Culture-Bound

As children grow and learn a specific culture, they are to some extent imprisoned without knowing it. Some anthropologists have referred to this existence as “culture-bound.” In this context the term culture-bound describes a person living within a certain reality that is considered “the reality.” Most people have learned ways to interpret their world based on enculturation. Thus, although certain interpretations are understandable and persuasive to persons brought up to share the same frame of reference, other people may not share these interpretations and therefore may make little sense out of the context. , who has traveled extensively around the United States, notes that connecting across racial lines is among the most difficult things on earth. In a perceptive work, A Country of Strangers, he notes, “Even as we look upon each other like strangers from afar, we are trapped in each other’s imaginations.” In Liberal Racism, suggests that rather than trying to overcome racism and create a color-blind world, individuals should fight for equality on nonracial terms. In fact, in polls most Americans agree that people should be judged for themselves, not for their race ( ).

Nurses are also culturally bound within the profession because they are likely to bring a unique scientific approach—the nursing process—to determining and resolving health problems. Many nurses are likely to consider the nursing process the best and only means of meeting the needs of all clients, regardless of their cultural heritage. However, clients may view this modern scientific approach differently, believing that the nursing process meets their needs in some ways but not in others. The nursing process may not consider alternative health services, such as folk remedies, holistic health care, and spiritual interventions. In these cultures, medicine is often practiced in unscientific ways, according to the Western viewpoint. Therefore, desirable outcomes for treatment may occur independently of medical and health care interventions.

Traditionally, American nurses have been socialized to believe that modern Western medicine is the answer to all humanity’s health needs. Most illnesses have been attributed to a biological cause ( ). More recently, Americans have been moving toward a more harmonious relationship with nature in which there is a growing sensitivity to the environment. Traditional attitudes toward disease are being reassessed. Today, more attention is given to the concept of the individual as an organic whole. Nurses are beginning to study and assess options outside of Western medicine that have been used by other cultures, such as Zen meditation, a Buddhist practice ( ), or tai chi, an exercise treatment used in China for hundreds of years to reduce chronic pain in older adults ( ). Many nursing leaders in America are calling for a change in nursing paradigms from scientific to holistic ( ; ; ).

Culture-Bound Syndromes

The nurse should appreciate that some illnesses are uniquely found in a given cultural group. Culture-bound syndromes is a term that refers to “diseases” that seem to be specific to a single culture or a group of related cultures. Culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for a pattern of sets of experiences ( ). In some cases the “illness” may be linked to a category in the Diagnostic and Statistical Manual of Mental Disorders (APA, 2014) but have symptoms, a course, and social responses that are influenced by local cultural factors. Examples are amok, a mental or emotional affliction known in the Philippines that causes one to become a killer, and susto, an ailment widely associated with Spanish-speaking groups in which the soul is believed to leave the body as a result of a frightening event ( ).

Ethnocentrism

For the most part, people look at the world from their own particular cultural viewpoint. Ethnocentrism is the perception that one’s own way is best. Even in the nursing profession, there is a tendency to lean toward ethnocentrism. Nurses must remain cognizant of the fact that their ways are not necessarily the best and that other people’s ideas are not “ignorant” or “inferior.” Nurses must remember that the ideas of laypersons may be valid for them and, more importantly, will influence their health care behavior and consequently their health status. In contrast to the term ethnocentrism is the word ethnic, which relates to large groups of people classed according to common traits or customs. In populations throughout the world, people are bound by common ties, elements, life patterns, and basic beliefs germane to their particular country of origin.

In general, the medical paradigm used in Western culture views health, illness, and dying as biophysical realities. However, the meaning a nurse places on life can affect relationships with clients. For example, a nurse’s belief that there is no relationship between illness and evil may conflict with a client’s belief that illness is a punishment from God or the work of spirits ( ; ; ). On one hand, some Puerto Ricans believe that sickness and suffering are a result of one’s evil deeds; on the other hand, many Ugandans believe that an infant’s illness or death is the result of a neighbor’s curse ( ).

It is also important for the nurse to be aware of treatment practices clients may present that do not appear in Western medicine and may seem shocking. For example, female genital cutting, which may range from a ceremonial pricking of the genitalia to the removal of the clitoris, occurs in 28 African countries with prevalence rates estimated at 50% ( ). Yet another concept that the nurse should appreciate is that moral definitions of an illness may arise from particular historical, social, or medical circumstances that are different in each society. For example, in some societies leprosy is common and considered just another debilitating illness, which many families tolerate. In other societies leprosy has been stigmatized, and lepers are quickly divorced, are pushed out of their homes, and end up as beggars ( ).

