After reading this chapter, the nurse will be able to:
Describe how health care practices and perceptions in Russia may have affected the health of Russian Americans.
Identify at least two health problems specific to Russian Americans.
Explain how Russian American people use space and gestures as communication mechanisms.
Enumerate at least two future-oriented values for Russian Americans.
Relate the importance of family to Russian Americans.
Describe specific characteristics of the Russian language.
Formulate and implement a patient plan of care with clients self-reporting as Russian American.
Overview of Russia
Russia (Russian Federation) is the largest (by landmass) country in the world, the largest of the 15 republics once known as the Soviet Union, and the largest country within the Commonwealth of Independent States ( ; ). Russia (conventional name, short form) was known as the Russian Empire during and after the reign of Peter I (ruled 1682–1725) and as the Russian Soviet Federative Socialist Republic prior to the collapse of the Soviet Union. Russia, occupying much of easternmost Europe and northern Asia, stretches from Norway to the North Pacific Ocean and from the Arctic Ocean to the Black Sea with a climate ranging from warm and humid to frigid ( ).
At approximately 1.8 times the size of the United States, Russia occupies 17,098,242 square kilometers and is, therefore, the largest country in the world (the United States is third with 9,826,675 square kilometers). This Russian landmass includes 11 standard time zones (an increase from 9 to 11) ( ). Of the 142,470,272 people in Russia, 77.7% are Russian, 1.4% are Ukrainian, 3.7% are Tartar, 1.1% Bashkar, 1% Chuvash, 1% Chechan, and 10.2% other. Within Russia’s most recent census, over 190 ethnic groups were represented ( ). Although the official language is Russian (96.3% claim Russian as their language), nearly 100 minority languages are spoken ( ; ). It is important to understand that Russian-born nonethnic Russians living inside and outside Russia have unique cultural traditions and insist on Russian identities.
Russia’s enormous land area is divided by the Urals (a mountain system constituting the traditional boundary between European and Asian Russia) into two land localities: European Russia and Siberia. European Russia is smaller in size but includes the greatest number of people, as well as Russia’s two largest cities, St. Petersburg (named Leningrad until September 1991) and Moscow, Russia’s capital.
Russia is the largest country in the world, yet much of Russia is sparsely populated and much of Russia’s landmass is inhospitable for agriculture (too dry or too cold) ( ). The Russian National Constitution of 1993, as amended, established three government branches: executive, legislative, and judicial, but of the three branches, the executive has the greatest powers ( ; ). Russia’s border countries include Azerbaijan, Belarus, China, Estonia, Finland, Georgia, Kazakhstan, North Korea, Latvia, Lithuania, Mongolia, Norway, Poland, and the Ukraine ( ). Russian land can be plain and grassy, forested, mountainous, frigid, and marshy; despite its size, large portions of Russia lack proper soil and climate for agriculture. Only 7.11% of the land is considered arable. Oil, natural gas, coal, metals, and wood are Russia’s main exports, and income from these natural resources has helped Russia recover from its 1998 economic collapse ( ; ). Regarding world production of agricultural and industrial products, Russia ranks first in sugar beets; second in crude oil and natural gas; third in electric power, iron, and potatoes; fifth in steel; and sixth in coal ( ).
However, despite these natural resources, 11% of Russia’s population falls below the poverty line. Russia has a 5.8% unemployment rate, not including a large underemployed labor force ( ). With a 6.8% inflation rate, it now takes 65.3 Russian rubles (the currency of the Russian Federation) to equal 1 U.S. dollar and nearly 76 rubles to equal 1 euro ( ). This compares with about 27 rubles per U.S. dollar in 2006.
Long-range economic concerns include a decreasing workforce, widespread corruption, and a poorly maintained infrastructure. In the 5-year post-Soviet period (1992–1996) Russia’s gross domestic product (GDP) fell 37%; however, an economic recovery followed in 1999. Unfortunately, economic problems persist and organized crime continues to play a role in many initiatives. Because Russia depends so heavily on commodity exports, especially fossil fuels and timber, the nation is vulnerable to shifts in world prices that hit Russia hard in 2014 ( ; ). In Russia, there are eight persons per kilometer, and 74% of the Russian population is urban. Median age is just 38, compared with 36.5 in 2000. Russia has experienced a troubling negative yearly percent change in population of −0.26% between 2010 to 2014, and this negative change is predicted to continue into 2050 ( ). This is influenced by the following ( ):
Low birthrates (11.8 births per 1000 population) and low life expectancies (just 64 years for males)
Low but improving fertility rates (current fertility rate is 1.5 births per woman, compared with 1.25 in 2000; the rate needs to be above 2.1 to ensure a stable population)
Death rates at 14 deaths per 1000 population
An impaired health care system, including a human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic (health care expenditures include 6.2% of the country’s GDP)
Moscow is Russia’s largest city (nearly 10.6 million people) and also its capital. St. Petersburg, to the north and west of Moscow, has 4.86 million people. In 2014, following Russia’s military interventions in the border neighboring country of Ukraine (including international economic sanctions), as well as the dramatic international fall in oil prices, expectations of Russia’s GDP growth were near zero ( ). Nearly three fourths of Russia’s mineral wealth is located in the Siberian regions. Harsh obstacles of climate (e.g., permafrost, which covers much of Siberia), distance, and geography thwart exploration and exploitation of these Russian resources ( ).
Russia declared independence from the Soviet Union on August 24, 1991. After the fall of the Soviet Union in December 1991, Russia and other former Soviet republics joined in the Commonwealth of Independent States. In early 1992, Russia made radical changes that had enormous implications for Russians, including privatization programs and lifting of price freezes, which had stifled free enterprise for decades. Russia became a federation and a United Nations member and adopted a constitution on December 12, 1993, that includes a multiparty system and scheduled elections. All citizens 18 years and older may vote. Presidents are elected by popular vote for a 6-year term (extended from 4 to 6 in 2008) and are eligible for a second term. Since May 7, 2012, with a 64% vote, the Chief of State of the Executive Branch has been President Vladimir Putin. His term will end in March 2018. Russia has no vice president ( ).
