Transcultural Nursing

Transcultural NursingBy Kristyn BeaverFerris State University

Welcome to the Transcultural Nursing presentation; by Kristyn Beaver.1Transcultural nursing affects each and every one of us as professionals. We meet people daily that have different lifestyles, beliefs, practices, superstitions, and family lives from our own. The professional nurse must be aware of his/her own personal beliefs and culture to deliver culturally competent nursing care effectively to their patients. A book published in 2008 called Caring for the Patients from Different Cultures by Geri-Ann Galanti was a very good book. It gives many examples of different cultures and how to best care for those individuals; some will be shared in these slides. The readings chosen will guide the participant through defining Transcultural Nursing to the ability to give examples of appropriate techniques to incorporate transcultural nursing into the professional nurses practice. Purpose of this presentation

As nursing professionals, caring for those of different cultures is common-place anymore. To adequately care for the patient, and his or her family, one must analyze ones own personal beliefs, culture, and customs. After being in tune to ones own culture, the nurse then needs to be aware of how his/her views might impact the care that he/she delivers; paying close attention to not let personal beliefs and attitudes impact quality patient care. Delivering care to the needs and beliefs of the patient is what makes the nurse culturally competent.

2Define transcultural nursingDefine standards for practice regarding transcultural nursing.To reflect on and be aware of personal values, beliefs, and culture that could affect patient care.Give examples of transcultural nursing and how to incorporate that into practice.

Objectives

3Culture is not only our race, ethnicity, and language; it is also shaped by our spiritual beliefs and practices, our environment, our economic background, physical and biological makeup, psychological aspects and also our political beliefs. (Smith, 2013)Defining culture

With over 3000 cultures worldwide, we are faced with many, many variations (Narayanasamy and White, 2004). In the countries all over the world, prejudice and racism still have strong footholds. This is representative in the inequalities in access to healthcare, lack of information in other languages, and diminished service use according to Narayanasamy and White (2004).

Narayanasamy and White (2004) are from Great Britain and wrote a paper regarding transcultural nursing in England. England has the same issues in their country as we do in ours; even with a National Health system. 4Demographics of the Michigan

79.3% White

14.1% African-American

4.4 % Hispanic

*0.6% Native American Indian

2.5% Asian

1.9% Are 2 or more races

In Berrien county where I live the percentages are very close to the State averages;79.9% white15.6% African American4.7% Hispanic1.7% Asian0.6% Native American Indian2.2% persons having 2 or more races.Ethnicities and Religions in our area of southwestern lower Michigan and north central Indiana include Roman Catholic, Jewish, Greek Orthodox, Seventh Day Adventist, Jehovahs Witness, Mormon, Muslims, Methodists, Pentecostal, Nazarene, Christian Reform, Christian Science, and Lutheran.

In regards to ethnicities, with at least 8 colleges and universities in a 25 miles radius of where I live, there is a multitude of diverse ethnicities. African (Malawi, Kenyon, Somalia, Nigeria), Russian, Asian (Chinese, Korean, and Taiwanese) Hispanic (Mexico, Venezuela, other south American Countries). Some of the Colleges include Notre Dame, IUSB, Bethel, in Indiana; and Andrews University in Berrien Springs. These large colleges bring a diverse student population; and most have families. 5Definition as stated by M. Leininger (1991) Transcultural nursing is a comparative study of cultures to understand similarities (culture universal) and difference (culture-specific) across human groups(Nursing Theories, 2012, p. 1)

This theory looks at how each person views their health and their disease based on their beliefs, religion, culture, and ethnicity (Leininger, 1991).

Other cultures may decide to seek alternative methods of healing before seeking help from modern medicine; or they may not seek help at all based on their beliefs (Leininger, 1991).

Nurses need to be flexible in planning care for people of different cultures to increase compliance in treatment and improve outcomes overall (Leininger, 1991).