Homogeneity

It is difficult to find a homogeneous culture in the United States. If a homogeneous culture did exist, all individuals would share the same attitudes, interests, and goals—a phenomenon referred to as ethnic collectivity. People who are reared in ethnic collectivity share a bond that includes common origins, a sense of identity, and a shared standard for behavior. These values are often acquired from experiences that are perceived to be cultural norms and determine the thoughts and behaviors of individual members ( ; ). The ultimate consequences of enculturation are carried over to health care and become an important influence on activities relative to health and illness behaviors. In the American culture there is a tendency to speak of culture as if it included a set of values shared by everyone. However, even within an ethnic collectivity, intraethnic variations occur and are obvious in health behaviors. For example, intraethnic variations are seen in the concept of mental illness ( ; ; ), in cultural definitions of health and illness, in skepticism about medical care and consequently the use or lack of use of health care services ( ; ), and in the willingness of the individual to assume a dependent role when ill ( ). Since there may not be obvious clues (e.g., language, physical appearance, clothing) to alert the nurse to intraethnic variations, it is essential to be alert to the presence of differences and to be sensitive in interactions with the client when nurse–client variations become evident ( ).

Bicultural

The term bicultural is used to describe a person who crosses two cultures, lifestyles, and sets of values. Some children of African-American, Hispanic, Asian, and American Indian heritage are socialized to be bicultural—that is, to acquire skills to function in both a minority and a majority culture ( ; ).

Ethnicity

Ethnicity is frequently and perhaps erroneously used to mean “race,” but the term ethnicity includes more than the biological identification. Ethnicity in its broadest sense refers to groups whose members share a common social and cultural heritage passed on to each successive generation. The most important characteristic of ethnicity is that members of an ethnic group feel a sense of identity.

Race

Efforts to precisely delineate the term race have been made by many scientists ( ). The AAPA suggests that race, in a pure sense of genetically homogeneous populations, does not exist in any human species today. also proposes that the biological concept previously held to be the “one drop rule” is dated and as such is no longer tenable in today’s society. Nonetheless, many biological scientists suggest that while socioeconomic status may have a more profound effect on health status, race is a viable term that merits attention. Thus, in contrast to the term ethnicity is the term race, which is related to biology. Members of a particular race share distinguishing physical features, such as skin color, bone structure, or blood group. Ethnic and racial groups can and do overlap because in many cases the biological and cultural similarities reinforce one another ( ). A more precise definition of race is a breeding population that primarily mates within itself ( ). There are very few races that still mate largely within the group, but some pure-blooded lineages are found in certain parts of the world, such as some of the descendants of West Africans who live along the Georgia and South Carolina seacoasts in the United States. These people have protected their lineage because they have refused to intermarry. These individuals are known as the Gullah people ; they have not only their own lineage but also their own distinct dialect of English ( ). It is important for the nurse to remember that regardless of race, all people have a cultural heritage that makes them ethnic. It is also important to appreciate that race has an interrelational effect with family structure and income that can influence health and academic and professional achievement ( ).

As views of racial and ethnic identities have changed over time, so have official categories and measurement procedures. The U.S. government weighed in on the question of race as far back as 1790, beginning the arduous process of classifying people into racial categories. Nonetheless, the categories and the method of measuring race or ethnicity have changed dramatically in the intervening decades since the first census was taken in concert with the political and economic forces that have evolutionarily defined this nation. With early censuses, the census takers simply answered the race question based on their perception of the individual. These early censuses were at the very least racially insensitive in that slave status was used as a proxy for a racial category. Even so, at that time, the only race options available for selection include “free White persons,” “slaves,” or all other “free persons” ( ; . As the census continued to evolve, the necessity for more specificity in racial categories became clear for those of mixed African-American and White descent, such as mulatto, quadroon, and octoroon. Beginning in the late 1800s, Asian groups were listed on the census for the first time. Those groups included Chinese, Japanese, and Filipinos ( ). In 1870, other Asian groups were added and included Korean, Vietnamese, and Asian Indian. Likewise, in 1870, American Indians for the first time were included as a separate group. Similarly, counting and measuring the Hispanic population has varied over time. Census takers began by identifying who was Hispanic by looking for a Spanish surname, the use of the Spanish language in the home, and the birthplace of the respondent or parents to indicate Hispanic ethnicity ( ). Over time, this crude way of measurement and counting any racial or ethnic group would prove to be obsolete.