Life Today in Russia
Today in Russia, life continues to be difficult and frustrating. Anti-Semitism escalates. Railroad stations are crowded with homeless, begging adults and children because of unemployment and underemployment, chemical addictions, mental illness, and lost pensions. Since 1992, a positive downward trend has occurred in Russia’s recorded poverty levels. In 1992, nearly 34% of Russia’s total population had incomes below the subsistence minimum level. This number dropped to 11% in 2013 ( ). Still, the total unemployment levels for Russian youth have reached 15% ( ). An estimated, though largely ignored, 1 to 4.5 million Russian children are homeless (doubled in the last decade), related to three categories of social problems and family dysfunction. First (41%) is that one or both parents have chemical dependency problems. The second is the loss of a mother, a father, or both (e.g., through death, prison, abandonment), and the third is domestic violence. Approximately 2 million Russian children suffer abuse ( ). An estimated 5 million Russians (3.4% of the population) are homeless, and most are men trying to reintegrate into society ( ). Hundreds freeze to death on the streets each winter ( ). They have been forced into the streets by cruelty, alcoholism, neglect, and abandonment. They are beggars, thieves, substance abusers, and prostitutes; many have been viciously attacked or are suffering from hypothermia, malnutrition, and depression and are illiterate. The vast majority of street children have attempted suicide at least once. Suicide rates by Russian children and teens are the highest in Europe with a 36% increase over the past few years and three times the world average. Homeless children and boarding school and orphanage graduates are more likely than others to commit suicide ( ). Crime and fraud are everywhere fueled by a normalized sense of injustice, insecurity, and mistrust ( ). After the dissolution of the Soviet Union, few if any controls enforced homelessness as well as law and order within the country. Thus, crime exploded. Theft and gangs proliferated, along with weapons and explosives. Without Soviet control, murder and crime rates doubled during the early 1990s. Russia’s police force is plagued by low pay, low prestige, and high levels of corruption ( ). Crimes against women (domestic violence, prostitution, and trafficking) are pervasive and severely underreported ( ). Trafficking of girls and young women as foreign brides is pervasive. A Google search using the keywords “Russian women” listed 197,000,000 sites; when the words “mail order” were added, 21,000,000 sites appeared. Although Russian criminal code has laws that protect women from interpartner violence, no clear mechanisms are in place to support the women or enforce these laws ( ; ). According to , most Russian pregnant women decreased their drinking while pregnant, but a full third of the pregnant women studied did not stop drinking.
Russia’s economy and infrastructure have recently shown signs of improvement. After more than a decade of steady decline, Russia is moving to a more market-based and globally integrated economy. Russia’s GDP grew last year by 1.3% ( ). The telecommunications industry has expanded (over 40.9 million Russians use the Internet), airports and airlines are being enhanced, and road construction and maintenance are improving. Importantly, governmental control over the economy and media has been reasserted by the Putin administration ( ; ).
Small economic gains have done little to improve Russians’ health. Health indicators are good social barometers when evaluating the success of any social or political reform. This is especially true during this transition time for Russians. For Russia, population decline and homelessness pose a clear threat to national and economic security as well as the human potential and viability of the nation. In 2014, Russian women of childbearing age had an average of 1.6 children, which means there are about two more deaths than births per 1000 ( ) By the year 2050, Russia’s population will have fallen by 28%. Male life expectancy in Russia dropped from 64 to 57 years between 1989 and 1994 and is currently again at 64 years for men and 76 years for women. Men and women with less education, who are homeless, and who have higher unemployment rates have higher death rates; alcohol plays an ever-increasing role in Russian mortality rates ( ; ; ). Interestingly, the total population includes just 0.86 males for each female ( ). Men, and very troubling, working men, die far sooner than women because of cardiovascular disease, poisonings, respiratory disorders (60% of Russian men and 22% of women smoke), traffic and industrial accidents, alcoholism, and suicide ( ; ). The infant mortality rate is 7.08 per 1000 live births ( ). Externally caused deaths in Russia are increasing and have been described as an epidemic of injury and violence. Rates of transport-related injury, poisoning, falls, burns, and drownings, as well as intentional injuries such as self- and other-inflicted violence have more than doubled since the mid-1980s ( ).
Tuberculosis (TB) is a major concern, killing more than 18,400 per year. In 2013, TB prevalence was 160,000. Significantly, over 19% of TB cases (50,000) are multidrug resistant (MDR), 36% of newly identified cases are drug resistant, and 4% of all new cases are for children under the age of 15 ( ; ; ). Poverty, unemployment, crime, and homelessness contribute to TB’s spread to 320 new TB cases each day. Importantly, children from these groups contract TB 10 to 20 times more frequently; among all TB cases in Russia, 12% occur in prisoners ( ). Russian prisons are filled with TB-afflicted and HIV-infected persons, in part because of severe overcrowding, and when released, they spread these infectious diseases to the general population ( ). HIV/AIDS is also a growing but often secret epidemic, with the number of infected Russians doubling within the past decade ( ). Among world populations, Russia and the Ukraine are believed to have the greatest HIV growth rates, with prevalence doubling every year ( ). More than half (60%) of all new HIV-positive cases in Russia are among injection drug users (IDUs), with 83,118 IDUs in St. Petersburg alone ( ). Since 1990, the number of IDUs has increased 20-fold ( ; ). Unfortunately, many, perhaps most, IDUs have not been tested or treated for HIV status ( ). The main infected persons are drug users and sex workers. By 2005, sex workers became a leading cause of HIV transmission (partly due to the government’s unwillingness to address and document the problem), and the international sex industry’s use of Russian women makes Russia’s rapidly rising HIV rates an international problem. In addition to prison transmission, HIV and TB infections have spread rapidly among young male Russian populations. The number of Russians infected with HIV has more than doubled since 2001 ( ; ). On December 8, 2005, thousands of Russian hospital patients learned that they may have been treated with HIV-infected blood. Hospitals are incredibly understaffed, with as few as 3 nurses to 40 surgical patients. Nearly all supplies are reused, including suture needles, gloves, drapes, basins, urinals and bedpans, and intravenous (IV) bottles ( ). Medications are expensive and access is tenuous. For example, use of modern, efficient, and effective forms of contraception among sexually active Russian women did not increase between 1994 and 2003 ( ).
