Space





Behavioral Objectives


After reading this chapter, the nurse will be able to:



  • 1.

    Discuss factors related to distance and immediate receptors that influence spatial behavior.


  • 2.

    Define the term personal space, and relate its significance to care plan development for clients from varying cultures.


  • 3.

    Explain how actions of the nurse may contribute to feelings of anxiety and loss of control for clients from transcultural backgrounds.


  • 4.

    List actions the nurse can take to promote feelings of autonomy and self-worth when caring for clients from transcultural backgrounds.


  • 5.

    Delineate the difference between tactile space and visual space, and show their relationship to transcultural nursing care.



Personal space is the area that surrounds a person’s body; it includes the space and the objects within the space. Personal space can also describe inner space that filters the incoming stimuli that a person receives ( ). defines inner personal space as dynamic, invisible lines of demarcation that can be divided into four concentric areas of space: (1) the inner spirit core, (2) an area of thoughts and feelings perceived as unacceptable, (3) an area of thoughts and feelings perceived as acceptable, and (4) an area of superficial public image. An individual’s comfort level is related to both inner and outer personal space; discomfort is experienced when personal space is invaded. Although personal space is an individual matter and varies with the situation, dimensions of the personal space comfort zone also vary from culture to culture ( ).


Traditionally, nursing research paid little attention to geographical approaches and the dynamics of nursing and space. However, change is occurring and research is beginning on the relationships among nursing, space, and place as an emerging geography of nursing and a health geography subdiscipline ( ; ). Andrews postulates that from a disciplinary perspective, studying the geography of nursing can explain the relationship between health geography and mainstream health service and medical concerns in a place-sensitive, patient-sensitive, and qualitative form ( ; ; ). Nevertheless, nurses have long drawn from the social science disciplines and appreciated that spatial behavior is an important consideration in measuring distance in relationships. Since spatial behavior is usually judged to be spontaneous and unintentional, individuals are typically more likely to trust the accuracy of actions rather than words as a reflection of true feelings. Although a large percentage of spatial behaviors are spontaneous and unintentional, communication in this domain can be managed to promote favorable and desired impressions. For example, a nurse may choose to stand when greeting a client to show respect.


To understand human behavior, one must understand something of the nature of our receptor systems and how the information received by these systems is modified by culture. Because spatial behavior is a response to sensory stimulation in the internal and the external environment, the phenomenon of space can be understood only as an integral part of the sensory systems—that is, sight, sound, touch, and smell. Spatial behavior encompasses a variety of behaviors, including proximity to others, objects in the environment, and movement.




Perception of Space


Sensory apparatuses fall into two categories:



  • 1.

    Distance receptors are concerned with the examination of distant objects. The sensory receptors for distance include the eyes, ears, and nose.


  • 2.

    Immediate receptors are used to examine the world up close. Sensory receptors used to examine the world up close include touch, which is the sensation received from the skin membranes ( ).

These two classifications can be broken down even further to facilitate the nurse’s understanding of the phenomenon of space. For example, the skin is the chief organ of touch and is sensitive to heat gain and heat loss; both radiant and conducted heat are detected by the skin. Therefore, the skin must be perceived as both an immediate receptor and a distance receptor. In general, there is a relationship between the evolutionary age of the receptor system and the amount and quality of information it can convey to the central nervous system. Many psychologists estimate that the touch system is as old as life itself ( ). Because the ability to respond to stimuli is based on touch, the response to touch is one of the basic criteria for the maintenance of life. In comparison, sight is believed to be the last and most specialized sense to develop in humans. From an anthropological view, vision became more important than olfactory response when our ancestors left the ground and took to trees in search of food and safety. Stereoscopic vision became essential for primitive humans because without it, jumping from branch to branch was difficult and dangerous.


Distance Receptors


Distance receptors include sensory apparatuses for visual, auditory, and olfactory perception. It is essential that the nurse understand the relationship between sight, touch, and smell and how the reaction to these stimuli can be modified by culture.


Visual and Auditory Perception.


As indicated earlier, vision was the last of the senses to evolve. However, it is by far the most complex. Seemingly, more data are fed to the nervous system through the eyes at a much greater rate than through the senses of touch or hearing. For example, the information a blind person can gather outdoors is limited to a circle of 20 to 100 feet because a blind person can perceive by way of auditory or olfactory stimuli only what is immediately surrounding him or her. However, with sight a person can see the stars at night. Even very talented blind persons are limited to an average speed of perception of 2 to 3 miles an hour over familiar territory. In contrast, with sight a person has to fly faster than sound before additional visual aids are needed to avoid bumping into things. The amount of information that can be gathered by the eyes in contrast to the ears cannot be calculated precisely. Such a calculation would require not only a translation process but also the knowledge of precisely what to count. A general notion held by most scientists is that the relative complexities of the two systems, visual and auditory, can be obtained by comparison of the size of the nerves connecting the eyes and the ears to the centers of the brain ( ; ).


