Social, Cultural, and Spiritual Context of Psychiatric Nursing Care

Social, Cultural, and Spiritual Context of Psychiatric Nursing Care

Linda D. Oakley

Disparities are widespread in the diagnosis and treatment of mental illness, as in other areas of health care (Miranda et al, 2008; Alegria et al, 2011; Lagomasino et al, 2011). The Surgeon General of the United States issued a report titled Mental Health: Culture, Race and Ethnicity (USDHHS, 2001) that emphasized the significant impact that sociocultural factors have on the mental health of all people. Its main message was that culture counts. The report underscored the following points:

Holistic psychiatric nursing care must take into consideration a wide range of patient characteristics in the assessment, diagnosis, treatment, and recovery process. People live within social, cultural, and spiritual contexts that shape and give meaning to their lives. These characteristics are expressed as beliefs, norms, and values and they can have both direct and indirect influences on patients’ perceptions of health and illness, their help-seeking behavior, and their treatment outcomes. They are strong determinants of actual and potential coping resources and coping responses, and they influence all phases of an illness, including treatment effectiveness.

These social, cultural, and spiritual characteristics can impact the person’s access to mental health care, the risk for or protection against developing a certain psychiatric disorder, the way in which symptoms will be experienced and expressed, the ease or difficulty of participating in psychiatric treatment, and the ability to achieve recovery. Thus quality psychiatric nursing care must incorporate the unique aspects of the individual into every element of practice and be based on an understanding of the importance of culture, as outlined in Box 7-1.

Cultural Competency

Cultural competency is a necessary step in the elimination of disparities in the diagnosis and treatment of mental illness, and is essential in patient-centered psychiatric nursing care. A specific competency for nurses, as defined by the American Association of Colleges of Nursing (2008), states that patient assessment, treatment, and evaluation are improved by applying knowledge of cultural factors, using relevant data, promoting quality health outcomes, advocating for social justice, and engaging in competency skill development.

Culturally competent nursing practice requires far more than recording the patient’s age, gender, ethnicity, and religion. It must first be based in desire, awareness, and understanding. In addition to being knowledgeable, skilled, willing, and concerned, the culturally competent nurse must be self-aware and self-reflective (Secor-Turner et al, 2010; Hoke and Robbins, 2011). Questions that the nurse can ask to assess one’s cultural competency are presented in Box 7-2.

As a practice skill, cultural competency is the ability to view each patient as a unique individual, fully considering the patient’s cultural experiences within the context of common developmental challenges faced by all people and the broader social environment. The nurse applies this information in nursing interventions that are consistent with the life experiences and values of each patient.

Five areas of cultural competency for nurses have been identified (Campinha-Bacote, 2009):

• Cultural desire—the motivation of the nurse to want to engage in the process of becoming culturally competent

• Cultural awareness—the conscious self-examination and in-depth exploration of one’s own personal biases, stereotypes, prejudices, and assumptions about people who are different from oneself

• Cultural knowledge—the process of seeking and obtaining a sound educational base about different cultures including their health-related beliefs about practices and cultural values, disease incidence and prevalence, and treatment efficacy

• Cultural skill—the ability to collect relevant cultural data regarding the patient’s presenting problem and accurately perform a culturally based assessment

• Cultural encounters—the deliberate seeking of face-to-face interactions with culturally diverse patients

Effectiveness in these five areas provides evidence of culturally competent psychiatric nursing care that is both appropriate and high quality (Williamson and Harrison, 2010; Wilson, 2011).

Cultural competency requires the nurse to ask the patient informed questions that are free of bias (Tillett, 2010). For example, a study of the association of ethnicity and sexual orientation (lesbian, gay, or bisexual) with risk of suicide attempt in black, Caucasian, and Latino youth found that young age and substance abuse behavior did not predict risk of suicide attempt. Instead, the risk of suicide attempt was associated with daily life experiences with multiple sources of stigma, bias, prejudice, and discrimination related to their sexual orientation and ethnicity (O’Donnell et al, 2011). These findings show the value of general cultural knowledge and the need to ask patients about their specific personal life experiences.

Patient-centered care requires knowledge of how social, cultural, and spiritual life experiences and personal characteristics may influence mental health, psychiatric nursing care, and treatment outcomes without bias, assumptions, or overly simplistic views of complex life experiences. Nurses who routinely ask patients questions about these aspects of their lives convey concern about their well-being and avoid stereotyping.

Risk Factors and Protective Factors

The concept of risk factors and protective factors is important to understanding how people acquire, experience, and recover from illness (Carpenter-Song et al, 2007). They develop over time and may change with personal circumstances.