For every 1000 people, Russia has 4.9 physicians, 8 nurses (an increase of 0.3% since 2000 and totaling 1.9 nurses per physician), 0.3 dentist, and 0.1 pharmacist. Russia has 62,000 hospitals (down from 126,000) and 9.3 hospital beds per 1000 population (down from 13.1 in 1992), with an average hospital stay of 11 days. Importantly, in 1992 Russia had 207,000 outpatient facilities; this number has dropped to 165,000 ( ; ). Compare these health care worker numbers with those in the United States, which has 2.5 physicians, 11.1 nurses, 1.6 dentists, and 4 hospital beds (with an average length of stay of 6 days) for every 1000 people ( ; ). Despite a negative population growth, the morbidity rate from all diseases increased from 106,328 in 2000 to 113,688 in 2012 ( ). The general health status of Russians is complex and fluctuates based on political and economic variables. Since 2000, morbidity levels of injuries and poisonings, respiratory and cardiovascular disorders, obesity, cancer, diabetes, and all other recorded parameters are increasing, yet deaths from all causes have, since 1992, increased only marginally; external causes of mortality such as homicides and transport injuries are in decline. Life expectancy for men in 2005 was 58.9 years, which increased to 64.6 years in 2012. Between ages 0 and 4, there are only 949 females for every 1000 males. This ratio dramatically changes by the age of 30 when there are more females than males; between ages 35 and 39, there are 1048 females for every 1000 males; by ages 60 to 64, there are 1424 females per 1000 males. Thus, the current difference in life expectancy for women and men is 11.3 years, down from 13.6 years in 2005 ( ). Russia’s health care system remains mostly public supported via a nationalized budget and, on record, is free. It does, however, suffer from the problems of inefficiency, incompetence, low salaries, and bribery ( ; ). Hospital staff often expect extra payment for medications, disposable needles, and extra services. Quality medical care depends on the patient’s ability to pay for these extras. Hospitals hope for additional government reforms that would improve care and system-wide efficiency, and visitors to Russia are warned of long waiting lines for care and strongly encouraged to obtain insurance coverage for medical evaluations prior to their arrival ( ). Hospitals and clinics are poorly managed, equipped, and maintained. Most physicians and nurses are paid low salaries ( ). Thus, there is a steady shortage of skilled and specialized nurses as well as other health care personnel. There is also a shortage of medical supplies and updated equipment ( ; ). In a study of the fragmented Russian health care system, confirm the absence of processes that Russia could use to bring about additional change. As evidence of poor health outcomes, the number of surgical site infections in St. Petersburg hospitals is 3.5 times the rates in the United States, much greater than expected or reported. Possible contributors to these high rates include inadequate antibiotic prophylaxis as well as poor or ineffective infection control practices ( ).
Preventive health care is a low priority, but the Russian Ministry of Health wants to change that by raising the bar for who qualifies for hospital admission, decreasing the number of hospital beds in Russia, and encouraging more doctors to specialize in preventative medicine ( ; ). As evidence of these changes, the total GDP spent on health care has risen from just over 3% to 6.2% ( ).
Many of the old Soviet-era system-wide health care challenges remain. Russian health care consists of outpatient clinics and emergency and in-patient care services. The need for primary care by the Russian population far outweighs the current system’s treatment abilities. Although primary care strategies are getting government attention, disorganization of district-level physicians, ineffective epidemiological monitoring, and poor payment structures actually prevent primary care providers from preventing disease. Instead, patients use expensive emergency care for their outpatient care needs. Rural areas have also seen dramatic shortages of skilled health care professionals, including nurses. Importantly, Russia has not developed a system by which highly skilled, community-based nurses would provide primary care services. If primary care is indeed a national priority and the need to reduce expensive inpatient and emergency care is addressed, community-based nursing care is essential to the improvement of health and health care in Russia ( ).
Russian children, when compared to their U.S. counterparts, begin drinking and smoking earlier, receive fewer prevention messages, and have fewer prevention programs available to them ( ; ). Nearly 60% of Russians smoke, with a dramatic increase among women under age 30 to nearly 30% ( ). New government efforts recently passed may help curb this trend with a bill passed in 2013 to ban smoking in public places and a new law identifying beer as an alcoholic drink rather than a food and banning the sale of beer in curbside booths ( ).
Russian nurses are learning to expand their roles as independent practitioners into community health areas ( ; ) with the help of the RNA, established in 1992. The RNA became a member of the International Council of Nurses in 2005 and has over 180,000 members in 56 Russian regions. Nurses’ goals include role advancement, professional development, economic and professional protection, and important health care system influence. The mission of this hugely important nursing association includes “Assisting the growth of the quality and accessibility of nursing care in Russia and improving the criteria indicating the health of the nation” ( ). Accomplishment of these goals will be essential if the steady increase in tobacco, IV drugs, and alcohol use in Russia is to change course, and Russian nurses express hope that, although the Russian health care system struggles, the life of a Russian nurse is better than it was 10 years ago. They express hope that modern advances will move Russian health care forward ( ). For example, in 2012 the RNA received a $149,946 grant to upgrade the quality of care received by cancer patients experiencing chemotherapy at different care settings. The organization will help develop a nursing education curriculum to educate 60 nurses who in turn will educate an additional 1200 nurses within inpatient, outpatient, ambulatory, and home care settings. Evidence-based practice standards will also be implemented and evaluated ( ).