Transcultural Theory

According to MacFarland and Andrews there is a companion instrument used to assist nurses in reviewing and used as a guide to understand each patients view. It is a comprehensive, holistic overview of the clients background (Clarke, MacFarland, Andrews, & Leininger, 2009p.234). It assesses the patients communication and language, interpersonal relationships including gender relationships, how they dress and their appearance, how they prepare foods, their use of space and related lifeways; this is known as the culturalogical assessment. MacFarland (2009) states that nursing has a societal mandate to serve people who seek the assistance of others to respond to their care needs (p. 235).

References:Clarke,P.N., McFarland, M.R., Andrews, M.M., and Leininger, M. (2009) Caring: some reflections on the inpact of the culture theory by McFarland & Andrews and a conversation with Leininger Nursing Science Quarterly. 22:233. doi: 10.1177/0894318409337020.

6Transcultural Nursing

When the patient, family and nurse (healthcare workers) work together to develop a plan of care based on the patients beliefs and customs, then it is a win/win for all involved. Patients are more compliant with treatments, diets and medications when they understand the why and how of each item. By getting the family involved, this increases the likelihood of success. In the US, independence is valued above all else. Whereas, in many other cultures, Hispanic and African cultures for instance, family is valued more than independence. What is valued and how we value things/positions or the like depends on our culture. Galanti (2008) wrote of a an extreme example of values. In the 1980s a Japanese boat captain lost his cargo and ship at sea in a horrible accident he could not have foreseen or prevented. In the US, the US captain would have called his insurance agent, the Japanese captain committed suicide. This is a major example of how different cultures view life and values.

By knowing and understanding different cultures and their values, beliefs, family ties, time orientation and simple things like dietary habits, helps nurses and healthcare workers in general take better care of their patients. 7Based on Roys Model (Roy, 1989 & Roy & Andrews 1991), there are some assumptions that are made:People are bio-psycho-social being that are in ever changing and adapting to their environment.Health and illness are inevitable dimensions of the persons life *The four modes of adaptation of the person is: physiologic needs, self-concept, role function and inter-dependence *Persons cope with their environmental changes based on their experiences. Nursing accepts the humanistic approach of valuing other persons opinions, and view points Interpersonal relations are an integral part of nursing *

*Nursing Theories ( Jan. 26, 2012) As retrieved from http://currentnursing.com/nursing_theory/Roy_adaptation_model.html on June 11, 2013. p. 1.

Roys Adaptation Model

Humans are amazing at adapting to their environments. Some call it assimilation. This is when people from other cultures assimilate into the culture they are living in. So, immigrants come to the US, by the 3rd generation, they are considered assimilated. First generation still hold to the old ways. Their children,2nd generation, incorporate both the old and the new and the 3rd generation is now assimilated into the new culture. 8What is diversity?Based on:AgeEthnicityReligionRaceNative LanguageHealth statusPhysical attributesNationalityEducational StatusEconomic statusWhat is stereotyping?Think about those with different attributes and how you view them and react to them? Compare:Hardworking ~ LazyWithholding ~ GenerousExpressive ~ Quiet Suspicious ~ warm/openAggressive ~ GentleEmotional ~ UnfeelingTraditional ~ open to changeIntelligent ~ Ignorant(Healthy People 2020 worksheets)

Based on Healthy Peoples 2020 worksheets to aide in defining what makes us diverse, and how stereotypes and stereotyping can affect patient care. By doing some soul searching and thinking about how we feel toward the above categories, this will make us more aware of our own feelings. Doing this enables us to set aside prejudices and really care for our patients. 9Root Cause Analysis

The Issue: A universal issue regarding healthcare is the multicultural patients and their unique problems, beliefs, family relations, experiences, and culture; how do nurses deliver competent care specific to that persons particular needs and desires.How can the issue be addressed? Every nurse explores his/her own beliefs and practices and how these differences in culture could affect patient care.What can be done? Each nurse provides culturally competent care with each patients; and family; unique identity taken into account to promote best outcomes.