By 1970, racial classification on the census changed from the census taker’s identification to self-identification. Yet, while this was a fairly significant change, it had a relatively minor impact on the count of racial and ethnic groups in the 1970 census compared with the 1960 census. Nonetheless, this change was the catalyst that would spur even greater changes in the census count in subsequent years ( ). The Office on Management and Budget (OMB) announced new standards for federal data on race and ethnicity in 1997 ( ). The Census Bureau, taking its cues from the OMB standards, recategorized racial categories to include, for the first time in 2000, five suggested categories, including White, Black/African-American, American Indian/Alaska Native, Asian, and Native Hawaiian/other Pacific Islander. The Census Bureau also added a sixth category, “some other race.” The Native Hawaiian/other Pacific Islander category was separated from the Asian category for the first time. A significant change—another first since the census started—allowed respondents to choose more than one racial category.

Biracial

When an individual crosses two racial and cultural groups, the individual is considered “biracial.” To be both biracial and bicultural often creates an almost insurmountable dilemma for an individual. Physical attributes such as color, shape of eyes, or hair may have a profound influence on others’ acceptance of the “biracial” individual. One problem associated with biracialism is the inability of the individual to identify or find acceptance in any one of the biologically related racial groups ( ). It is the total exclusion and the sense of not belonging to either of the racial or cultural groups that often create the dilemma. For example, an African-American who is an “octoroon,” a person with one eighth African-American blood, may have difficulty being accepted as African-American because of the lightness of the skin. Conversely, this same individual might be ostracized by some Whites because of the “blackness of the blood lineage.” Although interracial marriages are on the rise, issues of discrimination still occur. Golf champion Tiger Woods revealed in 1997 that in spite of his national stature, his mixed-race origin of White, Black, Indian, and Asian was sometimes met with hostility ( ). This probably is also true for Barack Obama, the first Black president elected in the United States in 2008, who is also of mixed racial heritage. Cose suggests that even in the emerging U.S. mestizo future, if the Latin American experience is a guide, people who are whiter will still have the advantage. Even in Brazil, where racial mixing is sometimes celebrated, status and privilege are still related to lighter skin. For some people of color, there is a perception that White America believes that color is the difference that makes the differences ( ).

Minority

A minority can consist of a particular racial, religious, or occupational group that constitutes less than a numerical majority of the population. With use of this definition for the term minority, it is obvious that all types of people can belong to various kinds of minorities ( ). Often a group is designated minority because of its lack of power, assumed inferior traits, or supposedly undesirable characteristics. In any society, cultural groups can be arranged in a hierarchical power structure. Dominant groups are considered to be powerful, whereas those in minority groups are considered inferior and lacking in power.

The term minority is not synonymous with numbers. In the United States, people of color (African-Americans, Latin Americans, Asian Americans) are considered minorities. However, when the population of the world is considered in its aggregate, it is obvious that people of color are in the majority.

Gender is another example of how the term minority is used erroneously. Females in the United States are a larger numerical percentage (50.9%) than males (49.1%) but are considered to be in the minority because of their underrepresentation in high-level managerial positions in the workplace ( ).

The significance of the term minority cannot be overemphasized. The central defining characteristic of any minority group, according to , p. 6), is its “experience with various disadvantages at the hands of another social group.”

Ethnic Minority

The term ethnic minority is often used because it is less offensive to people of color than other terms. Supposedly it takes into account ethnicity, race, and the relative status of the groups of persons included in the category. Were it not for the use of the word minority, perhaps this terminology would be less culturally offensive to some groups of people (that is, ethnic people of color). According to , use of the term people of color might be the preferable option, particularly in situations where sensitivity to racial preferences needs to be heightened. It is estimated that by the year 2050 about half of the total American population will be nonwhite, thus eliminating the meaning of the term ethnic minority ( ; ).

Stereotyping

Stereotyping is the assumption that all people in a similar cultural, racial, or ethnic group are alike and share the same values and beliefs. For example, stereotyping occurs when an African-American nurse is assigned to care for an African-American client simply because of ethnicity and race. It is stereotypical when the assumption is made that all African-Americans are alike and therefore the African-American nurse is more likely to be more sensitive to the needs of the African-American client. Race and ethnicity do not, in and of themselves, make persons “resident experts” on the belief and value systems of other persons. Whether stereotyping is engaged in as a result of scientifically proved, research-based data or because of past associations and experiences, stereotyping can ultimately lead to faulty data gathering and wrong interpretations.

