Cultural Patterns and Differences
Knowledge of expected cultural patterns provides a start-ing point for the nurse to begin to relate to people with ethnic backgrounds different from his or her own (Andrews & Boyle, 2007). Being aware of the usual differences can help the nurse know what to ask or how to assess prefer-ences and health practices. Nevertheless, variations among people from any culture are wide: Not everyone fits the general pattern. Individual assessment of each person and family is necessary to provide culturally competent care that meets the client’s needs. The following information about various ethnic groups should be a starting place for the nurse in terms of learning about greetings, acceptable communication patterns and tone of voice, and beliefs regarding mental illness, healing, spirituality, and medical treatment.
Several terms are used to refer to African Americans, such as Afro Americans, blacks, and persons of color. Therefore, it is best to ask what each client prefers.
During illness, families are often a support system for the sick person, although the client maintains his or her independence, such as making his or her own health-care decisions. Families often feel comfortable demonstrating public affection such as hugging and touching one another. Conversation among family and friends may be animated and loud. Greeting a stranger usually includes a hand-shake, and direct eye contact indicates interest and respect. Silence may indicate a lack of trust of the caregiver or the situation (Waters & Locks, 2005).
The church is an important and valued support system for many African Americans, who may receive frequent hospital visits from ministers or congregation members. Prayer is an important part of healing. Some in the African American community may view the cause of mental illness to be a spiritual imbalance or a punishment for sin. Afri-can American clients may use folk remedies in conjunc-tion with Western medicine (Waters & Locks, 2005).
Older adults usually prefer the term American Indian, whereas younger adults prefer Native American. Many Native Americans refer to themselves by a tribal name, such as Winnebago or Navajo. A light-touch handshake is a respectful greeting with minimal direct eye contact. Communication is slow and may be punctuated by many long pauses. It is important not to rush the speaker or interrupt with questions. This culture is accustomed tocommunicating by telling stories, so communicating can be a long, detailed process. Family members are reluctant to provide information about the client if he or she can do so, believing it violates the client’s privacy to talk about him or her. Orientation to time is flexible and does not coincide with rigidly scheduled appointments.
Mental illness is a culturally specific concept, and beliefs about causation may include ghosts, breaking taboos, or loss of harmony with the environment. Clients are often quiet and stoic, making few, if any, requests. Experiences that involve seeing visions or hearing voices may have spiritual meaning; thus, these clients may not view such phenomena as illness. Native Americans with traditional religious beliefs may be reluctant to discuss their beliefs and practices with strangers. If the client wears a medicine bag, the nurse should not remove it if possible. Others should not casually discuss or touch the medicine bag or other ritual healing objects. Other Native Americans belong to Christian denominations, but they may incorporate healing practices or use a spiritual healer along with Western medicine (Palacios, Butterfly, & Strickland, 2005).
The preferred term of address may be by region, such as Arab Americans or Middle Eastern Americans, or by coun-try of origin, such as Egyptian or Palestinian. Greetings include a smile, direct eye contact, and a social comment about family or the client. Using a loud voice indicates the importance of the topic, as does repeating the message. To appear respectful, those of Middle Eastern background commonly express agreement in front of a stranger, but it does not necessarily reflect their true feelings. Families make collective decisions with the father, eldest son, uncle, or husband as the family spokesperson. Most appointments viewed as official will be kept, although human concerns are more valued than is adhering to a schedule (Meleis, 2005).
This culture believes mental illness results from sud-den fears, attempts to manipulate family, wrath of God, or God’s will, all of which focus on the individual. Loss of country, family, or friends also may cause mental illness. Such clients may seek mental health care only as a last resort after they have exhausted all family and community resources. When sick, these clients expect family or health-care professionals to take care of them. The client reserves his or her energy for healing and thus is likely to practice complete rest and abdication from all responsi-bilities during illness. These clients view mental illness more negatively than physical illness and believe mental illness to be something the person can control. Although early immigrants were Christians, more recent immigrants are Muslims. Prayer is very important to Muslims: strict Muslims pray five times a day, wash before every prayer, and pray in silence. Western medicine is the primary treatment sought, but some may use home remedies andamulets (charms or objects used for their protective powers).