The optic nerve contains roughly 18 times as many neurons as the cochlear nerve; therefore, one might assume that it transmits at least that much more information. The eyes may act as a defense mechanism because they normally alert us to danger; the eyes may be as much as a thousand times more effective than the ears in gathering information to protect us from harmful stimuli. The area that the unaided ear can effectively cover in the course of daily living is quite limited. The ear is very efficient but only up to a distance of 20 feet. At about 100 feet, one-way vocal communication is possible but at a somewhat slower rate than at a conversational distance. Although two-way conversation is also possible at this distance, it is considerably altered. Beyond this distance the auditory cues begin to break down rapidly. The unaided eye, on the other hand, can gather an extraordinary amount of information within a 100-yard radius and is efficient for human interaction at up to a mile ( ).


The impulses that activate the eyes and the ears differ in speed and quality. For example, at a temperature of 0° C (32° F) at sea level, sound waves can travel 1100 feet per second and be heard in frequencies of 50 to 1500 cycles per second (Hertz). On the other hand, light rays can travel 186,000 miles (300,000 km) per second and thus are visible at a maximal frequency of 500 trillion at yellow-green ( ).


Many complex and remarkable instruments have been invented to extend the eyes and ears. Radio, television, and the Internet have revolutionized the perception of space and shortened distances among people worldwide. During World War II, radio was relied on quite extensively to bring news from the occupied countries to parts of the free world. Perhaps one of the most famous broadcasts of this period was done by Tokyo Rose, whose broadcasts, which were reported to be untrue, influenced many people in the listening audience about the nature and direction of World War II. However, radio lacked the visual stimuli offered later by television, which filled in perception gaps left by radio. Television came of age in the 1960s, when for the first time, brighter, clearer, and bolder pictures were offered to viewers. The addition of color filled another perception gap and enhanced our receptor fields. For the first time in history, from their living rooms, the people of the United States could view their president doing the ordinary, the extraordinary, and the unusual. For example, the people of the United States were informed about the Cuban missile crisis by U.S. President Kennedy on television. They were also able to see this president playing with his children in the Oval Office. In 1963, when President Kennedy was assassinated, little was left to the imagination of the people of the United States, who were mesmerized by complete television coverage from assassination to burial. Because of television, the nation and the world at large experienced grief that is still present today and mourned collectively.


The development of cyberspace technology has added another visual dimension to space. On September 11, 2001, the nation and the world collectively experienced shock as terrorists crashed airplanes into the World Trade Center and the Pentagon. Not only did many view the disasters as they happened on television and on the Internet, but also horrific images and reports of the September 11 terrorist attacks were broadcast for weeks. Technology also allowed the world to see the emotional reactions of others to the disaster and in turn precipitated responses of condolence. Immediately, e-mail messages offering sympathy to grieving Americans poured in from friends around the world. Cyberspace technology united the world in grief as memorials on each continent were displayed on the Internet. The visual impressions provided by technology enabled persons who did not directly experience the disaster to be profoundly disturbed by it ( ). In 2005, the nation experienced a similar phenomenon with the devastation of Hurricane Katrina that became a part of the lived experience of persons who had access to television or the Internet ( ). The Internet and multimedia technologies provided a range of quasi-public spaces that encouraged debate and active citizenship to assess the reaction of the government and the nation to this event ( ). More recently, natural disasters such as the massive earthquake in Haiti in 2010, which killed approximately 250,000 people, and the earthquake and tsunami in Japan in 2011 that killed thousands and caused a nuclear disaster have all been widely covered not only on television but through other social networks such as Twitter, Facebook, and YouTube.


In summary, visual space has an entirely different character from that of auditory space. The overriding quality that differentiates visual space from auditory space is that visual information tends to be less ambiguous and more focused than auditory information. Therefore, visual information is less subject to external manipulation than is auditory information. One major exception to this rule is the blind person who has learned to understand selectively the higher audio frequencies, which can assist him or her in locating objects within a familiar or unfamiliar room. For example, a blind person may know where the door is in a room by the relationship of the sound that comes from that direction.