Role of Gender and Cultural Significance

In traditional Chinese society, women have held subordinate roles to men, a belief that dates back to the first millennium b . c . ( ). Traditional Chinese believe that the universe developed from two complementary opposites: yin (Cantonese, yam ), the female, and yang (Cantonese, yeung ), the male. For some traditional Chinese Americans, the yin represents the dark, cold, wet, passive, weak, feminine aspect of humankind. In stark contrast, the yang represents the bright, hot, dry, active, strong, masculine aspect of humankind ( ). In traditional societies, there are written and unwritten roles that dictate the behavior of girls and women ( ). Although some countries in North America are highly evolved technologically, traditional beliefs about the role of women in society still persist throughout many regions of America. noted that discrimination exists for women in the workplace because women are viewed as having a higher absentee rate than their male counterparts. For many women, discrimination creates a barrier to entrance into the workplace and, even more important, places a “glass ceiling” on advancement that their male counterparts need not overcome ( ).

According to a U.S. General Accountability Office study in 2000 ( ; ), salaries of women and men in managerial jobs were even farther apart in 2000 than in 1995 in 7 of the 10 industries that employ the most women in the United States. By 2008, this disparity apparently had not ended. For example, in 2008, women who were full-time wage and salary workers had median weekly earnings of $638, or about 80% of the $798 median for their male counterparts ( ).

In 1995, female managers in entertainment earned 83 cents for every dollar earned by a male manager; by 2000, female managers in the industry earned only 62 cents. By 2008, the range of pay in the category now called Leisure and Hospitality ranged from the lower limits to 78 cents to 83 cents of their male counterparts ( ). Although women have tended to be an oppressed group in the workplace, numerous studies have indicated efforts by industries to implement policies and procedures to prevent discrimination on the basis of sex. For example, women may have access to benefits such as child care leave, alternative working arrangements, child care arrangements, special brief leaves to deal with family problems, and free prenatal classes ( ). Because breastfeeding reduces the incidence and severity of diarrhea, ear infections, allergies, and sudden infant death syndrome and lessens the risk of ovarian and breast cancer in mothers, programs that allow mothers to do so can result in significant savings for companies in medical claims ( ).

In some cultures, nursing is a low-status occupation. For example, in Saudi Arabia and Kuwait, care for the sick is carried out by health care providers hired from abroad for the purpose of caring for the bodily needs of the sick ( ). Clients or physicians from a culture where nurses are in the lower class may have difficulty accepting the nurse as being in a role of authority and as having expertise. In many parts of the world, female purity and modesty are major values, and disregard of these values can cause distress. For example, female purity is especially important in the Middle East and Muslim countries. In some cultures it is preferable to assign nurses of the same gender as care providers ( ). If the nurse is female and the client is male and is from a cultural group where touch is permitted only between members of the same sex and where direct eye contact is avoided, special modifications in care may be needed ( ; ).

Role of Disability and Culture

Today, almost exclusively, more attention has been directed toward a definition of culture that includes groups of people by such characteristics of race/ethnicity, religion, and cultural heritage. In addition, the same is true for the term health disparities. Statistical data now suggest that other population data, not just race and ethnicity, should now be used to define cultures of people, including those living with health disparities. Disabled people, for example, can now be considered a cultural group that lives with a number of health disparities. A person with a long-lasting condition or disability can be described as suffering from a health disparity. In 2009, 41.2 million individuals in the United States had disabilities ( ). reported a two to three times greater likelihood that individuals with disabilities would suffer from each of 16 secondary conditions, including falls or other injuries, respiratory infections, asthma, sleep problems, chronic pain, and periods of depression. Individuals with disabilities are also at higher risk for preventable physical, mental, or social disorders that may result from the initial disabling condition. Individuals with disabilities are more likely to report that their health is poor or fair (44.8%) than are individuals without disabilities (9.4%) ( ). These individuals are less likely to be involved in physical activity and more likely to smoke and be overweight ( . Negative social and economic circumstances are also more likely among individuals with disabilities, including decreased participation in social relationships, decreased employment, and decreased income for those employed ( . Thus, it is important to assess the individual with a disability by using the six phenomena of the Giger and Davidhizar model to determine the specific difficulties that this culturally unique individual may experience ( ) ( Figure 4-1 ).

