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Chapter: Medical Surgical Nursing: Perspectives in Transcultural Nursing

Culturally Mediated Characteristics

Nurses should be aware that patients act and behave in a variety of ways, in part because of the influence of culture on behaviors and attitudes.

Culturally Mediated Characteristics

Nurses should be aware that patients act and behave in a variety of ways, in part because of the influence of culture on behaviors and attitudes. However, although certain attributes and attitudes are frequently associated with particular cultural groups, as de-scribed in the following pages, it is important to remember that not all people from the same cultural background share the same behaviors and views. Although the nurse who fails to consider a patient’s cultural preferences and beliefs is considered insensitive and possibly indifferent, the nurse who assumes that all members of any one culture act and behave in the same way runs the risk of stereotyping people. The best way to avoid stereotyping is to view each patient as an individual and to find out the patient’s cultural preferences. A thorough culture assessment using a cul-ture assessment tool or questionnaire (see later discussion) is very beneficial.


People tend to regard the space in their immediate vicinity as an extension of themselves. The amount of space they need between themselves and others to feel comfortable is a culturally deter-mined phenomenon.

Because nurses and patients usually are not consciously aware of their personal space requirements, they frequently have diffi-culty understanding different behaviors in this regard. 

For example, one patient may perceive the nurse sitting close to him or her as an expression of warmth and care; another patient may per-ceive the nurse’s act as a threatening invasion of personal space. Research reveals that people from the United States, Canada, and Great Britain require the most personal space between themselves and others, whereas those from Latin America, Japan, and the Middle East need the least amount of space and feel comfortable standing close to others.


If patients appear to position themselves too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, patients should be permitted to assume a position that is comfortable to them in terms of personal space and distance. Because a significant amount of communication during nursing care requires close physical contact, the nurse should be aware of these important cultural differences and consider them when de-livering care (Davidhizar, Dowd, & Newman-Giger, 1999).



Eye contact is also a culturally determined behavior. Although most nurses have been taught to maintain eye contact when speak-ing with patients, some people from certain cultural backgrounds may interpret this behavior differently. Some Asians, Native Americans, Indo-Chinese, Arabs, and Appalachians, for example, may consider direct eye contact impolite or aggressive, and they may avert their own eyes when talking with nurses and others whom they perceive to be in positions of authority. Some Native Americans stare at the floor during conversations, a cultural be-havior conveying respect and indicating that the listener is paying close attention to the speaker. Some Hispanic patients maintain downcast eyes as a sign of appropriate deferential behavior toward others on the basis of age, gender, social position, economic sta-tus, and position of authority. Being aware that whether a person makes eye contact may be a result of the culture from which they come will help the nurse understand a patient’s behavior and pro-vide an atmosphere in which the patient can feel comfortable.


Attitudes about time vary widely among cultures and can be a barrier to effective communication between nurses and patients. Views about punctuality and the use of time are culturally deter-mined, as is the concept of waiting. Symbols of time, such as watches, sunrises, and sunsets, represent methods for measuring the duration and passage of time (Giger & Davidhizar, 1999; Spector, 2000).


For most health care providers, time and promptness are ex-tremely important. For example, nurses frequently expect patients to arrive at an exact time for an appointment, despite the fact that the patient is often kept waiting by health care providers who are running late. Health care providers are likely to function accord-ing to an appointment system in which there are short intervals of perhaps only a few minutes. For patients from some cultures, how-ever, time is a relative phenomenon, with little attention paid to the exact hour or minute. Some Hispanic people, for example, consider time in a wider frame of reference and make the primary distinction between day and night. Time may also be determined according to traditional times for meals, sleep, and other activities or events. For people from some cultures, the present is of the greatest importance, and time is viewed in broad ranges rather than in terms of a fixed hour. Being flexible in regard to schedules is the best way to accommodate these differences.


Value differences also may influence a person’s sense of prior-ity when it comes to time. For example, responding to a family matter may be more important to a patient than meeting a sched-uled health care appointment. Allowing for these different views is essential in maintaining an effective nurse-patient relationship. Scolding or acting annoyed at a patient for being late undermines the patient’s confidence in the health care system and might re-sult in further missed appointments or indifference to health care suggestions.