Even today it is not known what effects the incongruities between auditory and visual space have on individuals. Some data indicate that auditory space is a factor in performance. J. W. Black, a phonetician, demonstrated that the size and reverberation (vibrations of external sounds) of a room can affect an individual’s reading rate. In a classic study, found that people read more slowly in larger rooms, where the reverberation time, or circulation of sound, is slower than that in smaller rooms. interviewed subjects in regard to the slowing of reverberation time in a larger room. Among the inter­viewees was a gifted English architect who improved the performance of a malfunctioning committee by simply blending the auditory and visual worlds of the conference chamber where the committee met. The complaint the architect had received was that the chairman was inadequate and was about to be replaced. However, the architect had reason to believe that the difficulties this committee encountered were caused by more in the environment than just the chairman. In this situation the meeting room was next to a busy street, and traffic noises were intensified by reverberations from the hard walls and rugless floors inside the building and particularly in the meeting room. The architect was able to adjust the room by adding an acoustic ceiling, carpet, and soundproof walls. Once interferences were reduced, the chairman was able to conduct the meeting without undue strain, and complaints about the chairman ceased.


People who are brought up in different cultures learn unknowingly to screen out various bits of information and to sort information into relevant or irrelevant categories; once set, these perceptual patterns remain stable throughout life. For example, Japanese individuals tend to give meaning to spaces that a Westerner may classify as empty ( ). Japanese readers expect to be presented with the parts first and then the whole rather than getting the “big picture” and then a breakdown of material into its component parts ( ; ). In addition, Japanese people screen visually in a variety of ways and are more perceptive to visual stimuli. Japanese people are therefore perfectly content with paper walls as acoustic screens. A Westerner who finds himself in a Japanese inn where a party is going on next door may be in for a new sensory experience since only paper-thin walls separate each room. In contrast, German and Dutch people depend on double doors and thick walls to screen out sound and may have difficulty if they must rely on their own powers of concentration to do so. If two rooms are the same size and one screens out sound and the other does not, a sensitive German or Dutch person who is trying to concentrate will feel less intruded on in the former and thus less crowded ( ). Cultural patterning of space can also be seen in the arrangements of urban space in different cultures. For example, U.S. cities are usually laid out along a grid with the axis north–south and east–west. In Paris, main streets are laid out radiating from centers with no grid system ( ). The layout of French cities is only one aspect of the theme of centralization that characterizes French culture. In French offices, the most important person has the desk in the middle of the office.


Yet another aspect of cultural patterning of space is function of space. For example, space in India is sometimes related to concepts of superiority and inferiority. In Indian cities, villages, and even homes, spaces may be designated as inferior or polluted. Spaces in India are divided so that high and low castes, secular and sacred activities, and male and female can be kept segregated ( ).


Olfactory Perception.


Some cultures place more importance on olfactory perceptions than do others. For example, Americans are culturally underdeveloped in the use of their olfactory apparatuses ( ). contended that the deprivations of the olfactory stimulus are a result of the extensive use of deodorants and the suppression of odors in public places, which has resulted in a land of olfactory blandness and sameness that is difficult to duplicate anywhere else in the world.


People in the United States are continuously bombarded with commercials for room deodorizers, antiperspirants, mouthwashes, carpet deodorizers, and so on. All of these factors result in bland, undifferentiated spaces and deprive many people in the United States of the richness and variety of life. For example, if one is cooking with garlic, a room deodorizer may be used during the cooking process, causing the garlic smell to be eliminated. It is this type of behavior on the part of people of the United States that obscures memories. It is believed that smells evoke much deeper memories than either vision or sound; when the sound or the sight of what has happened has passed, the memory of the smell lingers on. Even today many U.S. citizens equate certain holidays, such as Christmas, with certain smells. For example, because Christmas is traditionally equated with the smell of baked goods, holly, pine, and fruit, today many people in the United States try to reproduce these smells at Christmas. An individual who has an artificial Christmas tree may buy a pine-scented spray to create the effects of a fresh tree. Another old-fashioned scent for many U.S. citizens is country potpourri, which has now been simulated in aerosol cans for easy dispensing. A new car odor can be simulated by a car spray that smells like new leather. Soap may be purchased to re-create a desired feeling; for example, the soap Mother used at home may create a feeling of hominess. Smells may also create a negative reaction; for example, an individual who washes with lye soap may be thought to have body odor because the smell is unusually strong and medicinal. A medicinal smell is perceived by most individuals in the United States to be appropriate for a hospital room but not elsewhere.


Odor is perhaps one of the most basic methods of communication. It is primarily chemical in nature and is therefore referred to in a chemical sense. The olfactory sense has diverse functions and not only differentiates individuals but also makes it possible to identify the emotional state of others. Even an infant can learn to identify his or her parents through the sense of smell. Although the young infant has not learned to see and discriminate patterns well, the infant can distinguish identity through the olfactory sense.