10Patient Centered Care:Definition: Recognize the patient or designee as a source of control and full partner in providing compassionate and coordinated care based on respect for patients preferences, values, and needs (QSEN, 2013)Knowledge: how can we empower patients and families in all aspects of healthcareExamine safety and quality as well as cost containment to improve outcomes.Need to understand pain and suffering.Have knowledge on patients preferences, values, emotional status, family, and beliefs.Skills: To provide patient centered care incorporating the patients values, beliefs, family and needs of the patient.Assess presence and extent of pain and suffering.Assess emotional and physical status.Ask family or patient their expectations of pain and pain relief.Communicate!Attitudes: Seek learning opportunities. *Value seeing healthcare situations through the patients eyes, *be aware of personal beliefs and values in pain and pain management, *patients expectations influence outcomes

Quality & Safety Education for Nurses (QSEN)

QSEN: Quality and safety education for nurses strives to educate nurses on 6 areas:pt. centered care, teamwork and collaboration, evidence based practice, quality and improvement, safety, and informatics.Nurses need to remember and to value stopping and seeing things through the patients eyes. Patients are fathers, mothers, daughters, sons, brothers, sisters, uncles and aunts. They have lives, history, experiences and have seen things weve never seen. The hospital stay is but a stop along their journey. Care should be centered around them.

Narayanasamy and White (2004) introduced the ACCESS model in England to address cultural competence in 2002. A- Assessment: focus on cultural aspects of clients lifestyleC- Communication: be aware of variations in verbal and non-verbal responsesC- Cultural negotiation and compromise: become more aware of aspects of other peoples culture as well as understanding of clients view and explain their problems.E- Establishing respect and rapport: A therapeutic relation which portrays genuine respect for clients cultural beliefs and values is required.S-Sensitivity: Deliver diverse culturally sensitive care to culturally diverse groups.S- Safety: Enable clients to derive a sense of cultural safety (p. 109).

This is a model much like the QSEN but another way to stating it.

11Nursing Assessment AdaptationQuestions should be asked in an open-ended way

The Four Cs:1. What do you Call your problem? 2. What do you think caused the problem? 3. How do you cope with your condition? 4. What concerns do you have regarding the condition? (Galanti, 2008 p. 2-5)

With Patient centered care, we must first understand the patients views of his/her illness or even health.

The first question looks at the patients perception of the problem. What do you think is wrong? The same symptoms may have different meanings in different cultures. Nurses (and doctors) need to understand the patients point of view and in doing so can help avoid barriers to adherence to treatments and will improve overall relationships and thus, outcomes.

Second question: Cause of the problem: Not everyone believes that illnesses are caused by germs (Galanti, 2008, p. 4).Some cultures view illnesses as a form of punishment for sins or wrong-doings. Third C is Coping: This is getting to the what other treatments have you used? This gives the nurse (or doctor) the idea of what alternative healing methods have been used. The Fourth C: Concerns: This is searching out the patients perception of seriousness of the illness, potential fears to treatments or to the disease itself. Also, reviews patients self efficacy in handling treatment and long term prognosis.

References: Galanti, G.A. (2008). Caring for Patients from Different Cultures. Philadelphia, PA. University of Pennsylvania Press. 12Teamwork and Collaboration:Definition: Function effectively within nursing and intra-professional teams, fostering open communications, mutual respect, and shared decision-making to achieve quality patient care (QSEN, 2013)Knowledge: *Be aware of varying communication styles.Be aware of own knowledge and what you can contribute to the team. Identify barriers and facilitators of effective team.Skills: * Choose communication styles that diminish the risk associated with authority gradients among team members.Solicit input from other team members.Clarify roles and function within own scope of practice.Act with integrity consistently and respect differing views. Communicate effectivelyAttitudes: Respect othersValue others contributionsContribute to conflict resolutionAppreciate risks associated with handoffs among providers and across transitions in care.(QSEN, 2013)

QSEN continued

13Be aware of patients nonverbal communication.Avoid using positive and negative when giving test results. Avoid using yes or no questions. Ask open ended questions like: What questions do you have instead of do you have questions?.Remember the 4Cs questions discussed earlier. They will be most helpful. Use professionally trained interpreters whenever possible. IF they arent available, use the telephone interpreters. Avoid using family as interpreters (if possible). Avoid using gestures to communicate, they can mean other things in other cultures.Be aware of eye contact in each culture. Some cultures view this as aggressive behavior and some view lack of eye contact as a sign of respect. (Galanti, 2008).Communication Key Points

Cuing in on patients facial expressions can be key in knowing whether the patient is in pain, or if they understood instructions. Remember, the 4 C address the cause, how they cope, what the patient calls the problem, and concerns.