Historically, Slavic tribes began migrating into Russia around the fifth century, and the first Russian state was established in the ninth century by Scandinavians. Mongols overran the country until 1480, and Ivan the Terrible became the first tsar in 1547. Peter the Great (1682–1725) tried to Westernize Russia, but the pace was slow. Russia had no universities until 1755. In 1917, after Tsar Nicholas II abdicated (and during the October Revolution), Lenin and the Bolsheviks overthrew the government. Between 1918 and 1924, the tsar and his family were murdered, the Bolsheviks declared ideological war on Europe, Joseph Stalin (Josif V. Dzhugashvili) became general secretary, and the Union of Soviet Socialist Republics (USSR) was established.
Further political change in Russia has been dramatic and historic. The current political situation began on March 11, 1985, when the former USSR KGB chief, Secretary Konstantin Chernenko, died and was replaced by Mikhail Gorbachev.
Between 1985 and 1990, the Gorbachev–Shevardnadze team created a new human rights movement within the USSR. Gorbachev’s reforms, identified as perestroika (restructuring) and glasnost (openness), swept the country with promises of a modern democracy and freedom. However, Gorbachev inherited an inefficient, centralized, and decaying empire ( ; ). Gorbachev believed that free enterprise and a carefully controlled form of democracy could be the overhaul needed for communism. To help him with this plan, he heralded a known reformer, Boris Yeltsin.
Yeltsin proved to be forceful, authoritarian, proud, chaotic, and critical of Gorbachev’s leadership. Therefore, in a powerful control move, Gorbachev publicly humiliated and fired his former protégé. This embarrassing termination triggered Yeltsin to campaign against the Communist Party and to run as a candidate for a parliamentary seat as the people’s deputy from Moscow. Yeltsin achieved enormous popularity among the people, 90% of the vote, and leadership of a growing group of people who opposed communism ( ).
In February 1990, the USSR’s Central Committee eliminated a constitutional clause that guaranteed the leading role of the Communist Party. Independence from the Soviet Union is identified as occurring on August 24, 1991 ( ). Yeltsin left the Communist Party in 1990. After confrontations with the Baltic republics, Gorbachev began discussions that would lead to the creation of a “voluntary” union of the republics.
In May 1991, Soviet citizens were given the right to emigrate. The law titled “On the Procedure for the Exit from the USSR and Entry into the USSR of Citizens of the USSR” came into full effect in January 1993. This law was heralded as one of the most significant steps toward an open Russian society and marked the end of Communist-enforced isolation ( ). This law restored the rights of the Russian people to travel freely.
In a historic move and by democratic vote, the citizens of the Russian Republic (highest population and most wealthy republic) elected Boris Yeltsin (June 12, 1991) as its first president, with a 57% vote ( ; ). However, shortly thereafter, Gorbachev was overpowered in a dramatic conspiracy coup. After that time, there were ongoing struggles over rulership of this land as power passed back and forth between Yeltsin and coup forces. Yeltsin had great power but failed to use this power to make immediate and necessary reforms. Yeltsin’s popularity declined dramatically as a result of internal fighting among the 1033-member parliament (also called Congress of People’s Deputies ).
The Congress (or Duma), Russia’s highest legislative body, was formerly dominated by an anti-Yeltsin majority of ex-Communists ( ). During Yeltsin’s tenure, his economic policies received much criticism, and by the spring of 1993, eight attempts on his life had been reported ( ). However, Yeltsin continued to push for democratic reform ( ), including opening classified Soviet archives, allowing Russians the right to own property and businesses, and attempting to stabilize the unit of Russian currency, the ruble. Other reforms included increasing social care for the needy, formalizing a system of granting benefits and privileges ( ), enforcing public disclosure of environmental accidents, dismantling state economic controls, and cutting the military by half, including dramatic nuclear arms cuts, to invest resources in other areas. Vladimir Putin (Yeltsin’s hand-picked successor) was president from 2000 to 2008 and again took office on May 7, 2012. Putin has inherited the conflict in Chechnya, which continues to draw international and national criticism. Universal suffrage occurs at age 18 ( ). The military draft in Russia includes males ages 18 to 27, and the length of required service is 1 year. In 2013, only 65% of the Russian men called up for military service were healthy enough to serve ( ).
For many years following the Soviet collapse, the Russian military experienced disregard. Now, under Vladimir Putin, a shift toward Russian military supremacy and power internally and beyond its borders has occurred. Putin is implementing military reforms to establish a crisis-reaction force and special operations force as well as professionalized and better organized ground forces. As evidence, its military budget has more than doubled within just 10 years. (However, because over half of Russia’s federal budget income is based on oil and gas products, as these commodity prices fall, defense spending will likely follow.) As seen recently in the Crimea, Ukraine, and Georgia, Putin’s administration is using military force to preserve Russia’s hold on border nations. Western sanctions against these military efforts have, however, imposed economic hardships for Russian banks and businesses ( ).
In contrast to continued military restructuring, Russia’s democratic reforms have slowed and in some cases reversed. Today, the greatest danger in Russia is the widespread disregard for democracy and the repression of free speech, such as unbiased radio, television, and newspaper coverage of political issues ( ; ).
Immigration to the United States
As Russia has undergone rapid changes over the years, with dramatic economic fluctuations, life in Russia has been unbearable for some, and immigration to the United States has increased. Since the fall of the Soviet Union, many in Russia have chosen to leave in order to improve their own lives but, more important, to improve the lives of their children. Thus, the likelihood has significantly increased that a nurse in the United States may care for Russian clients and their families and that the nurse herself or himself may be Russian. Although collectively referred to as Russians as a group, Russian immigrants are diverse with diverse ethnic identities. For example, Russian Americans may self-report as Jews, Pentecostals, Muslims, or Orthodox and come from vastly different political, religious, social, and economic spheres ( ; ).
Since the late 1800s, there have been five significant waves of Russian immigration to the United States: 1880s to 1914, 1920 through 1939, 1945 through 1955, 1970s through 1992, and the post-Soviet era to now ( ; ). They arrived in the United States after facing severe economic hardship and political and religious persecution. In many ways, immigrants have come from two Russian homelands. One includes Russia as it exists today, a land inhabited by ethnic Russians. The second includes territories in addition to Russia, once claimed by the Russian Empire and the Soviet Union. This diversity has blurred U.S. census reports, making actual census numbers difficult to interpret, and has diversified descriptions of Russian American cultural groups. Importantly, Soviet and Tsarist governments severely restricted emigration. Imperial Russia forbade emigration for everyone except Jews, which relates directly to the small numbers of non-Jewish Russian Americans prior to 1920 ( ).