In a hospital setting an employee who has an unpleasant odor creates a real management dilemma. The supervisor may counsel and even reprimand the employee for poor hygiene. Employees who have the smell of alcohol may be sent home. It is important that the nurse appreciate that odors may be caused by pathological conditions, as in certain diabetic states, or the result of certain mouthwashes or soaps. If a client has an unpleasant odor, the nurse should first assess whether some pathological condition is present, such as an inflammatory process. In a psychiatric hospital, a client’s odor could be associated with a condition such as schizophrenia, and although there is some thought that such an odor may be pathological, it is more likely to be related to a lack of motivation for self-care skills.


Immediate Receptors


Immediate receptors are those that examine the world up close, such as tactile stimuli received by way of the skin membranes. It is important that the nurse appreciate the effect culture may have on an individual’s reaction to these stimuli and how these stimuli can be modified by cultural influences.


Skin Membranes.


Human beings receive a tremendous amount of information from the distance receptors, which include the eyes, ears, and nose. Because of the vast amount of information that is received from the distance receptors, few people think of the skin as a major sense organ. However, if we humans lacked the ability to perceive heat and cold, we would soon perish. Without the ability to perceive heat and cold and to react appropriately to these stimuli, we would freeze in the winter and become overheated in the summer. The skin, as a major sense organ, is so grossly overlooked that even some of its subtle sensing and communicating qualities go unnoticed. Nerves called proprioceptors keep us informed as to exactly what is happening as we work our muscles. These nerves provide the feedback that enables us to move our bodies smoothly; thus, they occupy a key position in kinesthetic space perception. The body also has another set of nerves called exteroceptors, which are located in the skin and convey the sensations of heat, cold, touch, and pain to the central nervous system. In light of the fact that two different systems of nerves are used in the perception of space, kinesthetic space is considered qualitatively different from thermal space. However, nurses must remember that these two systems work together and are mutually reinforcing most of the time.


It has been only in modern scientific times that some remarkable thermal characteristics of the skin have been discovered. The capacity of the skin for emitting and detecting radiant or infrared heat is extraordinarily high. One might assume that is so because it was important to survival in the past and most certainly had a significant function in early human beings. Although the discovery of the thermal characteristics of the skin has been only within recent times, the nurse should not overlook the importance of the skin as an immediate receptor.


Humans are well equipped to send and receive messages concerning emotional states based on changes in skin temperature. Skin temperature can give very important clues to the emotional state of the individual. A common indicator of embarrassment or anger in fair-skinned individuals is blushing. However, dark-skinned people also blush. Therefore, blushing cannot be perceived as simply a matter of change in skin coloration. The nurse must carefully observe dark-skinned persons when looking for changes in emotional state, such as embarrassment or anger, by noting a swelling of regions of the forehead. The additional blood to these areas will raise the temperature, and these areas will appear flushed. Therefore, even if there is no significant change in color to these areas in dark-skinned individuals, these areas will feel warm to the touch.


Many novel instruments have been developed to study heat emission. These instruments should make it possible to study the thermal details of interpersonal communication, an area not previously accessible to direct observation. Thermographic devices (infrared-detection devices and cameras) that were originally developed for satellites and homing missiles have been used for recording subvisual phenomena. Photographs taken in the dark using the radiant heat of the human body have shown that an inflamed area of the body actually emits more heat than the surrounding areas. Diagnosis of cancer is also possible with thermographic devices that measure blocked circulation of blood. Thermographic devices have been useful in health care delivery because skin color does not affect the amount of heat delivered; dark skin does not emit more or less heat than light skin. Thus, the observable phenomenon in all individuals regarding heat emission is the blood supply in a given area of the body.


Increased heat on the surface is detected in three ways:



  • 1.

    Thermal detectors in the skin, particularly if two individuals are close enough to each other.


  • 2.

    Intensified olfactory interactions, which are augmented when skin temperature rises. Perfumes and lotions may be smelled at a greater distance when the body temperature is increased.


  • 3.

    Visual examination, which can give clues to an increase or decrease in body temperature. For example, an individual who is pale may have a decrease in body temperature, whereas a person who appears flushed may have an increase in body temperature.

