According to the U.S. Census Bureau, 33% of U.S. resi-dents currently are members of nonwhite cultures. By 2050, the nonwhite population will more than triple. This changing composition of society has implications for health-care professionals, who are predominantly white and unfamiliar with different cultural beliefs and practices (Purnell & Paulanka, 2008). Culturally competent nurs-ing care means being sensitive to issues related to culture, race, gender, sexual orientation, social class, economic situ-ation, and other factors.
Nurses and other health-care providers must learn about other cultures and become skilled at providing care to people with cultural backgrounds that are different from their own. Finding out about another’s cultural beliefs and practices and understanding their meaning is essential to providing holistic and meaningful care to the client (Table 7.3).
Culture has the most influence on a person’s health beliefs and practices. It has been shown to influence one’s concept of disease and illness. Two prevalent types of beliefs about what causes illness in non-Western cultures are natural and unnatural or personal. Unnatural or personal beliefs attribute the cause of illness to the active, purposeful intervention of an outside agent, spirit, or supernatural force or deity. The natural view is rooted in a belief that natural conditions or forces, such as cold, heat, wind, or dampness, are responsible for the illness (Giger & Davidhizar, 2007). A sick person with these beliefs would not see the relationship between his or her behavior or health practices and the illness. Thus, he or she would try to counteract the negative forces or spirits using traditional cultural remedies rather than taking medi-cation or changing his or her health practices.
Giger and Davidhizar (2007) recommended a model for assessing clients using six cultural phenomena: communication, physical distance or space, social or-ganization, time orientation, environmental control, and biologic variations. Each phenomenon is discussed in more detail below and in Table 7.4.
Verbal communication can be difficult when the client and nurse do not speak the same language. The nurse should be aware that nonverbal communication has different meanings in various cultures. For example, some cultures welcome touch and consider it supportive, whereas other cultures find touch offensive. Some Asian women avoid shaking hands with one another or men. Some Native American tribes believe that vigorous handshaking is aggressive, whereas peo-ple from Spain and France consider a firm handshake a sign of strength and good character.
Although Western cultures view direct eye contact as positive, Native American and Asian cultures may find it rude, and people from these backgrounds may avoid look-ing strangers in the eye when talking to them. People from Middle Eastern cultures can maintain very intense eye contact, which may appear to be glaring to those from dif-ferent cultures.
Various cultures have different perspectives on what they consider a comfortable physical distance from another person during communication. In the United States and many other Western cultures, 2 to 3 feet is a comfortable distance. Latin Americans and people from the Middle East tend to stand closer to one another than do people in Western cultures. People from Asian and Native Ameri-can cultures are usually more comfortable with distances greater than 2 or 3 feet. The nurse should be conscious of these cultural differences in space and should allow enough room for clients to be comfortable (Giger & Davidhizar, 2007).
Social organization refers to family structure and organi-zation, religious values and beliefs, ethnicity, and culture, all of which affect a person’s role and, therefore, his or her health and illness behavior. In Western cultures, people may seek the advice of a friend or family member or may make most decisions independently. Many Chinese, Mexi-can, Vietnamese, and Puerto Rican Americans strongly value the role of family in making health-care decisions. People from these backgrounds may delay making deci-sions until they can consult appropriate family members. Autonomy in health-care decisions is an unfamiliar and undesirable concept because the cultures consider the col-lective to be greater than the individual.
Time orientation, or whether one views time as precise or approximate, differs among cultures. Many Westerncountries focus on the urgency of time, valuing punctuality and precise schedules. Clients from other cultures may not perceive the importance of adhering to specific follow-up appointments or procedures or time-related treatment regi-mens. Health-care providers can become resentful and angry when these clients miss appointments or fail to fol-low specific treatment regimens such as taking medications at prescribed times. Nurses should not label such clients as noncompliant when their behavior may be related to a dif-ferent cultural orientation to the meaning of time. When possible, the nurse should be sensitive to the client’s time orientation, as with follow-up appointments. When timing is essential, as with some medications, the nurse can explain the importance of more precise timing.
Environmental control refers to a client’s ability to control the surroundings or direct factors in the environment (Giger & Davidhizar, 2007). People who believe they have control of their health are more likely to seek care, to change their behavior, and to follow treatment recommen-dations. Those who believe that illness is a result of nature or natural causes are less likely to seek traditional health care because they do not believe it can help them.
Biologic variations exist among people from different cul-tural backgrounds, and research is just beginning to help us understand these variations. For example, we now know that differences related to ethnicity/cultural origins cause variations in response to some psychotropic drugs (discussed earlier). Biologic variations based on physical makeup are said to arise from one’s race, whereas other cultural variations arise from ethnicity. For example, sickle cell anemia is found almost exclusively in African Ameri-cans, and Tay-Sachs disease is most prevalent in the Jewish community.
Socioeconomic status refers to one’s income, education, and occupation. It strongly influences a person’s health, including whether or not the person has insurance and adequate access to health care or can afford prescribed treatment. People who live in poverty are also at risk for threats to health, such as inadequate housing, lead paint, gang-related violence, drug trafficking, or substandard schools.
Social class has less influence in the United States, where barriers among the social classes are loose and mobility is common: people can gain access to better schools, housing, health care, and lifestyle as they increase their income. In many other countries, however, social class is a powerful influence on social relationships and can determine how people relate to one another, even in a health-care setting. For example, the caste system stillexists in India, and people in the lowest caste may feel unworthy or undeserving of the same level of health care as people in higher castes. The nurse must determine whether social class is a factor in how clients relate to health-care providers and the health-care system.