These factors are the same as the predisposing factors that nurses assess in the Stuart Stress Adaptation Model of psychiatric nursing care (Chapter 3). Understanding the risk and protective factors involved in health and illness is essential in the prevention, early detection, and effective treatment of both physiological and psychological illnesses.

Six patient characteristics, influenced by social norms, cultural values, and spiritual beliefs, have been shown to be predisposing factors related to mental health and mental illness. These factors are age, ethnicity, gender, education, income, and spirituality. They influence the patient’s exposure to stressors, appraisal of stressors, coping resources, and coping responses, as described in the Stuart Stress Adaptation Model (Figure 7-1).

For example, poverty is a risk factor for many psychiatric disorders, such as depression and anxiety, and numerous psychosocial problems, such as divorce and abuse. However, poverty also can occur as a result of a psychiatric disorder such as schizophrenia. So too, spirituality, religion, and family and cultural traditions can sustain hope and promote positive coping behaviors in the face of overwhelming adversity, whereas their loss can lead to mood and cognitive changes or destabilization that increases the risk of psychiatric disorders.

The culturally competent nurse does not assume knowledge of a patient based on casual observations of age, ethnicity, or gender. Neither should a nurse draw generalizations about groups based on these factors. Literature that describes and summarizes the values or beliefs of specific populations, such as Black Americans, Hispanics, and Asians, often creates new stereotypes, and these generalizations can further depersonalize nursing care. In contrast, the sociocultural view is based on the assessment of social, cultural, and spiritual factors that are individualized and that change over time.

Findings about these risk and protective factors and their possible health effects are described in the following sections. Box 7-3 lists some sociocultural trends and their influence on the health care system.


The following U.S. sociocultural trends will influence the health care system and the way health care is provided:

These trends will have a profound impact on the health care system for the following reasons:

• As the aging population grows, an increase in chronic conditions and chronic diseases related to behavior will occur that will exact a greater toll on the health care system.

• A rise in the number of young people will bring new waves of problems typically committed by the young, such as murder, rape, robbery, and assault. Almost half of all violent crimes are committed by people younger than age 24, with those 15 to 19 years of age responsible for the most crime. The overall crime rate has increased 500% since 1960.

• Minority populations are currently underserved, a problem that may only intensify. In addition, an increase in low–birth-weight babies among minority populations is anticipated.

• Minority populations are underrepresented in all health care professions, causing concern about whether health care providers will understand health problems within a cultural context and be able to provide culturally sensitive care.

From CRS Report for Congress: The changing demographic profile of the U.S, Library of Congress, 2011.


Age influences an individual’s experience of life stressors, variations in support resources, and coping skills. From school age, to young adult, to retirement and fragile old age, individuals are faced with challenges and changes in their life. Age-related increases and decreases in the use of mental health services can reflect emerging trends in the physical, social, cultural, and spiritual domains of life.

Young adolescents can face many social stressors, such as bullying, at a time when they have not yet developed effective coping skills. Such social stressors can be distressing at any age. However, when they are experienced during transition age periods, such as early adolescence, new parenthood, or recent retirement, they can seem more overwhelming if at the same time the individual must develop new skills and resources to cope effectively.

Aging “baby boomers” will face the same challenges as previous generations but boomers have different expectations. Many expect to be able to remain active, healthy, and independent. Their expectations can mean greater demands on all health care services, including mental health care.

Although age alone can be a determining personal characteristic, age interacts with all other characteristics and therefore can be somewhat less predictable. For example, different interactions of age and income, age and gender, and age and ethnicity can yield different effects. Culturally competent practice requires asking the patient about specific age-related experiences and concerns.


Ethnicity is a cultural characteristic based on racial, national, tribal, genetic, linguistic, and family origins. Individual members of culturally intact groups can have more shared beliefs and values and less variation between communities. However, because ethnicity is largely a cultural characteristic, persons who have similar physical features can have important cultural differences and distinctions.

For example, Latin American, Hispanic, and Hispanic American are terms used to represent native Spanish speakers. Yet the racial, national, language, and cultural backgrounds of Hispanic people are as diverse as Mexico, the Caribbean islands (including Puerto Rico, Cuba, and the Dominican Republic), Central and South America, and Spain. Each group has its own distinct history, customs, beliefs, and traditions.

Similarly, the terms Asian and Asian American refer to 40 different ethnic groups with 30 different languages. As a census category, Native American includes Alaskan and Hawaiian natives, but both groups have hundreds of tribes, each with their own history, languages, and traditions. Black Americans living in the United States also represent highly diverse countries, as do Caucasian Americans. Although there may be similarities in physical characteristics for each of these groups, differences in ethnic and cultural heritage may be immense.