Certain individuals or racial groups are more aware of subtle changes in skin temperature. In addition, some persons accentuate or take advantage of this medium of communication. For example, an individual knowledgeable about variations in skin temperature according to location may apply perfume to certain parts of the body. The phenomenon of crowding is a chain reaction set in motion when there is not enough space to dissipate the heat within a crowd and the heat intensifies. A hot crowd will require more room than a cool crowd if they are to maintain the same degree of comfort and lack of involvement. It is important for the nurse to remember that when thermal spaces overlap and people can smell each other, they become more involved and may even be under the chemical influences of each other’s emotions. Some individuals by virtue of cultural heritage have trouble with the phenomenon of crowding. These individuals are more likely to be unable to sit in a chair soon after someone else has vacated it. An example of this phenomenon is often given by sailors on submarines who are forced to participate in “hot bunking,” the practice of sharing a bunk as soon as someone gets out of it. It is not understood why one’s own heat is not objectionable whereas a stranger’s may be. It may be attributable in part to the fact that humans have a great sensitivity to small differences; therefore, individuals respond negatively to a heat pattern that is not familiar ( ).


Body-heat regulation lies deep in the brain and is controlled by the hypothalamus. Culture affects attitudes in regard to the perception of skin temperature changes. Human beings exert little or no conscious control over the heat system of the body. Many cultural groups tend to stress phenomena that can be controlled and deny those that cannot. In other words, because some individuals by virtue of their cultural heritage have been taught to ignore certain uncontrollable stimuli, they experience body heat as a highly personal stimulus. Body heat is therefore linked to intimacy as well as to the experiences of childhood. An adult who as a child was used to close personal contact with parents and other loved ones may have a pleasant association when in a crowded environment where heat and warmth are radiated. On the other hand, an adult who was subjected to discomfort in close relationships or who was not exposed to closeness as a child may experience a great deal of difficulty and anxiety when in a close environment, such as an overcrowded bus.


A person born in a heavily populated country where closeness was necessitated by overcrowding may experience conscious discomfort in moving to another locality where closeness is not the norm. On the other hand, persons born in thinly populated countries may have a conscious feeling of overcrowding in a country where closeness is the norm. For example, a tourist from the United States visiting a country such as Jamaica or China or a city such as Hong Kong, all of which are extremely overpopulated, may quickly react to the experience of closeness and associate the country or this particular city with unpleasantness. This experience is not limited to different cultures but may also be noted when a rural person visits an urban setting, such as a person from rural Mississippi visiting New York City.


The English language is full of expressions that relate to skin sensation and body temperature changes. For example, it is not uncommon in the United States to hear individuals say that another person made them hot under the collar, gave them a cold stare, involved them in a heated argument, or warmed them up. These expressions may be more than just a figure of speech; they may be a way of recognizing the changes in body temperature that occur both personally and in other people. Thus, these common experiences have been incorporated into language in the United States.


Relationship between Tactile Space and Visual Space


Touch and visual spatial experiences are so interwoven that they cannot be easily separated. Young children and infants learn to reach, grasp, fondle, and mouth everything in the environment. Teaching children the relationship between tactile and visual space is a difficult task that requires many years of training for children to subordinate the world of touch to the visual world. Visual and tactile space can be distinguished by the fact that tactile space separates the viewer from the object, whereas visual space separates objects from each other. As early as described two different perceptual worlds: sight oriented and touch oriented. According to Baliant, the touch-oriented world is both immediate and friendlier than the sight-oriented world, in which space is friendly but filled with dangerous and unpredictable objects—namely, people. Using Baliant’s definition of tactile space, it is difficult to conceive that designers and engineers have failed to grasp in all of their scientific research the deep significance of touch, particularly active touch (actually contacting others or objects). Individuals incorporate both tactile and visual stimuli in relating to the world. For example, although automakers tend to rely heavily on visual perception when designing a particular car, they are also concerned with tactile perception, as evidenced by their attention to such things as luxury upholstery, automatic windows, doors, gas-cap locks, ornate trimmings, and carpeting. In response to such stimuli, prospective buyers touch both the car’s interior and exterior before making a purchase.


Some objects in the environment are appraised and appreciated almost entirely by touch, even when these objects are visually presented, such as objects made from wood, cloth, or ceramics. The Japanese are very conscious of the significance of texture. Emphasis is placed on the smoothness of the item being crafted. It may be perceived that it requires more time to make a smooth-textured item than a rough-textured item and that the time spent on the crafted item is related to the care and concern of the craftsman. The objects that are produced by Japanese people may be perceived as being made by caring craftsmen.