Immigrants from the pre-1914 Russian Empire escaped from a country economically far behind its European neighbors. They were poor and often desperate. Importantly, Russian Jews were only allowed to live in Russian Empire areas outside of mainland Russia (e.g., Lithuania, Moldova, Poland, Ukraine) ( ).
From the late 1800s to 1914, more than 3.2 million Russian Empire immigrants arrived; just 65,000 were ethnic Russians (1.6 million were Jews). Many of the arriving Jews left the Russian Empire to escape Jewish persecution. Many chose not to identify themselves as Russian ( ). The second wave of Russian immigration occurred as a direct result of the political chaos of the Bolshevik Revolution and civil war. All were opposed to the Communist regime.
More than 2,000,000 persons fled Russia in the early 1920s. The third wave took place following World War II. Immigrants in the second and third waves were considered traitors by the Soviet government. In contrast, in the fourth wave, beginning in 1970, immigration was legal although severely limited for Jews who were allowed to travel only to Israel; many chose to continue migrating on to the United States. Immigration policies were relaxed in the mid-1980s under Mikhail Gorbachev. The policies allowed Jews and non-Jews to leave the Soviet Union. Now, however, Russian immigrants can no longer claim political or religious persecution as they enter the United States ( ). Therefore, numbers have slowed, although anti-Semitism has flourished in post-Soviet Russia. Actual recorded numbers of persons obtaining lawful permanent U.S. resident status from Russia by year ( ) include 2,608,299 between 1900 and 1919, 28,132 between 1970 and 1979, 33,311 between 1980 and 1989, 433,427 between 1990 and 1999, 167,152 between 2000 and 2009, and 43,820 between 2010 and 2013. Since 2000, 203,470 Russians have immigrated to the United States. Most Russian Americans are living in the northeastern part of the United States (36%) with 17% in the Midwest, 21% in the South, and 25% in the West ( ).
Russian immigrant Jews were and are well educated (all high school graduates go on to college), with approximately 14 years of education (with an approximate equal number of births to deaths). Most entered the United States as refugees because of emerging and ever-increasing anti-Semitism. For many Russian Jews, the Jewish communities in which they settle provide tremendous social, religious, and economic support. Russian-speaking Jews are highly likely to be members of Jewish community centers ( ; ). For most Russian immigrants to the United States, their sphere of family and friends rests primarily with other Russian Americans; this is partly due to U.S. immigration laws that offer the right to U.S. immigration based on family preference. Therefore, most new Russian Americans are related in some way to earlier Russian immigrants.
From 1971 to 2009, approximately 410,000 Russian Jews entered the United States ( ). Russian Jews make up 10% of the population of American Jews, with a current estimate of approximately 700,000 to 750,000 Russian-speaking Jews in the United States. About half live in New York areas, and large numbers are located in Boston, Chicago, San Francisco, and south Florida ( ; ). Furthermore, 70% of Russian-speaking immigrants from the former Soviet Union self-identify as Jewish, and most of the remaining 30% belong to Russian-Jewish households ( ; ). Prior to the 1990s, Russian-speaking Jewish immigrants assimilated into American culture fairly well. As refugees, they entered the United States with an identity and a level of preparation called anticipatory socialization. Since 1990, that has changed. Recent non-Soviet Russian immigrants did not endure the long delays and confusion that earlier immigrants endured. Some recent immigrants were processed and arrived in the United States within a year or less. Immigration was more economic than political, and immigrants were less well prepared for American life ( ).
Historically, Soviet Jews were the most oppressed ethnic group in the USSR. In addition, policies of the former USSR encouraged, even mandated, the immigration of the family as a unit ( ). Therefore, when younger family members wished to leave Russia, older parents also had to leave. Yet despite the numerous challenges they have faced, 64% of Russian-speaking Jews (those having lived in the United States 9 or more years) report they are completely (or mostly) satisfied with life in the United States ( ). Nearly 81% of Russian-speaking Jews in the United States have relatives or friends in Israel. Thus, they retain strong political and emotional ties with Israel.
The number of Russian-speaking Jews in the United States outnumber all those living in Russia and Ukraine combined, and more Russian Jews live in New York City than in any other place worldwide ( ). Now, the official religion in Russia, Russian Orthodox, has a unique relationship with the Russian government ( ). Thus, the Russian Orthodox church has resumed its privileged place at the heart of Russian culture ( ; ) and has powerfully dictated policies relative to religious freedom. Violence, hate crimes, and overt sentiments of ethnic cleansing against Jews, Muslims, and other religious and ethnic minorities have dramatically increased ( ), with little interference from police or government officials.
According to the U.S. Bureau of the Census, of those persons speaking a language other than English at home, 1.5% spoke Russian; this number equates to 905,843 persons. Of those persons, 52.3% say they spoke English very well, 25.6% spoke English well, 16.8% did not speak English well, and 5.3% spoke no English ( ). For the most part, Russians who immigrate to the United States are well educated (most having college or technical degrees and holding careers as health care professionals, economists, teachers, engineers, and skilled craftsmen and technicians) and speak at least some English. Russian Americans are courageous people who are voracious readers and passionately devoted to music, philosophy, art, and science ( ; ; ).
Despite years of hardship, Russian immigrants are proud, forward-thinking people with a strong internal locus of control. Russian immigrants come to a specific location because they have relatives or other contacts in these locations, meaning that large pocket populations of Russian Americans have emerged in various regions in the United States.