Smith (2013) points out that when patients feel disrespected, shamed or stereotyped that is when nursing care become unsafe and mistakes happen due to miscommunication. When nurses practice culturally competent care, then outcomes and the quality of care improve.

14The Nursing Standards that would be relevant to this subject:Standard 7: Quality of Practice. In this standard the nurse improves the quality of nursing practice by including patients and families in their healthcare needs and goals, then outcomes will improve.Standard 8: Education . The nurse grows in knowledge of the art and science of nursing by seeking new learning opportunities, engaging in ongoing continuing education and seeking out new experiences. Standard 11: Collaboration. In working with and collaborating with other members of the healthcare team; along with the patient and family, outcomes will improve. Nurses aide in referrals to other agencies for help such as home healthcare. Communicating with the patient and family will allow the patient to have control of their own life. Ultimately, the goal is to have the patient functioning in the best capacity that he/she can. Standard 12: Ethics. To give culturally competent care is being an ethical nurse.(ANA, 2004)Nursing Standards

Jehovahs Witness

Refusal of blood transfusionsDont celebrated birthdays or other holidaysCan be rejected by their religious community if they accept blood transfusion.Think of the role that Jehovah's Witness have played in bringing about bloodless surgeries. (Galanti, 2008)Religion and Spirituality

Religion and Spirituality is a longer chapter in Galantis (2008) book. Over the next slides, we will review some prominent religions. We will begin with Jehovah's Witness. The refusal of blood transfusions are based on three areas of the bible; Leviticus 17:10: Whatsoever maneateth any manner of blood; I willcut him off from among his people; Leviticus 17:11: For the life of the flesh is in the blood; and Acts 15:20: Abstain from things strangled and from blood (Galanti, 2008 p. 66). Their refusal of blood is based on scripture. Their belief is that 144, 000 people who are without sin/ blemish, will get to spend eternity with God in heaven. Those that are good, can spend eternity on Earths paradise and those with sin, will be cast into nothingness (Galanti, 2008).

With regard to the blood; parents have been known to abandon their children who were given blood under court order. (this is an extreme example, but it is their beliefs) The question that arises, do the parents have the right to make decisions for their children. People who have accepted blood have been banished from their religious community (Galanti, 2008).

Acts such as celebrating birthdays is seen as placing themselves higher than God, so it is not done. Saluting the American flag is seen as worshiping idols, so it is not done.

Some other Points about Jehovah's Witness: They do not believe in faith healing. Reading of scriptures can be of calming and be comforting to the sick person. No organ donations.

16Muslim:They follow a diet free of Pork and alcohol. They follow day time fasting during their religious holiday of Ramadan. Autopsies are permitted only for medical and legal issues; otherwise they do not allow.Burial: Cremation is not done. Bodies are washed by same sex person and burial is usually with in 24 hours.(Galanti, 2008).Religions continued

It is a custom that they eat with their right hand and use their left for toileting and hygiene. They pray 5 times a day facing Mecca. They do allow for circumcisions for the male children.

Avoid direct eye contact with the opposite sex to avoid any hint of sexual impropriety(Galanti, 2008,p. 238)

They do believe in the evil eye or jealousy and may wear amulets to ward off this evil eye (Galanti, 2008)

17Jewish:Sabbath starts at sundown on Friday and ends at sundown on Saturday. They do no work or anything that is perceived as work; cooking, making phone calls, or driving.End of life: when a person dies, it is custom that a family member remain with the body as a sign of respect. Orthodox Jewish will follow a Kosher diet; forbid eating pork, shell fish, and the mixing of meat and dairy products. Boys are circumcised on the eighth day of life. (Galanti, 2008)

Religions continued

During Sabbath, for most Orthodox Jews, it is forbidden to do any work; even using the call light. This will need to be taken into consideration when caring for them during Sabbath. Extra effort will need to be made to make sure the patient has what he or she needs; and nursing staff will have to do most of the work for them.