Hahn’s Culture and Disability Assessment Model.

(Adapted from Giger, J. N., Davidhizar, R. (2004). Transcultural nursing assessment and intervention, St. Louis: Mosby.)

Family Groups

One group of paramount concern for the nurse when working transculturally is the family. In fact, as the family goes, so goes the health care system. Nevertheless, a consensus about the definition of the word family does not exist. offers 21 definitions of family. In terms of the U.S. Census, the term family households is defined as “people who occupy a housing unit” ( ). It is estimated that in 2010, there were 77,538,296 family households and 39,177,996 nonfamily households, representing 66.4% and 33.6% of all U.S. households, respectively. Married couples maintained 48.4% of all families, whereas women with no husband maintained 13.1% ( ).

Regardless of cultural background or the nature of the family, the family is the basic unit of society in the United States. From a sociological perspective, family may be defined as a social unit that interacts with a larger society. The discipline of economics may define family in terms of how it works together to meet material needs. From a psychological perspective, family may be defined as a basic unit for personality development and the development of subgroup relationships, such as parent–child relationships. Still another definition is offered from a biological perspective, which conceptualizes the family as a unit with the biological function of perpetuating the species. However, even while families deliver most health care and at one time being in a family was expected, today not being in a family is both common and accepted and has profound implications for health care delivery ( ).

Types of Family Structures

Characteristics of a Family System

According to general systems theory, a system is a group of interrelated parts or units that form a whole. When general systems theory is applied to the family, the individual family members are those units that make up the identifiable family system. These parts or units act as one or more subsystems within the larger system. Within the family system, the subsystems refer to the ways in which the members align themselves with one another. For example, in the family system, the parents may be one subsystem and the children another subsystem. At the same time, males and females of the family system may be two other subsystems. A subsystem may consist of any number of members who are linked by some common factor. Within the family system, membership in a particular subsystem may be determined by generational considerations, sexual identity, areas of interest, or a specifically designated function. Individual family members may belong to several different subsystems. Family members also belong to external systems, such as the community system, the school system, and career systems. Subsystems may be constructed to ensure that important functions within the family system are carried out to maintain the overall family structure.

studied the family as a living open system and thus viewed family nursing as an emerging conceptual framework for nursing care. Nurses have cared for families for years; however, it is only recently that nurses have begun to study the family as a whole ( ; ).

Communication within the Family System

The verbal and nonverbal interaction among family members is communication. Factors that contribute to the family members’ patterns of communication include (1) the pattern of members in acknowledging each other’s verbal and nonverbal messages, (2) the degree of responsibility each member takes for expressing individual feelings, thoughts, and reactions in a constructive way, (3) the extent to which the family encourages a clear exchange of words, (4) the extent to which family members are allowed to talk for themselves, and (5) the patterns of spontaneous talking. Bonding among family members results from the forms of communication patterns that exist.

Roles in the Family

Family member roles are patterns of wants, goals, beliefs, feelings, attitudes, and actions that family members have for themselves and others in the family. Roles are both assigned and acquired, and they specify what individuals do in the family. Although they are usually dependent on social class and cultural norms, roles are dynamic and change in response to factors both within the family and without. Roles are reciprocal and complement roles taken by other family members. Family equilibrium is dependent on how well roles in the family are balanced and reciprocated ( ; ).

The way in which a family member assumes a particular role is influenced by various factors, including temperament, height, weight, gender, birth order, age, and health status. Certain roles, however, depend solely on the sex of the family member. Females can be sister, daughter, wife, mother, or girlfriend, whereas males can be brother, son, father, husband, or boyfriend. Other roles, such as breadwinner, childrearer, homemaker, cook, handyman, and gardener, are performance roles and depend on the person’s ability to perform a certain task. In contrast to performance roles are emotional roles, such as leader, nurturer, scapegoat, caretaker, jester, arbitrator, or martyr, which may be adopted at certain times as a means of adjusting to the demands of a family system, to an extended family crisis such as a long-term family illness, or to long-term family conflict. The functions of emotional roles are to reduce conflict among family members and to promote temporary adaptation among family members. However, consistent use of emotional roles may impair adaptation, thus hindering the growth of the family. An example is when one family member, perhaps the oldest child, assumes the role of family caretaker, supporting other members and arbitrating disputes. The role may take on negative characteristics in this instance because the family caretaker may appear outwardly strong and capable but inwardly have unrealistic feelings, such as “I can’t fail” or “I can’t be weak.” In this emotional role, this person may function under pressure to be perfect but at the same time have feelings of self-doubt and fear. It is important for the nurse to remember that roles have a significant effect on individual adjustment. Role function is influenced by the values of social groups to which the individual belongs. For example, in an international study by , Finnish Lutheran women placed less value on bearing and rearing children than other groups studied (American Mormons and Canadian Orthodox Jews).