Starting in 1992, immigration from Russia was reported separately, not as part of the “former Soviet Union” statistical group. Immigration numbers also include a seldom reported yet important number of Russian children adopted by U.S. citizens. Since 1992, Russia, with its limited resources to care for orphaned children, has become a major source of foreign children adopted by U.S. citizens, with a total of 6270 children adopted by American adults between 1996 and 1997. In 2009, 1580 immigrant orphans from Russia were adopted by U.S. citizens. These children were 56% male; 77% were between 1 and 4 years old ( ). Importantly, these children are Russian-speaking, and many have physical or psychological health problems related to congenital malformations and maternal substance abuse problems ( ). Many children living in Russian orphanages have been abandoned by parents and relatives. Importantly, with a resurgence in Russian nationalism, the Russian people and government are becoming more protective of their children, and adoption has dropped to less than 20% of former levels. As evidence, the total number of adoptions between 1999 and 2011 was 45,112 (an average of about 3400 per year. In 2011, just 962 adoptions took place ( ).
Life Today for Russians in the United States
Russian Americans report new and much welcomed freedoms in the United States. For example, Russian American Jews and Pentecostal Christians are often able to fully practice their faith for the first time upon arriving in the United States, and Russian parents commend the skills their children learn in schools. They report no longer feeling like persecuted members of minority groups. Russian Americans especially appreciate creative skills of thinking, analysis, and discussion. Russian women are familiar with working outside the home in well-paying professional positions. In Russia, most health care professionals are women. They are also used to doing the work of the home and are expected to do all or most of the household chores such as cooking and cleaning ( ).
Russian Americans try hard to maintain strong social networks, family stability, and a self-identity that includes their Russian heritage ( ). Within the family, Russian American women have been responsible for nurturing the Russian culture identity among family members, and Russian women counsel strong values of philanthropy and community ( ). Therefore, Russian immigrant communities often provide supportive services such as career and employment guidance, housing assistance, professional networking, technical training programs, classes in English as a second language, and health care. Importantly, Russian Americans have high levels of social participation and interactions within Russian communities.
Americans should understand that in Russia, medical treatment, although limited (at least on record), remains free. Education, including postsecondary university and professional studies, is also often provided at low or no cost, although teachers and university instructors are poorly paid. Therefore, many Russian immigrants, including women, have had some form of technical training or advanced education. Nevertheless, Russian immigrants may have difficulty understanding the concepts of insurance, private pay, medical malpractice, health maintenance organizations, medical referrals, diagnostic-related groups, and reimbursement coding. The large and growing Russian-American population, when compared with other immigrant groups, is better educated and enjoys higher levels of discretionary income. For example, of the number of foreign-born Russian immigrants, 54.7% have attained at least a bachelor’s degree, and 16.5% are self-employed. Russian Americans are also more likely to own their own homes and have health insurance. Almost half of foreign-born Russians (47.4%) own their own home and, along with their U.S.-born children, nearly 80% have health insurance coverage ( ). Over 44% of Russian Americans are over the age of 55, and just 8.6% are between 0 and 24 years old (compared with 21% of all foreign-born U.S. residents). Thus, the age composition of the Russian-born U.S. population is skewed toward elders. Clearly, this group of well-educated people is keenly interested in health promotion; illness prevention; and skillful, culturally competent, health care professionals ( ; ).
Dialect, Style, and Volume
The official language of Russia, and the most widely spoken of the Slavic languages, is Russian. This language has a 33-character Cyrillic alphabet (reduced to 33 characters with the 1917 Soviet revolution) named after the ninth-century apostle to the Slavs, St. Cyril. St. Cyril created the alphabet so that the Bible could be translated for liturgy use in the Slavic countries ( ). In the tenth century, the Cyrillic alphabet was adopted by Russians, simultaneously with Christianity. The Cyrillic alphabet was last renovated in 1918. Russian belongs to the eastern branch of the Slavic linguistic family. More than 250,000,000 people speak Russian worldwide. For most Russian American newcomers, Russian is the language used to connect with family and friends. Additionally, the Russian language helps maintain Russian heritage and identity for Russian Americans. Evidence of this trend is the continued large number of Russian speakers and dramatic increase in Russian-based media (e.g., newspapers, books, television stations, Web sites) ( ).
For most Russians, English is the most popular of all the Western languages. This newfound popularity of English on the part of the Russian people is related to media broadcasts, movies, rock video television programs, and Western business opportunities. In addition, professional literature (including health and medicine) is often in English, and medical students are frequently required to read English-language medical journals. There are 261,900,000 cell phones, 40,853,000 Internet users, 14,865,000 Internet hosts, and 3300 television stations (most controlled by federal or local governments) ( ). Although information is hard to suppress and English is widely used, government-controlled media and propaganda broadcasts flourish under Putin’s grip.
Russian is sometimes referred to as a “house green” language because articles (such as the ) and verbs (such as is ) are often unnecessary. The Russian language is a flexible, beautifully rich language. Paralanguage qualities, such as tone, inflection, speed, vowel emphasis, and verbal pauses, contribute to the variety and meaning of Russian words and sounds. Russians freely use paralanguage and other nonverbal indicators to denote the value being placed on what is said. The spirit of the Russian people, their warmth and love, come through clearly in this dialect ( ). Importantly, just as in the United States, the Russian language carries geographic variances and vernaculars.
Russian Americans’ first language may not be Russian but may instead be from the region where they grew up. Many Russian Americans studied some English while in Russia. However, the English they memorized was boring and often British English, which is significantly different in sound, spelling, and pronunciation from American English, making language comprehension difficult. In addition, American vernacular variances and geographical accents can cause problems.
Although many well-educated Russians studied English at some point in their education, English proficiency is not easy, especially for older Russian American immigrants. However, many elderly Russian Americans speak a mix of Russian and English, using both simultaneously ( ). In the United States, Russian speakers rank fifteenth of total speakers of various languages. Using self-report information, there are about 3.13 million Russian Americans ( ); in 2015, 981,000 people aged five and older speak Russian at home. This number is expected to jump to 1,048,000 by 2020 ( ). However, younger Russian immigrants have made the adjustment to English with less difficulty. For younger Russian immigrants, the first priority on arrival in the United States is to learn conversational English, the second priority is to enroll children in school, and the third priority is to find good employment. Nearly half of all Russian speakers are over age 44 ( ). Most Russian Americans maintain a bicultural identity that varies based on age, employment, newcomer status, and levels of acculturation. Acculturation differences among family members may produce conflict and stress. Compounding this stress is that Russian American parents and elders expect youth to obey authority, bow to parental controls, and perform interdependently with family members. Russian children, by contrast, have absorbed American values of autonomy and independence ( ).