Touch is the most personal of all the sensations. Touch is sometimes described as the most important sense because it confirms the reality perceived through the other senses ( ). As discussed in Chapter 2 , touch is central to the human communication process and is often used to communicate messages. Touch is a part of most intimate relationships, which are increasingly recognized as integral to health. Although relationships can exist without touch, distance creates loneliness, which has been related to lack of health ( ). James Lynch, author of The Broken Heart: The Medical Consequences of Loneliness, noted that there is a cardioprotective nature of community life and loving relationships ( ). In fact, studies have found that loneliness at the time of surgery is a contributor to death at both 30 days and 5 years following coronary artery bypass grafting and that the recurrent cardiac event rate at 6 months after initial myocardial infarction was significantly higher among those who lived alone ( ; ). Positive intimate relationships increase longevity, lower morbidity, and increase personal happiness ( ).


In contrast to tactile space is the phenomenon of visual space. To understand visual space, the nurse must understand that people do not see exactly the same thing when actively using their eyes in a natural situation; people do not relate to the world around them in exactly the same way. For example, different persons will visually notice different objects because of perceptual differences ( ). It is important for the nurse to recognize these differences and at the same time be able to translate from one perceptual world to another. The distance between the perceptual worlds of two persons of the same culture may be considerably less than the distance between the perceptual worlds of two persons of different cultures. There is significant evidence that people brought up in different cultures live in different perceptual worlds. North Americans tend to have a more linear perceptual field. This difference is demonstrated in art and architectural design. American artists prefer designs that are linear, whereas Chinese and Japanese artists prefer depth and maintaining constancy in a design.




Spatial Behavior


Spatial behavior is often described in nursing literature in relation to the universal need for territoriality ( ; ; ; ; ). People by nature are territorial. Territoriality refers to a state characterized by possessiveness, control, and authority over an area of physical space. If the need for territoriality is to be met, the person must be in control of some space and must be able to establish rules for that space. The need for territoriality cannot be fully met unless individuals can defend their space against invasion or misuse by others ( ). has suggested three important aspects of territoriality to consider when planning nursing care: a physical space of one’s own, a personal space, and the territory of expertise or role. One can also relate territoriality needs to spatial behaviors of or proximity to others, to objects in the environment, and to body movement or position. Territoriality serves to achieve diverse functions for individuals, including meeting needs for security, privacy, autonomy, and self-identity. Group rights must also be considered in relation to space. In cultures where priority is given to the group over the individual (Asian cultures, many Latino and Mediterranean cultures, most Arab cultures, and cultures of Africa and the Middle East), group rights and shared space are important considerations. In cultures where priority is given to the individual rather than the group (United States, Canada, cultures of North and West Europe, Australia, and New Zealand), privacy is more likely to be valued ( ). In a culture where priority is given to the individual, a person may choose to be alone when feeling ill or in pain ( ). Palos, a multicultural researcher at the Department of Symptom Research at the University of Texas M. D. Anderson Cancer Center and School of Public Health in Houston, states that finding 20 relatives at the bedside arises out of the concept of collectivity rather than polarity and may be a strange concept to health care professionals oriented to the biomedical model based on autonomy ( ). It is important for the nurse to understand the effect such variables may have on spatial behavior and the ethical implications ( ).


Proximity to Others


Proxemics is the term for the study of human use and perception of social and personal space ( ). Individuals tend to divide surrounding space into regions of front, back, right, and left ( ). The front region is considered the most important, is the largest, is recalled with the greatest precision, and is described with the greatest detail. Proxemics has been shown to allow one to predict self-esteem and self-evaluative moods, even after controlling for the con­tribution of the personality dimensions of neuroticism, extroversion, and agreeableness ( ). Physical distancing from others varies with setting and is culturally learned ( ). Generally, in Western culture there are three primary dimensions of space: the intimate zone (0 to 18 inches), the personal zone (18 inches to 3 feet), and the social or public zone (3 to 6 feet) ( ). The intimate zone may be used for comforting, protecting, and counseling and is reserved for people who feel close. The personal zone usually is maintained with friends or in some counseling interactions. Touch can occur in the intimate and personal zones. The social zone is usually used when impersonal business is conducted or with people who are working together. Sensory involvement and communication are often less intense in the social zone. Wide variations to these general dimensions do occur and are often influenced by cultural background ( ). has suggested that childrearing practices affecting sleep behavior may have an effect on the use of space, especially as it determines acceptable interaction distance. He reported on varying cultural approaches apparently related to family group sleeping arrangements and the Western middle-class practice of separating the child from parents for sleep. According to , the Western practice of putting small children in a room of their own, which separates them from other family members, may enculturate children to desire isolation and separation and cause or facilitate a desire for more extensive territory.