Family Organization

To understand family organization, the nurse must remember that structuring of both functions and goals must be addressed. It is also important for the nurse to remember that most families are dynamic, endlessly adaptable, and continuously evolving in both structure and function. The functional ability of a family depends in part on the individual needs and wants of the members. If the nurse is unable to assist family members in meeting needs within the family structure, pain may be felt and confusion may exist. The nurse must keep in mind that, in the American culture, families are expected to be self-perpetuating and at the same time be the primary system for the transfer of social values and norms.

In the American culture, two primary goals are inherent in the family: (1) the encouragement and nurturance of each individual and (2) the production of autonomous, healthy children ( ). Marital partners are expected to be supportive and protective of each other. Both the husband and the wife are expected to share a sense of meaning and emotional closeness within the boundaries of their relationship, thus fostering the goal of personality development. In families in which supportive relationships do not exist, the achievement of the first goal (the encouragement and nurturance of each individual) is not attainable. The second goal of the family includes encouraging children to develop their own identity and individuality by allowing them to develop ideals, feelings, and life directions. At the same time, children are encouraged to sense both similarities to and differences from others and to be able to initiate activities based on this information ( ). Factors that must be addressed to determine the degree to which the family will accomplish these two primary goals include the patterns of relationships and adaptive mechanisms that are present. There are many reasons why some families fail to accomplish these two primary goals, including psychiatric disturbance of family members, incomplete maturation of children, and disintegration of the family system. When the family uses adaptive mechanisms, internal equilibrium may result. These adaptive mechanisms are dependent on (1) the level of communication skills within the family, (2) the individual contributions of each family member to the family welfare, (3) the mutual respect and love within the family, (4) the types, kinds, and amounts of stressors encountered, (5) the response pattern to stressors encountered in the internal and external environment, and (6) the support or resources available and the opportunity to participate in support systems ( ; ). For example, a family that has an alcoholic father may not be able to accomplish goals because this problem may result in psychiatric disturbances in the wife and children, and ultimately the family system may disintegrate. The reasons for the disintegration of this family include not only the individual psychiatric disturbances but also accompanying difficulties, such as incomplete maturation of children and adult members, financial instability, inability to adapt successfully to stressors, and, more important, the inability of each family member to perceive the family unit as caring and loving ( ).

Kinship

In the first criterion, kinship, there are three dyads that imply the existence of or location for the individual within the family structure: husband–father, wife–mother, or child–sibling. There are several conventional forms of family structures that are composed of these positions, including the nuclear family and the stem family. The nuclear family, which was discussed earlier, may consist of a husband, a wife, and their nonadult children and is based on all three dyads, with their marital, parental, and sibling elements. Whereas the nuclear family is restricted to a depth of two generations, the stem family encompasses three generations: grandparents, parents, and children.

Function

The second criterion, function, describes the purpose, goals, and philosophy of the family organization. Family function is defined as the expected action of an individual in a given role. In a description of family organization, the term function is used to depict family roles and the assigned tasks for those roles. Every family has unit functions that must be performed to maintain the integrity of the family unit and to meet the needs of the family. If individual family members’ needs and societal expectations are to be met, the functioning role of the family must be clearly delineated. In family systems with two or more individuals, the family members have unit functional responsibilities related to their social positions. Depending on position within the family structure, an individual may function in a variety of roles, such as companion, decision maker, health motivator, or sexual partner. It is important for the nurse to remember that the maintenance of the family system is dependent on these various roles. Some cultural groups function in traditional ways in which the family is viewed as a holistic functioning unit. Other cultural groups may function as a disaggregate unit, meaning that the family does not function as a unit but that members function independently.