The meaning people associate with touching is culturally deter-mined to a great degree. In some cultures (eg, Hispanic, Arab), male health care providers may be prohibited from touching or examining certain parts of the female body. Similarly, it may be inappropriate for females to care for males. Among many Asian Americans, it is impolite to touch a person’s head because the spirit is believed to reside there. Therefore, assessment of the head or evaluation of a head injury requires alternative approaches. The patient’s culturally defined sense of modesty must also be considered when providing nursing care. For example, some Jew-ish and Islamic women believe that modesty requires covering their head, arms, and legs with clothing.



Many aspects of care may be influenced by the diverse cultural perspectives held by the health care providers, patient, family, or significant others. One example is the issue of informed consent and full disclosure. In general, a nurse may argue that patients have the right to full disclosure about their disease and prognosis and may feel that advocacy means working to provide that dis-closure. Family members of some cultural backgrounds may be-lieve it is their responsibility to protect and spare the patient, their loved one, the knowledge of a terminal illness. Similarly, patients may, in fact, not want to know about their condition and may ex-pect their family members to “take the burden” of that knowl-edge and related decision-making (Kudzma, 1999). The nurse should not decide that the family or patient is simply wrong or that the patient must know all details of his or her illness. Simi-lar concerns may be noted when patients refuse pain medication or treatment because of cultural beliefs regarding pain or belief in divine intervention or faith healing. Determining the most ap-propriate and ethical approach to patient care requires an explo-ration of the cultural aspects of these situations. Self-examination by the nurse and recognition of one’s own cultural bias and world view, as discussed earlier, will play a major part in helping the nurse to resolve cultural and ethical conflicts. The nurse must promote open dialogue and work with the patient, family, physi-cian, and other health care providers to reach the culturally ap-propriate solution for the patient.



People from all cultures celebrate civil and religious holidays. Nurses should familiarize themselves with major holidays for members of the cultural groups they serve. Information about these important celebrations is available from various sources, including religious organizations, hospital chaplains, and patients themselves. Routine health appointments, diagnostic tests, surgery, and other major procedures should be scheduled to avoid those holidays a patient identifies as significant. Efforts should also be made to accommodate patients and family or significant others, when not contraindicated, as they perform holiday rituals in the health care setting.



The cultural meanings associated with food vary widely but usu-ally include one or more of the following: relief of hunger; pro-motion of health and healing; prevention of disease or illness; expression of caring for another; promotion of interpersonal closeness among individuals, families, groups, communities, or nations; and promotion of kinship and family alliances. Food may also be associated with solidification of social ties; celebra-tion of life events (eg, birthdays, marriages, funerals); expression of gratitude or appreciation; recognition of achievement or ac-complishment; validation of social, cultural, or religious ceremo-nial functions; facilitation of business negotiations; and expression of affluence, wealth, or social status.

Culture determines which foods are served and when they are served, the number and frequency of meals, who eats with whom, and who is given the choicest portions. Culture also determines how foods are prepared and served; how they are eaten (with chopsticks, hands, or fork, knife, and spoon); and where people shop for their favorite food items (eg, ethnic grocery stores, spe-cialty food markets).


Religious practices may include fasting (eg, Mormons, Catholics, Buddhists, Jews, Muslims), abstaining from selected foods at particular times (eg, Catholics abstain from meat on Ash Wednesday and on Fridays during Lent), and considerations for medications (eg, Muslims may prefer to use non-pork-derived in-sulin). Practices may also include the ritualistic use of food and beverages (eg, Passover dinner, consumption of bread and wine during religious ceremonies). Chart 8-2 summarizes some dietary practices of selected religious groups.


Many groups tend to feast, often in the company of family and friends, on selected holidays. For example, many Christians eat large dinners on Christmas and Easter and consume other traditional high-calorie, high-fat foods, such as seasonal cookies, pastries, and candies. These culturally-based dietary practices are especially significant in the care of patients with diabetes, hy-pertension, gastrointestinal disorders, and other conditions in which diet plays a key role in the treatment and health mainte-nance regimen.