Among the Eskimos and Northern Indians of Canada, the practice of separate bedrooms varies dramatically because living quarters are often small, with all persons sleeping in the same room ( ; ; ). For these individuals, proximity to others in small living quarters is often a necessity for survival since staying inside and near the body heat of others may be necessary to avoid freezing in the frigid arctic temperatures. The need for space also varies for many Southeast Asian immigrants who have come to the United States as refugees. These individuals are also accustomed to living in crowded living situations. Therefore, for some Southeast Asian Americans, spacious living accommodations may cause discomfort ( ). investigated college students at Dayalbagh, India, and noted that more roommates led to larger space requirements, decreased tolerance for crowding, and a more negative attitude toward room environment. However, high cooperation among roommates moderated the effects of crowding. noted that a preferred interpersonal distance score in inmates was effective in predicting prison fighting behavior with a 71% degree of success.


Spatial needs and the desire for a certain proximity to certain people continue through life and have been studied in the elderly. In nursing homes, elderly clients may have certain chairs identified as theirs and become upset when a stranger sits in that chair or in the seat nearby that is reserved for a special friend. Moving from household to household to stay with adult children on a rotating basis, rather than being viewed as a pleasant variation, is also likely to be upsetting to older people. Since the elderly are more likely to experience separation from others through the death of a spouse and the moving away of offspring, their spatial needs may appear to change; that is, they may withdraw or may reach out more for others ( ).


Interpersonal messages are communicated not only by body proximity but also by the location and availability of the nurse during the day. A client who knows that the nurse will answer when the call bell is pressed feels differently from the client who does not understand how the call bell works or feels that it is an imposition to ask for help and waits for the nurse to ask what can be done ( ).


Individuals have different requirements for sensory stimulation. Either overstimulation, as by crowding, or understimulation, as by isolation, may cause an untoward reaction. For example, in times of disaster, overstimulation induced by crowding can be so extreme that it can result in insanity or death. In this example, a person is perceived as being in a little black figure and unable to move about freely, which causes the person to jostle, push, and shove. How the individual responds to jostling and therefore to the enclosed space depends on how he or she feels about being touched by strangers. This constant touching and being touched may result in widespread panic and “freezing” in disaster situations ( ).


An enclosed space requirement can also be overstimulating. For example, a client who must remain in a hospital room in bed and in isolation for a lengthy period can be overstimulated because of the spatial limits presented by the boundaries, including bed rest and the four walls of the room. Nursing interventions for this client include opening curtains, frequently calling by intercom to check on the client, and stopping by to see the client as often as possible. A client in isolation can suffer from understimulation in regard to tactile stimulation. The few people who do enter the room may hesitate to touch the client out of fear of contracting the illness. One of the greatest problems expressed by clients with acquired immunodeficiency syndrome (AIDS) is the isolation they experience because of physical distance from others. Family members afraid of catching AIDS may hesitate to touch, hug, or kiss the AIDS victim. Caregivers also may show their fear by standing a greater distance from the client, wearing gloves, and having less frequent encounters with the client ( ). How individuals perceive and interact with human immunodeficiency virus (HIV) risk varies by a myriad of social, contextual, and setting-related issues ( ). The strong link between curing, the major focus of health care, and caring by health care practitioners has been emphasized by , who cite touch as one of the special constructs of the caring process. As a therapeutic element of human interaction, touch can help the nurse to show caring. noted a divergent response to touch among elderly in a nursing home. For some, touching was interpreted as a violation of personal space, while at other times touching was perceived as a comforting form of communication.


The image of the nurse as someone standing close to the bedside and having physical proximity is changing. Within the wider discourse of fiscal restraint on health care spending, professional nurses need not be in physical proximity for meanings to be generated, to be acted upon, and to have effects in the present. Modern technology is redefining the need for physical proximity. The needs of modern health care are redefining where the nurse’s presence needs to be to accomplish the needs of professional nursing ( ).


Cultural Implications


noted that although there are variations in spatial requirements from person to person, individuals in the same cultural group tend to act similarly. For example, nomads do not seem to desire a permanent territory but are content with establishing a temporary territory and then moving on. Because individuals are usually not consciously aware of their personal space requirements, they frequently have difficulty understanding a different cultural pattern. What may be considered an act of friendliness by one person (such as standing close to another person) may be perceived by the other as a threatening invasion of personal space. A person who wishes to maintain distance will indicate this by body language. Clients who step back, do not face the nurse directly, or pull their chair back from the nurse are sending messages indicating additional space requirements. The nurse’s responsiveness to the client’s spatial requirements is an important factor in the client’s emotional comfort. It is important that the nurse be cognizant of the effects of culture on the client’s spatial needs and use sensitivity in responding to the client’s need for personal territory. Subtle cultural variations in the use of nonverbal signals often lead to misunderstanding; thus, to meet the client’s needs, it is essential that the nurse have knowledge of cultural variations in spatial requirements.