When the nurse is providing care, it is particularly important to assess who has the decision-making function in the family. For example, a decision about consent to treatment, receiving care or teaching, or whether to follow instructions may need to be made individually ( ). On the other hand, a client may not feel comfortable in making a health care decision without the spouse or family. In some situations the client may defer to the spouse for decision making ( ). In still other situations, another individual or group, such as a deacon or a church, may need to be involved. In a traditional Mexican family, the man is the decision maker. When a decision regarding health care is needed, a woman may defer any decision until her husband can arrive ( ). Consideration for families’ decision-making style is included in the recent additions to the standards of the Joint Commission for the Accre­ditation of Healthcare Organizations (JCAHO), which acknowledge the autonomy of the client and/or of the family in the health care decision-making process ( ). Decisions about who makes decisions regarding the end of life may also be culturally determined, although it can never be assumed that all members of the group will act the same or share the same beliefs. For example, among Asian and Pacific Island cultures, the interaction of Buddhism, Confucianism, and Christianity generally supports filial piety. While the family assumes the decision-making role, terminating treatment for a parent can influence the fate of the living and be equated with ancestor murder. Thus, many families will want to provide artificial feedings and hydration to the terminally ill and to demented patients not taking food and fluids orally since they feel that only God decides when it is time to die ( ).

Another family function that the nurse needs to examine is in relation to the family’s physical, affectional, and social properties ( ). Physical functions include providing food, clothing, and shelter; protecting against danger; and providing health care. Affectional functions include meeting emotional needs. Social functions include providing social togetherness, fostering self-esteem, and supporting creativity and initiative. Another approach to examining family functions views the family from a task-oriented perspective ( ). Tasks include socialization of children, strengthening com­petency of family members in relation to their adjustments within organizations, appropriate use of social organizations, providing an environment that fosters the development of identities and affectional behavior, and creating a satisfying, emotionally healthy environment essential to the family’s well-being. Adaptation is essential to the family’s ability to carry out functions and tasks and to meet the changing needs of society and other social systems, such as political and health–illness systems.

One of the most significant dimensions affecting child­rearing practices in America today is managing children’s time with computers, TV, and video games. It is estimated that the average American child in 2002 spent an average of 4.5 hours a day at home in front of a screen, an increase of 30 minutes from the previous year. In 1999, the average American child grew up in a home with two TVs, two VCRs, three audiotape players, two CD players, one videogame player, and one computer, according to a Kaiser Family Foundation study; children had an increasingly sedentary lifestyle and increased exposure to violent and sexual images ( ). Parents are challenged to protect their children online using software packages such as Cyber Patrol, Net Nanny, and Cybersitter, but nothing is promoted as perfect, and children remain vulnerable to pornography and sex predators on the Internet ( ; ).

Location

Family location is also a significant criterion for understanding the family. and discussed the variations that occurred among values of African-American families when families were evaluated in urban versus rural settings. Martin found that when families moved from rural to urban settings, there was an erosion of values emphasizing “mutual aid” and a contrasting increase in individualism, materialism, and secularism. When urban African-Americans are compared with their rural counterparts, it appears that urban African-Americans may view their counterparts as lacking the toughness and sophistication needed to make headway in a dominant urban culture. Despite the variations that occur with location changes, geographical separation does not mean a severing of kinship ties, according to Martin; rather, geographical separation may strengthen the emotional bonds among relatives. Today there is a tendency among African-Americans, whether urban or rural, toward a migration back home and getting back to their people. For some African-Americans there has been an increasing awareness that the urban centers have not met their hopes and aspirations. From the 1940s to the 1970s, there was a migration by some African-Americans away from the rural South. In the 1980s there was a trend toward migration of some African-Americans away from the urban North back to the urban South. For example, significant numbers of urban Northern African-Americans have migrated to such cities as Atlanta, Dallas, and Houston ( ).

Religious Groups

According to many sociologists, religion is a social phenomenon ( ). Religious practices, therefore, are usually rooted in culture, and each culture typically has a set of beliefs that define health and the behaviors that prevent or treat illness ( ). However, many persons, particularly those with religious convictions, tend to think of religion in an entirely different way. For some people religion is seen in the context of a person’s communion with the supernatural, and religious experiences fall outside ordinary experiences, whereas other people view religion as an expression of an instinctual reaction to cosmic forces ( ). Another worldview of religion depicts it as an explicit set of messages from a deity. For the most part, all these beliefs tend to de-emphasize, ignore, and perhaps even reject the sociological dimensions of religion. Nevertheless, whether it is being considered in general, in regard to a particular religious family such as Christianity or Buddhism, or in regard to a very specific religious group, such as Baptists, religion is believed to interact with other social institutions and forces in society and to follow and illustrate sociological principles and laws. In other words, regardless of what religion is or is not, it is a social phenomenon and as such is in a continual reciprocal, interactive relationship with other social phenomena.