Along with psychosocial adaptations, nurses must also consider the physiologic impact of culture on patient response to treat-ment, particularly medications. Data have been collected for many years regarding differences in the effect some medications have on persons of diverse ethnic or cultural origins. Genetic predispositions to different rates of metabolism cause some pa-tients to be prone to overdose reactions to the “normal dose” of a medication, while other patients are likely to experience a greatly reduced benefit from the standard dose of the medication. An antihypertensive agent, for example, may work well for a white male client within a 4-week time span but may take much longer to work or not work at all for an African-American male patient with hypertension. General polymorphism—variation in response to medications resulting from patient age, gender, size, and body composition—has long been acknowledged by the health care community (Kudzma, 1999). Culturally competent medication administration requires that consideration of ethnicity and related factors such as values and beliefs regarding the use of herbal sup-plements, dietary intake, and genetic factors can affect the effec-tiveness of treatment and compliance with the treatment regimen (Giger & Davidhizar, 1999; Kudzma, 1999).




Interventions for alterations in health and wellness vary among cultures. Interventions most commonly used in the United States have been labeled as conventional medicine by the Na-tional Institutes of Health (n.d.). Other names for conventional medicine were allopathy, Western medicine, regular medicine, mainstream medicine, and biomedicine. Interest in interven-tions that are not an integral part of conventional medicine prompted the National Institutes of Health to create the Office of Alternative Medicine (OAM) in 1992, and then to establish the National Center for Complementary and Alternative Med-icine (NCCAM) in 1999.


The NCCAM grouped complementary and alternative med-icine interventions into five main categories: alternative medical systems, mind–body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies (National Institutes for Health, National Center for Comple-mentary and Alternative Medicine, accessed 9/8/01).


·       Alternative medical systems are defined as complete systemsof theory and practice that are different from conventional medicine. Some examples are traditional Eastern medicine (including acupuncture, herbal medicine, oriental massage, and Qi gong); India’s traditional medicine, Ayurveda (in-cluding diet, exercise, meditation, herbal medicine, mas-sage, exposure to sunlight, and controlled breathing to restore harmony of an individual’s body, mind, and spirit); homeo-pathic medicine (including herbal medicine and minerals); and naturopathic medicine (including diet, acupuncture, herbal medicine, hydrotherapy, spinal and soft-tissue ma-nipulation, electrical currents, ultrasound and light therapy, therapeutic counseling, and pharmacology).


·      Mind–body interventions are defined as techniques to facilitatethe mind’s ability to affect symptoms and bodily functions. Some examples are meditation, dance, music, art therapy, prayer, and mental healing.


·       Biologically based therapies are defined as natural and bio-logically based practices, interventions, and products. Some examples are herbal therapies (an herb is a plant or plantpart that produces and contains chemical substances that act upon the body), special diet therapies (such as those of Drs. Atkins, Ornish, and Pritikin), orthomolecular thera-pies (magnesium, melatonin, megadoses of vitamins), and biologic therapies (shark cartilage, bee pollen).


·      Manipulative and body-based methods are defined as inter-ventions based on body movement. Some examples are chi-ropracty (primarily manipulation of the spine), osteopathic manipulation, massage therapy (soft tissue manipulation), and reflexology.


·      Energy therapies are defined as interventions that focus onenergy fields within the body (biofields) or externally (elec-tromagnetic fields). Some examples are Qi gong, Reiki, therapeutic touch, pulsed electromagnetic fields, magnetic fields, alternating electrical current, and direct electrical current.


A patient may choose to seek an alternative to conventional medical or surgical therapies. Many of these alternative therapies are becoming widely accepted as feasible treatment options. Therapies such as acupuncture and herbal treatments may be rec-ommended by a patient’s physician to address aspects of a condi-tion that are unresponsive to conventional medical treatment or to minimize side effects associated with conventional medical therapy. Alternative therapy used to supplement conventional medicine may be referred to as complementary therapy.


Physicians and advanced practice nurses may work in collab-oration with an herbalist or with a spiritualist or shaman to pro-vide a comprehensive treatment plan for the patient. Out of respect for the way of life and beliefs of patients from different cultures, it is often necessary that the healers and health care providers respect the strengths of each approach (Palmer, 2001). Complementary therapy is becoming more common as health care consumers become more aware of what is available through information in printed media and on the Internet.


As patients become more informed, they are more likely to participate in a variety of therapies in conjunction with their con-ventional medical treatments. The nurse needs to assess each pa-tient for use of complementary therapies, remain alert to the danger of conflicting treatments, and be prepared to provide information to the patient regarding treatment that may be harmful. The nurse must, however, be accepting of the patient’s beliefs and right to control his or her own care. As a patient advocate, the nurse facili-tates the integration of conventional medical, complementary, and alternative medical therapies.


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