The preferred term for people from Cambodia is Khmer (pronounced Kuh-meer’) or Sino-Khmer (if Chinese Cam-bodian). Those who have assimilated into Western culture use a handshake for greeting, whereas others may slightly bow, bringing the palms together with the fingers pointed upward, and make no contact with the person they are greeting. Many Asians speak softly, so it is important to listen carefully rather than asking them to speak louder. Cambodian clients highly value politeness. Eye contact is acceptable, but women may lower their eyes to be polite. Silences are common and appropriate; nurses should avoid meaningless chatter. These clients may consider it impo-lite to disagree, so they say yes when not really agreeing or intending to comply. It is inappropriate to touch someone’s head without permission because some believe the soul is in the head. Cambodian clients usually include family members in making decisions. Orientation to time can be flexible (Kulig & Prak, 2005).
Most Khmer emigrated to the United States after 1970 and believe that mental illness is the result of the Khmer Rouge war and associated brutalities. When ill, they assume a passive role, expecting others to care for them. Many may use Western medicine and traditional healing practices simultaneously. Buddhism is the primary reli-gion, although some have converted to Christianity. An accha (holy person) may perform many elaborate ceremo-nies in the person’s home but will not do so in the hospital. Healers may visit the client in the hospital but are unlikely to disclose they are healers, much less what their practices are. Some Khmer still have a naturalistic view of illness and may be reluctant to have blood drawn, believing they will lose body heat needed for harmony and balance (Kulig & Prak, 2005).
The Chinese are often shy in unfamiliar environments, so socializing or friendly greetings are helpful. They may avoid direct eye contact with authority figures to show respect; keeping a respectful distance is recommended. Asking questions can be a sign of disrespect; silence is a sign of respect. Chinese is an expressive language, so loudness is not necessarily a sign of agitation or anger. Traditional Chinese societies tend not to highly value time urgency. Extended families are common, with the eldest male member of the household making decisions and serving as the spokesperson for the family (Chin, 2005).
Mental illness is thought to result from a lack of har-mony of emotions or from evil spirits. Health practices may vary according to how long immigrants have lived in the United States. Immigrants from 40 to 60 years ago are strong believers in Chinese folk medicine, whereas immi-grants from the last 20 years combine folk and Westernmedicine. First- and second-generation Chinese Americans are mostly oriented to Western medicine. Many Chinese use herbalists and acupuncture, however, either before or in conjunction with Western medicine. Rarely, these clients will seek a spiritual healer for psychiatric prob-lems to rid themselves of evil spirits. Many Chinese are Buddhists, but Catholic and Protestant religions are also common.
Cubans, or Cuban Americans if born in the United States, are typically outgoing and may speak loudly during normal conversation. Extended family is very important, and often more than one generation resides in a household. These clients expect direct eye contact during conversation and may view looking away as a lack of respect or honesty. Silence indicates awkwardness or uncertainty. Although orientation to social time may vary greatly, these clients view appointments as business and are punctual (Varela, 2005).
Cuban clients view stress as a cause of both physical and mental illness, and some believe mental illness is hereditary. Mental illness is a stigma for the family; thus, Cuban clients may hide or not publicly acknowledge such problems. The person in the sick role often is submissive, helpless, and dependent on others. Although Cuban cli-ents may use herbal medicine to treat minor illness at home, they usually seek Western medicine for more seri-ous illness. Most Cubans are Catholic or belong to other Christian denominations, so prayer and worship may be very important.
Smiles rather than handshakes are a common form of greeting. Facial expressions are animated, and clients may use them rather than words to convey emotion. Filipino clients consider direct eye contact impolite, so there is little direct eye contact with authority figures such as nurses and physicians. Typically, Filipinos are soft spoken and avoid expressing disagreement (Rodriguez, de Guzman, & Cantos, 2005); however, their tone of voice may get louder to emphasize what they are saying or as a sign of anxiety or fear. They are likely to view medical appoint-ments as business and thus be punctual.
They believe the causes of mental illness to be both reli-gious and mystical. Filipinos are likely to view mental ill-ness as the result of a disruption of the harmonious func-tion of the whole person and the spiritual world. These causes can include contact with a stronger life force, ghosts, or souls of the dead; disharmony among wind, vapors, diet, and shifted body organs; or physical and emotional strain, sexual frustration, and unrequited love. Most Filipinos are Catholic; when very ill, they may want to see a priest and a physician. Prayer is important to the client and family, and they often want to receive the reli-gious sacraments while sick. Filipinos often seek bothWestern medical treatment and the help of healers to remove evil spirits. The ill client assumes a passive role, and the eldest male in the household makes decisions after conferring with family members (Rodriguez, de Guzman, & Cantos, 2005).