Regardless of its definition, be it theological or sociological, many different kinds of groups are based on religion. Generally, religious structures fall into two basic types: the church type and the withdrawal-group type. The church type of structure is broadly based and represents the normative spiritual values of a society that most people adhere to by virtue of their membership in the society, such as Hinduism in India or Catholicism in Spain. For the most part, membership in certain societies dictates the faith that the person should belong to if that person has not made a conscious, deliberate choice to adhere to something else. The church type of structure is generally a comprehensive system that allows for individual variations and in practice does not make extremely rigorous demands on its members. In the United States, the church type of structure is encompassed within numerous major denominations. This denominational structure is in sharp contrast with the church type of structure in other countries, such as India or Spain, where most of the people belong to one faith and one church. In some countries, particularly the United States, individual churches are often closely identified with an ethnic group rather than with a social class, and churches thrive, more or less, as a means of asserting ethnic identity. For example, the Black church, regardless of denominational faith, has become synonymous with the Black life experience. The Amish people, on the other hand, subscribe to one denominational belief; however, the belief is synonymous with the Amish life experience.

The second type of religious structure is the withdrawal group, which expresses the beliefs of those for whom personal commitment and experience are more important than the family and the community functions of religion ( ). Withdrawal groups meet the needs of those who believe that the majority’s faith or lack of faith is not for them. Persons involved in withdrawal groups define themselves by making a separate choice. These groups include the Amish or Jehovah’s Witnesses, which tend to represent a more intense or unbending commitment than that held by the average person adhering to a religion. These groups may be called sects . Groups that combine separation with syncretism and new ideas and that emphasize mystical experience are often referred to as cults . However, the word cult is often used in Western society with caution because it has acquired a negative connotation. In some religious groups, such as the Church of Jesus Christ of Latter-Day Saints (Mormons), Muslims, Jehovah’s Witnesses, Seventh-Day Adventists, Buddhists, or Hindus, as well as that of the Gypsy culture, the extended social organization of the religion is considered more important than membership in the individual family. It is essential to remember that while this view is held by some theological scholars ( ), many members of these religious groups do not necessarily share this belief. For example, in the Church of Jesus Christ of Latter-Day Saints (the Mormon Church), children are taught at a very young age that families are eternal. In this sense, the family is viewed as a stable, cohesive group bonded by love and as such is one of the most important units on earth today ( ).

As persons from different religions increasingly intermarry, it is becoming more common for parents not to share the same faith. The proportion of Jews who married Gentiles, around 10% for the first half of the century, according to the American Jewish Committee, doubled in 1960, doubled again by the early 1970s, and in the 1990s leveled off at just over 50%. Approximately one of three American Jews lives in an interfaith household ( ). Comparable figures are 21% for Catholics, 30% for Mormons, and 40% for Muslims. Thus, a new form of religious identification in America is developing that is analogous to a “mixed race.” However, although diversity is increasingly acceptable among American religions, observances inevitably involve some sectarianism. Even though raising children in two faiths promotes diversity, it is sometimes confusing for the children, who may feel that they are not as good as their all-Jewish or all-Christian cousins. Although attitudes toward intermarriage are becoming more liberal, for some it creates confusion over which holidays to celebrate and which church children should attend. On the other hand, intermarriage is not completely accepted in the United States. There are conservative sects, such as Old Colony Mennonites and Missouri Synod Lutherans, who are less tolerant of intermarriage and insist on born-again spouses ( ).

There are 215 distinct church traditions represented in the United States. Many of these groups represent the process of dividing and reuniting that has been a characteristic of religious life in America ( ; ). Data from the American Religious Identification Survey indicated that there were 228,182,000 persons in the United States in 2008 who considered themselves members of a church; this is up from 2000, when more than 152 million claimed membership ( ). The denomination with the largest membership is the Catholic Church, with 57,199,000 members, comprising 24% of the U.S. population; the Southern Baptist Convention has 16.2 million (all Baptists, including Southern Baptists, total 36,148,000), the United Methodist Church has 11,366,000, and the Church of God in Christ has 6.4 million. The Church of Jesus Christ of Latter-Day Saints ranks fifth, with a membership of 3,158,000, but is noted to have had a very brisk increase in membership since its origin in 1830. The Church of God in Christ, which has historically been the largest Black Pentecostal church, is now among the five largest denominations, indicative of the growth of Pentecostal churches ( ) ( Tables 4-1 and 4-2 ).

TABLE 4-1

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