With regards to their diets: separate dishes should be used to not have meat and dairy products touch each other. (Galanti, 2008)

Bleeding times of the month for women; the men will not take anything from a womans hand while the woman is menstruating, or in labor. Usually, while the woman is in labor, the man may either stand in the corner with his back toward his wife praying, or he may be out of the room entirely. 18Roman Catholic:Some religious symbols used by Catholics to bring comfort and strength: Rosaries, Scapulars and Crucifixes and other Religious statues. Sacrament of the sick or the laying of hands. Most do not believe in birth control. They appose abortion of any kind. They do not believe in euthanasia. It is believed that life should end naturally when God chooses to take them.

Religions continued

Symbols of Faith such as the scapular, rosary, and statues bring great peace to those who believe that the Saint or the Mother Mary is there to help protect them or for Mary to ask her son, Jesus, to intercede on their behalf. Dont underestimate those symbols (Galanti, 2008).

Sacrament of the sick is a blessing to aide in healing. People are anointed with holy oils and prayed over for strength and fast recovery.

With regards to birth control; like any religion people are free to make choices. Catholics are no different. Some may be quite devout and follow the teachings quite strictly (and this is for any religion), however, not everyone agrees with every teaching in every religion. Some of it has to do with waverings in their own beliefs or questions they may have or teachings they just dont agree with .so with that in mind, some Catholic families may choose to have a tubal ligation or vasectomy or other forms of birth control (Galanti, 2008).Key Points to remember about Religions:Honor requests for, and be aware of need to have, same sex providers whenever possible.Provide clergy when asked. Provide privacy for prayers.Be respectful of others religious beliefs, even if they conflict with your own.Some eastern religions may not allow you to draw blood from them, as this would only weaken then further (in their belief system)Some eastern religions may not let you shave any part of their body for any reason for surgery (Galanti, 2008)(whole list can be found on page 78 in her book). 19Families!

How do you feel about family? How do you handle difficult families? This can be a very trying part of our jobs; to say the least.Most of the difficult family issues usually surround cultural differences. If a nurse simply sits and asks for clarification or how nursing can make their stay better, this would usually help tremendously!Families come in all shapes and sizes. We have the blended, adopted, friends considered as family, and traditional. There are the single parent: mom raising children, dad raising children or even grandparents raising the children.

20Key Points to remember with familiesMen are the decision makers in many cultures. Be aware that a patient may need or want to discuss decisions with the family before making a decision.There are many cultures who value interdependence and not independence. Be aware not to impose personal beliefs of independence on someone who does not wish to be so.In many cultures families will want to stay with the patient, please honor this as much as possible. Include family in care and treatments when appropriate.Ask the patient what they know of their condition, family members may be trying to protect a loved one from a bad prognosis or diagnosis. Show families that you care about their loved one.(Galanti, 2008)

Some simple tasks the family can do for the patient; such as massaging the hands or feet and helping comb their hair or maybe shaving can be small ways to help. Many families become difficult because they feel helpless. Remember, how would we feel if that was our loved one. By giving them small tasks, this may help make them feel part of the healing process and give them some control.

On admission, if possible, spend some time with the family too to answer questions. If possible, offer to meet with them daily for updates.

Including families in the discharge process on admission will be helpful. Itll be helpful to know if Grandma with the fractured hip has stairs at home or not; if she lives alone, who prepares her meals, etc.

The statement about asking what the patients know about their condition; in some Asian and African cultures, the family is told the diagnosis then the family tells the patient. In the African culture, this is to help ease the patients mental status in receiving bad news. In the Asian culture, family may opt to not inform the patient of the diagnosis. A husband for instance might withhold his own diagnosis to save his wife pain. 21Key Points to remember

Women as housewives and mothers: not every culture views independence the same as the US. In fact, in most, it is the womans job to be the housekeeper for their in-laws (such as Asian and Hispanic) Men make the decisions in many cultures. Men are the spokespersons and the authority figures in most cultures.Many cultures favor having sons. Male dominant cultures.Sexual segregation. Female genital cutting.