Haiti has two official languages, French and Creole, and a strong oral culture that uses stories as educational tools. In Haiti, 80% of the people neither read nor write, but liter-acy may vary among Haitians in the United States. Videos, oral teaching, and demonstrations are effective ways to communicate information. Haitians are polite but shy, especially with authority figures, and may avoid direct eye contact. Handshakes are the formal greeting of choice. Haitians may smile and nod as a sign of respect even when they do not understand what is being said. Tone of voice and hand gestures may increase to emphasize what is being said. There is little commitment to time or schedule in Haitian culture, but clients may be on time for medical appointments if the provider emphasizes the need for punctuality (Colin, 2005).
Mental illness is not well accepted in Haitian culture. These clients usually believe mental illness to have super-natural causes. The sick person assumes a passive role, and family members provide care for the individual. Home and folk remedies are often the first treatment used at home, and clients seek medical care when it is apparent the person needs medical attention. Haitians are predomi-nantly Catholic and have a very strong belief in God’s power and ability to heal (Colin, 2005).
Japanese Americans identify themselves by the generation in which they were born. Issei, the first generation of Japanese Americans in the United States, have a strong sense of Japanese identity. Nisei, second-generation Japanese Americans born and educated in the United States, appear to be Westernized but have strong roots in Japanese culture. Sansei (third generation) and Yonsei (fourth generation) are assimilated into Western culture and are less connected to Japanese culture.
Greetings tend to be formal, such as a smile or small bow for older generations and a handshake for younger generations. There is little touching, and eye contact is minimal, especially with authority figures. These clients control facial expressions and avoid conflict or disagree-ment. Elders may nod frequently, but this does not neces-sarily indicate understanding or agreement. Self-disclosure is unlikely unless trust has been established, and then only if the information is directly requested. Nurses should phrase questions to elicit more than just a yes or no answer. Promptness is important, so clients are often early for appointments (Shiba, Leong, & Oka, 2005).
Mental illness brings shame and social stigma to the family, so clients are reluctant to seek help. Evil spirits arethought to cause loss of mental self-control as a punish-ment for bad behavior or failure to live a good life. These clients expect themselves and others to use will power to regain their lost self-control and often perceive those with mental illness as not trying hard enough. Western psycho-logical therapies based on self-disclosure, sharing feelings, and discussing one’s family experiences are very difficult for many Japanese Americans. The nurse might incorrectly view these clients as unwilling or uncooperative (Shiba, Leong, & Oka, 2005).
Buddhism, Shinto, and Christianity are the most com-mon religions among Japanese Americans, and religious practices vary with the religion. Prayer and offerings are common in Buddhist and Shinto religions and are usually performed in conjunction with Western medicine.
Diversity is wide among Mexican Americans in terms of health practices and beliefs, depending on the client’s education, socioeconomic status, generation, time spent in the United States, and affinity to traditional culture. It is best for the nurse to ask the client how he or she would like to be identified (e.g., Mexican American, Latino, or Hispanic). Most Mexicans consider a handshake to be a polite greeting but do not appreciate other touch by strangers, although touching and embracing warmly are common among family and friends. To convey respect, Mexican clients may avoid direct eye contact with author-ity figures. They usually prefer polite social interaction to help establish rapport before answering health-related questions. Generally, one or two questions will produce a wealth of information, so listening is important. Silence is often a sign of disagreement, which these clients may use in place of words. Orientation to time is flexible; the client may be 15 or 20 minutes late for an appointment but will not consider that as being late (Guarnero, 2005).
There is no clear separation of mental and physical ill-ness. Many Mexican Americans have a naturalistic or per-sonalistic view of illness and believe disease is based on the imbalance of the person and the environment, includ-ing emotional, spiritual, social, and physical factors (Guarnero, 2005). Mexican Americans may seek medical care for severe symptoms while still using folk medicine to deal with spiritual or psychic influences. Between 80% and 90% of Mexican Americans are Catholic and observe the rites and sacraments of that religion.