Nurses and clients from the population groups of American Indians, Appalachians, Japanese Americans, and Mexican Americans often find a comfortable position between the personal and social distance ( ). studied cultural differences in the use of personal space. He compiled a range of space by nationality and found that persons in the United States, Canadians, and the British require the most personal space, whereas Latin American, Japanese, and Arabic persons need the least. These latter groups seemingly have a much higher tolerance for crowding in public spaces than some other cultural groups, such as North Americans and northern Europeans, but they also appear to be more concerned about their own requirements for the space they live in. In particular, the Japanese tend to devote more time and attention to the proper organization of their living space for perception by all the senses ( ). Asians are generally more sensitive to personal space and are more likely to feel comfortable conversing from a distance of 5 or 6 feet. Maintaining distance for some Asian Americans is an indication of respect. Therefore, it is important to remember to avoid invading the personal space of these individuals. Some West Indians maintain little space between friends when communicating, but for some West Indians, an outsider is expected to maintain some distance when interacting ( ). Arab Americans value modesty and privacy, particularly with strangers. Comfort and personal disclosure are increased if the care provider is of the same sex ( ; ; ).


A White American female nurse from a nontactile culture may experience discomfort when a male client from a tactile culture, such as the Latin American, African-American, or Indonesian cultures, stands in the intimate zone while describing symptoms ( ; ). Touching between persons of the same sex, including men, is more common among Arabs than it is among Americans. However, among some Asian cultures, touch between women is less common. For example, in some Asian cultures women do not shake hands with each other or with men ( ). In the United States the kind of familiarity common among Arabs may be considered a homosexual pass ( ). note that a handshake in Latin America, particularly between two men, is seen as cold and impersonal. For some Latins, the doble abrazo, in which two men embrace by placing their arms around each other’s shoulders, is the accepted form of greeting. On the other hand, touching the shoulders of a Japanese man is seen as a humiliation and an unpardonable breach of traditional etiquette. reported that members of some societies in Africa and Indonesia also came closer and maintained body contact during conversation.


Abuse and violence involve intrusion on the physical, personal, or cognitive space (verbal functioning or mental strategizing) of another. However, violence is interpreted in a cultural context and according to cultural norms ( ). Wife beatings may not be considered abuse in some cultures. Violence can be subtler. A contemptuous boss may give a female employee an office in the basement or a desk in a public area while male employees have private offices near the employer. This invasion of space carries with it an innuendo that can lead to violence ( ).


In the Thai and Vietnamese cultures, the head is sacred, and patting the head of a small child is considered offensive. For these individuals the head is considered to be the “seat of life.” When the head is touched, it is believed that the spirit leaves through this channel. Therefore, when the head needs to be touched for medical reasons, it is important to explain the reason and to ask permission of the adults ( ; ).


In the United States, a person who stands at a slight angle to another person indicates a body position of readiness to communicate. A desire to exclude a third person can be shown by two persons who face each other directly and have ongoing eye contact. Rejection is also communicated by a person who stands at a right angle to another ( ). The position of the toes can create distance by communicating rank. A person who feels subordinate will usually stand with the toes inward, whereas a person who feels superior will stand with the toes facing out ( ). A comparison of the movie shown in the United States, Three Men and a Baby, and the French comedy on which it was based, Three Men and a Cradle, illustrates the differences in responses in the two cultures. In the French version, when the natural father returns to the two bachelors who have been inconvenienced by the care of the baby, icy silence occurs. The two men sit stiffly in their chairs and refuse to answer their friend’s questions or even acknowledge his presence. In the version seen in the United States, when the natural father returns, he is pummeled and a loud scene occurs ( ).


Territoriality influences relationships between people. Some German people tend to need a larger space and are less flexible in their spatial behavior than some American, French, and Arab people. Differences in spatial patterns between persons in different cultures apply not only to their body proximity but also to such behavior as changing geographic location. For example, Germans often live in the same house their entire lives, whereas Americans tend to change houses approximately every 5 years, and nomads are content with temporary territories rather than permanent ones. According to , some Puerto Ricans and African-Americans may have different perspectives about space. Some African-Americans have more eye contact when they speak, have greater body activity, and have a closer personal space ( ). However, as indicated in Chapter 2 , some African-Americans have been socialized through a long history of hostile, punitive interactions with Whites to avoid direct eye contact. This behavior may also influence personal space zones ( ).

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Dec 29, 2019 | Posted by in NURSING | Comments Off on Space
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