing middle-class island Puerto Rican and mainland Anglo mother–infant pairs. All mothers were interviewed in their homes by ethnically matched interviewers in their native language. According to the researchers, the Puerto Rican mothers used physical control in a meaningful and predictable manner in their interactions with their infants. The Puerto Rican mothers persistently and actively structured interactions with their infants in a manner consistent with their long-term socialization goal, teaching infants to be attentive, calm, and well-behaved, compared with teaching infants to be assertive and self-confident. The researchers concluded that their findings supported the need to explore the role of culture in early relationship formation and to define culturally specific definitions of sensitive caregiving ( ).
In a small city in the northeastern United States, research was conducted to explore the experience of fatherhood among young Puerto Rican fathers whose sexual partners were teenagers when their first child was born. The setting was selected because of the persistently high adolescent birth rates in this urban environment. Of the 40% Hispanic population in the city, 90% are Puerto Rican. The 30 fathers participating in the study were Puerto Rican, ranging in age from 14 to 24 when their first child was born, and had an income below the federal poverty guidelines. Two findings were unanticipated by the researchers: (1) ten (33%) of the fathers interviewed reported that they had planned pregnancy with their partner for at least a year and (2) children challenged the fathers to act more responsibly in the world on behalf of their children. The fathers acknowledged concern about how their children perceived them and that children made them aware of their mortality. The unexpected findings, although not generalizable, emphasize the importance for nurses to recognize that reproductive health behaviors occur beyond stereotypical assumptions. The positive and affirming component of identity helps to explain the persistence of adolescent pregnancy, in spite of health promotion messages to avoid it ( ).
Since 85% of Puerto Ricans are members of the Roman Catholic Church, beliefs related to Roman Catholicism are a significant influencing factor for many Puerto Ricans. For example, when a new store opens in San Juan, the owner often invites a priest to bless the business. When individuals plan a meeting, one may say Si Dois quierre, or “If God will” ( ). The other 15% are Protestants (8%), nonreligious (2.3%), and others (3%) ( ). There is a separation of church and state; however, because of the high numbers of Catholics, Catholic traditions and customs prevail among the people. Puerto Ricans consider themselves a religious people and often attribute good fortune to the deity. However, although most Puerto Ricans and Puerto Rican Americans are Christians, many also practice espiritismo, or spiritualism, a blend of Indian, African, and Catholic beliefs. The belief that good and evil spirits are present and can be encouraged or warded off with the proper herbs and rituals is often still present among Puerto Ricans who live in the United States. Even if Puerto Ricans in the United States do not actively practice spiritualism, many respect the beliefs ( ).
The literacy rate in Puerto Rico is 94.1% ( ). Puerto Ricans value education, and families encourage children to not only finish high school but also attend college. This importance is underscored by the fact that a teacher’s salary in Puerto Rico in 1997 was $1500 a month, far above the mean income. Puerto Rico has 50 institutions of higher education and rates sixth in the world for college education rates. Some 56% of college-age persons are attending institutions of higher learning ( ).
Implications for Nursing Care
The nurse should be aware that Puerto Ricans have a strong need for family support and that decision making usually occurs in a family context. The nurse should also be aware that Puerto Ricans in the United States are also likely to be strongly loyal to their country and to feel a strong sense of nationalism. Rather than calling themselves Americanos, many Puerto Ricans prefer to call themselves Puertorriquenos or Boricuas . When referring to “my country,” the reference is usually to Puerto Rico rather than the United States. Some Puerto Rican descendants born in America refer to themselves as Puerto Ricans, saying, “I am Puerto Rican, but I wasn’t born there.” When the nurse is able to speak knowledgeably about Puerto Rican culture or has visited the country, even if only to get off a cruise ship at San Juan for a few hours to visit Fort San Cristobal or the El Yunque rain forest, this familiarity will facilitate a bond with the patient ( ). Puerto Ricans in the United States are generally eager to talk about their plans to return and visit their homeland ( ). Thousands of Internet sites are available to keep Puerto Ricans in the United States in touch with what is happening in Puerto Rico and to provide opportunities to share thoughts and feelings. The Puerto Rico Herald is available in both English and Spanish online.
It is important for the nurse to consider that appropriateness of maternal responses and reproductive health behaviors is based in part on cultural factors. Assessment of mother–child interactions must be understood in terms of cultural beliefs about parenting and child development ( ). The power of gender relations in adolescent health behavior must be considered an integral part of the solution to unintended pregnancy among teenagers. Male partners must be included in a comprehensive approach to contraceptive counseling and preparation for parenting ( ). Health behaviors, as well as personal development, occur in a context of cultural values.