For ethnic and racial minority groups, personal protective factors often are embedded in a tightly shared social identity. Such groups may have well-defined healing practices and traditions that are important positive resources for the nurse to consider when providing care.

In contrast, patient ethnicity also can have direct and indirect negative effects on the development of and recovery from psychiatric disorders and access to health care services. Many minority individuals lack medical insurance or access to health care providers (Kovandzic et al, 2011). Difficulty with language and communication or lack of knowledge in how to negotiate the mental health care system also limits their ability to receive needed care.

Stigma is associated with mental illness, and this can be another barrier for those in need of mental health services (Pope, 2011). Ethnic minority groups, who may already confront prejudice and discrimination because of their group affiliation, often suffer a double stigma when faced with the burdens of mental illness. This is one reason why some ethnic minority group members who would benefit from mental health services decide not to seek or accept recommended treatments (Oakley et al, in press).

Differences exist in the prevalence of certain disorders among various ethnic groups and in their use of mental health services (Hatzenbuehler et al, 2008; Keyes et al, 2008). Misdiagnosis, overdiagnosis, and undertreatment are particular areas of concern (Hampton, 2007).

For example, African-American men are less likely to be diagnosed with depression and anxiety and more likely to be diagnosed as psychotic or paranoid (Metzl, 2009). In turn, the observation that African-American men can be more likely to receive this diagnosis increases the stigma of mental illness in some African-American communities.

Some ethnic minorities who historically were prohibited from seeking mainstream health care or who were subjected to experimental health care without their consent may consider distrust of health professionals to be an important shared cultural value and belief, which can contribute to existing health disparities.

Other minority group members may delay seeking help until their problems are intense, chronic, and at a difficult-to-treat stage, or until community and family support systems have been exhausted. Delays in accessing care and early termination from care can result in a poorer prognosis and create a cyclical reliance on more costly health care services.


As a predisposing factor, gender is similar to ethnicity in that at first glance there appears to be distinctive male and female patterns of risk and protection. However, when all psychiatric disorders are included, the prevalence of mental illness among males and females is approximately equal.

The difference between the two groups is in the type of disorder that is most commonly diagnosed. Substance abuse and antisocial personality disorder are the most prevalent psychiatric disorders among males, whereas affective disorders and anxiety disorders are most prevalent among females. In contrast, the prevalence of schizophrenia and manic episodes for males and females is about equal.

These findings suggest that male and female role socialization plays a part in the perception of health and illness, and that the risk of psychiatric disorders may be gender typed by sociocultural factors, including the way they perceive and cope with life stressors. For example, women are more likely to ruminate about distressing life experiences, whereas men are more likely to seek distractions.

Recent studies of human genes and psychiatric disorders have opened new avenues of understanding about male and female differences based on biological predisposing factors.

The following clinical example demonstrates the interaction of ethnicity and gender and the way in which they can affect a person’s response to stress.


Jose, a 36-year-old Mexican-American male, planned to graduate from college in May and marry his fiancée, Lisa, in June. The couple met in class 2 years ago and has dated most of that time. Jose recently visited Lisa’s family for the first time. Lisa’s parents were of German descent and were unhappy to learn that she planned to marry Jose in 3 months. Lisa’s father told her that if she goes through with her wedding plans he will disown her. He said that her mother and brothers agreed with him and that Lisa would have to choose between her plans and her family. When Lisa told Jose about her father’s reaction, he reminded her that his family welcomes their marriage and they can be happy together. Lisa said she could not marry Jose if it meant going against her family.

Jose was hurt and angry and did not understand Lisa’s decision. Driving back to campus he was cited for speeding. When he returned to his apartment he spent 2 days alone drinking beer. He did not eat, sleep, shave, or shower. By the third day his shock and hurt feelings still had not improved. He went out for a walk thinking he might buy more beer or go home to his family. While walking he passed a group of men, one of whom called him “illegal.” This upset him even more. When he got back to his apartment he wrecked his desk and threw out everything on it, including his completed master’s thesis that had been accepted for publication.

Exhausted, he finally called his father and told him everything. His father said, “Son, I love you so much; your family is so proud of you; you’re a good son. I’ll be there in an hour, OK?” Jose agreed and then sat down and waited for his dad to arrive.

Feb 25, 2017 | Posted by in NURSING | Comments Off on Social, Cultural, and Spiritual Context of Psychiatric Nursing Care
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