Preferences for personal space vary among Puerto Ricans; so it is important to assess each individual. Typically, older and more traditional people prefer greater distance and less direct eye contact, whereas younger people pre-fer direct eye contact and less distance with others. Puerto Ricans desire warm and smooth interpersonal relationships and may express gratitude to health-care providers with homemade traditional cooking; theseclients might interpret the refusal of such an offer as an insult. There may be some difficulty being on time for appointments or limiting the length of an appointment ( Juarbe, 2005).
Physical illness is seen as hereditary, punishment for sin, or lack of attention to personal health. Mental illness is believed to be hereditary or a result of sufriamientos (suffering). Mental illness carries great stigma, and past or present history of mental illness may not be acknowledged. Religious and spiritual practices are very important, and these clients may use spiritual healers or healing practices (Juarbe, 2005).
A formal greeting or a handshake with direct eye contact is acceptable. These clients reserve touching or embracing and kissing on the cheeks for close friends and family. Tone of voice can be loud even in pleasant conversations. Most clients are on time or early for appointments (del Puerto & Sigal, 2005).
Russians believe the cause of mental illness to be stress and moving into a new environment. Some Russian Chris-tians believe illness is God’s will or a test of faith. Sick people often put themselves on bed rest. Many Russians do not like to take any medications and will try home rem-edies first. Some older Russians believe that excessive drug use can be harmful and that many medicines can be more damaging than natural remedies. Primary religious affilia-tions are Eastern Orthodox, with a minority being Jewish or Protestant (del Puerto & Sigal, 2005).
South Asians living in the United States include people from India, Pakistan, Bangladesh, Sri Lanka, Nepal, Fiji, and East Africa. Preferred terms of identification may be related to geography, such as South Asians, East Indians, Asian Indians, or Indo-Americans, or by religious affilia-tion, such as Sikhs, Hindus, or Muslims. Greetings are expressed orally as well as in gestures. Hindus and Sikhs press their palms together while saying namaste (Hindus) or sasariyakal (Sikhs). Muslims take the palm of the right hand to their forehead and bow slightly while saying AsSalamOAlaikuum. Shaking hands is common among men but not among women. Touching is not common among South Asians; rather, they express feelings through eyes and facial expressions. They may consider direct eye contact, especially with elders, rude or disrespectful. Silence usually indicates acceptance, approval, or toler-ance. Most South Asians have a soft tone of voice and consider loudness to be disrespectful. Although not time conscious about social activities, most South Asians are punctual for scheduled appointments for health care (Lee, Lei, & Sue, 2001).
South Asians believe mental illness to result from spells cast by an enemy or possession by evil spirits. Those who believe in Ayurvedic philosophy may believe a person is susceptible to mental problems related to physical imbal-ances in the body. Sick people usually assume a passive role and want to rest and be relieved of daily responsibili-ties. Hindus worship many gods and goddesses and believe in a social caste system. Hindus believe that reciting charms and performing rituals eliminate diseases, enemies, sins, and demons. Many believe that yoga eliminates certain mental illnesses. Muslims believe in one God and pray five times daily after washing their hands. They believe that reciting verses from the holy Koran eliminates diseases and eases suffering. Sikhs also believe in one God and the equality of all people. Spiritual healing practices and prayer are common, but South Asians living in the United States readily seek health care from Western physicians as well (Lee et al., 2001).
Vietnamese greet with a smile and bow. A health-care pro-vider should not shake a woman’s hand unless she offers her hand first. Touch in communication is more limited among older, more traditional people. Vietnamese may consider the head sacred and the feet profane, so the order of touching is important. As a sign of respect, many of these clients avoid direct eye contact with those in author-ity and with elders. Personal space is more distant than it is for European Americans. Typically, the Vietnamese are soft spoken and consider raising the voice and pointing to be disrespectful. They also may consider open expression of emotions or conflict to be in bad taste. Punctuality for appointments is usual (Nowak, 2005).
Vietnamese believe mental illness to be the result of individual disharmony or an ancestral spirit returning to haunt the person because of past bad behavior. When sick, clients assume a passive role and expect to have everything their way.
The two primary religions are Catholicism and Bud-dhism. Catholics recite the rosary and say prayers and may wish to see a priest daily. Buddhists pray silently to them-selves. Vietnamese people believe in both Western medi-cine and folk medicine. Some believe that traditional heal-ers can exorcise evil spirits. Other health practices include coin rubbing, pinching the skin, acupuncture, and herbal medicine (Nowak, 2005).