Additional stress occurs when Russian youth are frequently required to act as culture brokers for their older parents and grandparents. Brokering duties, especially prevalent among recent immigrants, such as acting as language and information interpreters for education, government, and health care institutions, are common. For Russian American teens, these brokering tasks have created increased levels of stress and relationship problems with family and friends ( ). Using skilled language interpreters, not friends or family, is important because of potential language barriers, impediments to free and clear communication, and confidentiality and ethics violations. Family, especially younger family members, may be embarrassed and anxious during the crisis of an illness or problem. Elderly Russian Americans with English competence enjoy better mental and physical health and, according to , language was not a significant predictor of health service use among elderly Russian immigrants in Boston. Notably, interpreters translate more than just words. They must also convey paralanguage, nonverbal, and subtle meanings. Thus, an additional advantage to using trained Russian interpreters is that, even when Russian Americans speak English well, they express emotions more fluently and use greater numbers of active verbs (versus adjectives) than when speaking of the same situation in English ( ). Fortunately, many medical, chemical, and scientific terms are cognates, and although the written appearance of the word is different between Russian and English, the sound is similar. A few medical cognates are organ(ism), appetite, function, pulse, doctor, hospital, physical, diagnosis, normal, and problem .
The volume of speech used by Russian Americans is not significantly different from that used by some Irish Americans. In Russia, because loud, aggressive demands were often necessary to receive medical care, some Russians became loud when attempting to be understood or get attention. Thus, even normal conversation may seem loud and boisterous.
Russians often use touch freely with intimate and close friends. It is not unusual to see Russian women embracing and kissing other women, as well as Russian men embracing and kissing other men. Friends who have been separated often greet each other, in public or in private, in this fashion. The technique of kissing each cheek three times seems to be a cultural trait adopted from the Middle East. The gentle kiss of a man on a woman’s hand is a gesture of respect and admiration. Also, a handshake of agreement from a Russian is often more binding than a signed document. Handshakes are welcome when accompanied by direct eye contact, and gloves must not be worn. Prior to any touching, Russians may ask for and need the health care provider to explain what will be done and why ( ).
Russian people are commonly perceived as kind, caring, and generous. When trust has been established, they express these feelings willingly and publicly. They are by nature and experience, however, cautious. Some Russians evaluate situations and people with great care. Emotions are also freely expressed. Russians have a quick appreciation for jokes and satire, often venting their feelings in this form of expression. It has been said that Russian people cry and laugh easily and that genuine expression of emotions is valued. Russians also tend to exhibit less control over negative emotions, especially with strangers ( ).
Russian people who learned English in Russian schools may have learned from a non-native speaker. Therefore, the sound of English will be different. Native Russians who are eager to practice conversational English with a native English speaker often approach tourists traveling in Russia. However, for most new Russian immigrants, conversational English is likely to be unrecognizable.
Russian people have learned through years of government rule to look and act neutrally. With strangers and in crowded places, eye contact is avoided, affect is flat, posture is not erect, and eyes are diverted. Upon arriving in the United States, Russian Americans often express great wonder at the freedom with which Americans make nonverbal connections with strangers. However, Americans tend to be cooler and more distant with close friends and family, avoiding unsolicited advice-giving, than Russians. Historically, a distrust of authority and subsequent reliance on family and friends for help, advice, and care were survival mechanisms. Thus, for Russians, it is common to visit friends and neighbors on a whim, bringing food and gifts without notice, whereas in the United States this practice is uncommon ( ). As interesting evidence, the Russian language includes two ways of saying the plural “you,” one for only the closest of friends and family and a second, more generic, term when speaking with colleagues or strangers.
Russians understand that public behavior needs to be respectful. Disrespect is shown when persons fold their arms across their chest, stand with hands in their pockets, slouch, cross legs so as to expose the sole of the shoe, and walk into a house with shoes on ( ). Smiling at another person must be sincere ( ). Until trust and comfort have been established, Russian Americans’ nonverbal communication style is subtle and with few gestures. They do, however, feel free to maintain eye contact, and they do allow and expect nurses to use touch and gestures freely during the implementation of nursing procedures. Older Russian American immigrants are more entrenched in social amenities, often preferring to express themselves verbally. “Please” and “thank you” are integral to their speech, and they use these words at every possible opportunity. Russian men will courteously open doors for women. Nodding one’s head is a gesture of approval; outstretching one’s hand is a gesture of salute. When compliments are given, they are sincere. Gifts and flowers are presented during important meetings as a gesture of tribute. The person seated first in a room is the one with the most authority or prestige. Nurses should not use the common American-based “OK” sign when speaking with a Russian because this is considered rude. Russian Orthodox followers will cross themselves from the forehead to the upper chest, then the right to the left shoulder ( ).
Implications for Nursing Care
Russian Americans expect the nurse to be warm and caring, to demonstrate empathy, and to help them cope with physical and emotional problems. An often expressed expectation of the nurse by the Russian American is that the nurse be friendly. This expectation is demonstrated by an “inviting,” open posture; a smile; and a low and calm voice. As health care professionals, nurses are expected to show support in word and deed, suggest specific interventions that will improve the patient’s situation, and begin these interventions immediately. Nurses should also anticipate patient needs, even when not expressed directly ( ). Appropriate touch is considered a sign of friendliness and caring. Russian Americans do not appreciate a light, “chatty” approach to health care; they believe appearance and demeanor must always remain professional. Russian Americans want to be certain that the nurse understands them. They can easily become very shy; this is especially true of recent immigrants. Because their English may be tenuous, Russian Americans may hesitate to ask for clarification.
Russian American patients need to be assessed for their level of acculturation, English language skills, and education and social status. When doing histories or intake screenings on Russian Americans with English literacy, nurses need to understand that if they are speaking and thinking in English, they will describe symptoms and events differently than when speaking and thinking in Russian. ( ). Even if a Russian American is fluent in English, communicating in English during times of pain, stress, and anxiety will be difficult. Knowledge of this difficulty is especially important when working with elder Russian Americans. Nurses must always avoid using family and friends as language interpreters and culture brokers.
Russian Americans expect the nurse to speak slowly and clearly and to choose simple words when needed. Russian Americans may demonstrate limited listening skills, perhaps because of language barriers, and may be unwilling to make independent health care decisions. Russians may assume the nurse and physician will tell them everything they need to know about their health problem and often prefer a more direct, versus indirect, approach to their care needs. However, gestures and demonstrations, to clarify and promote understanding, are expected and appreciated. “Look at my eyes,” explained one Russian American. “My eyes will tell you that I do not understand because I will have a stupid expression!”
In most instances, Russian Americans will comply with medical directives and teachings if they believe that the nurse is trustworthy, honest, caring, sincere, and competent. Nurses will not be believed or trusted by Russian Americans if they are perceived to be mask-like, robotic, insincere, or phony in their caring behaviors. Nurses should address Russian American clients by “Mr.” or “Mrs.” followed by the family name. However, use of the first name, followed by the patronymic (their father’s first name plus a feminine or masculine ending, depending on the person’s sex) may be an acceptable alternative. Well-educated and professional Russian American women often retain their maiden names. Using this formal method of address will convey the nurse’s respect. To address a Russian by his or her first name only is improper and presents a grave social error. Russians also object strongly to terms of endearment, such as “dear,” “hon,” “sweetie,” “darlin’,” “dude,” and “hi, guy,” when used by health care workers ( ). As explained by one Russian American, “I want you to believe me when I tell you I have a problem. Here the nurses are perfect. We will respect them and listen to them. They know their job, and they know what they are supposed to do.”
Russian Americans tend to speak freely regarding physical problems. Once language is no longer a concern, the nurse will find that clients respond warmly. However, Russian Americans may be uncomfortable using gestures when speaking to the nurse. The nurse must be aware that although younger Russian immigrants adapt well to English, older Russian immigrants may not. Often, elderly Russian immigrants choose to associate only with Russian-speaking friends and relatives, which presents a difficult problem if an interpreter is unavailable. To add to this difficulty, Russian Americans may allow only Russian to be spoken at home. Because many Russian Americans are multilingual (Yiddish, German, French, Polish, etc.), it is an advantage if the nurse understands another language familiar to the client. One way to convey respect and an understanding of Russian culture is to provide avenues for client teaching through Russian literature. Health literature written in Russian, in addition to Russian-language audio and video presentations, may prove to be great teaching aids. Additionally, cognate words and trained interpreters should be used at all times. found that Russian Americans occupied an additional 5.6 minutes of physician time for each visit. These authors believed this time was spent because of the extra demands for interpreting health information. Therefore, nurse managers will need to adjust workload requirements for nurses working with Russian American clients.
The challenge for nurses is to expand their own culture to care effectively for members of the Russian American ethnic group. These skills can strengthen the nurse as a person and as a culturally competent health care professional.
The Russian culture exists on two very different levels. To strangers and new acquaintances, a Russian may remain aloof, preferring to speak and work in the social or public zone. However, once friendship and familiarity have been established, Russian people are comfortable within a personal zone and will stand up close to that person when speaking or listening. The intimate zone is reserved for spouse or children, except for health care workers performing within a professional capacity. When hospitalized, Russians are extremely compliant and are generally able to tolerate the loss of privacy.
Individuals are perceived according to the boundaries they maintain, which include the degree of permeability and flexibility. Permeability is defined as the degree to which a boundary is open or closed; for the most part, permeability varies from closed to open. When an individual has closed boundaries, very little exchange occurs between this person’s internal and external environments, and the person may be perceived as being quiet, withdrawn, and set in his or her ways. On the other hand, if boundaries are open, much exchange occurs between the person’s internal and external environments, and this individual may be perceived as being talkative and social and as one who enjoys taking risks. Russian Americans may be very superstitious. Death or other potentially negative events should not be spoken of in the abstract. Joking, teasing, or play-acting is not appropriate in a serious or potentially serious situation.
Flexibility is defined as the ability of a person to move along a permeability continuum. A person who is sometimes closed and sometimes open and who thereby uses the entire permeability continuum is considered flexible. On the other hand, a person who always gravitates toward the closed end of the continuum, which is indicative of a low degree of flexibility, is described as a rigid, closed person. A person who is always open and never closed is described as an open individual. People who are perceived as rigid and closed may be quiet and withdrawn and seldom if ever share intimate secrets, dreams, or thoughts, even with best friends or a spouse ( ).
Some Russian persons are perceived as rigid and closed because they remain aloof and distant. However, the word friend is not a casual term to Russians. Friendship is taken very seriously by Russian Americans, with specific terms in Russian reserved for this special relationship. Close Russian friends may embrace, but mere acquaintances may not even shake hands. Russians may prefer to greet and meet acquaintances on a verbal level only.
Implications for Nursing Care
The nurse who cares for Russian American clients will generally find that health-assessment procedures done in the intimate areas such as the genitalia are accepted without argument or problem, provided that adequate information and justification have been given before the procedure, the nurse is perceived as a trusted health care professional, and permission from the client has been professionally requested and provided. The nurse should be aware that, for the most part, Russians prefer to remain at a social distance rather than an intimate distance with caregivers. If personal distance must be invaded to provide therapeutic assistance, the nurse should provide a careful explanation before the intervention to alleviate the stress and anxiety created by the violation of space. As with all aspects of care, it is important for the nurse to modify approaches based on a careful assessment of the individual client and family.