Roles of Men and Women

Women of other cultures:It is their job~ and they take great pride in their ability to care for the house and the children. Many cultures do the housekeeping for their in-laws. The sons (who are shown preferential treatment in many cultures) are the responsible parties when caring for aging parents; along with his wife. The daughters are married and care for their husbands parents.

Men making the decisions in other cultures is the normal! Many women will defer questions to their husband to answer and also defer the decision for medical treatment to them as well. Galanti (2008) tells several stories where women and the children are brought to the hospital after MVA and decline treatment (many that were needed immediately) until their husbands came. This is not uncommon. Even if they take pain medications might be up to the husbands. This might be mistaken for abuse in our culture and nurses need to make sure they are making that distinction.

As spokespersons and authority figures, nurses need to be aware that this isnt abuse, they see it as their duty. There are stories in the book (Galanti, 2008) that are used where the 27 y.o daughter was to have surgery; tumor removal with potential hysterectomy if needed. The father, the authority, said to remove the tumor but not the uterus. Even after explaining the possible need he still refused and the daughter said to abide by what he said. In their culture, she would never be able to marry if she were not able to produce children; no uterus, no children. To those from the US, it would be insulting to think of us as baby making machines, however, we must respect others cultures and allow others to exercise their rights to choose; in this case, the adult daughter chose to have her father make the decision (Galanit, 2008, story on pg 113-114).

Asian cultures especially value having sons over having daughters; as we hear on the news how baby girls are often left to die or are placed in orphanages. As sons care for their parents in those cultures, the parents value having sons. Daughters often are cast aside or tend to the brother.

Sexual segregation. Remember to accommodate having same sex care givers for Middle-eastern women and men. Male nurses for the men and female for the females. Sexual purity is highly valued and the males of the family will go to great lengths to secure and protect the females purity. Females should be cared for by females whenever possible; including by female physicians. In many cultures it is not acceptable to shake the hands of the opposite sex; like it is in our country/ culture. And it isnt just men coming into womens rooms or male physicians for female patients, it can be women caring for or touching the men. In the Buddhist's culture; Buddhist's priests cannot be touched by women at all. It is seen as tempting him and even a tensing of the muscles would be seen as a breaking of the vows and he would have to do penance (Galanti, 2008, story on pg. 63).

Discussed in another presentation, this is still practiced in parts of the world; even with all the publicity it has received. Mostly practiced in African cultures, it is seen as a girls passage to womenhood and also of her purity and virginity for her husband. There are few different procedures that can be done. One is the cutting of the tip of the clitoris (probably most common) then the extreme is the infibulation where the labia majora and minora are cut and sewn tightly. It can be a source of infection; both from the cutting and the inability to clean and empty the bladder if it is sewn too tight. Nurses and Physicians need to remember to keep their own feelings in control when dealing with these women. They are sensitive and should not be judged. This is a practice that many women of the African countries do not want to give up. They believe this is THE way to secure a good husband for their daughter and to ensure/ guarentee her purity to her husband (Galanti, 2008).

22Staff Relations Key Points to rememberNurses and DoctorsForeign-born physicians and other staff too, should be given American Culture classes as American Culture is different from their native country.American nurses use a team approach when caring for patients; this isnt so in other cultures. Doctors (men) have a higher status than nurses (women) in those cultures.Try to avoid giving assignments that might conflict with religious convictions (p.147)Keep the lines of communication open. Open-communication is essential.Remember if you speak other languages, if this is done in the work-place, it can be considered rude to other staff; they feel excluded. (Galanti, 2008).

Nurses and doctors in other countries have very different roles. Doctors in some other countries are the provider and the nurses do as the doctor says. Unlike in the US where independent nurses will question and sometimes refuse to follow orders the nurse deems unsafe or inappropriate and this will cause conflict with that physician. Physicians are at a much higher status in other cultures as well.

Nurses in other countries are only responsible for taking vital signs, giving medications and other technical things as the doctor orders; not giving emotional support, caring for physical needs like emptying bedpans or bathing; or do critical thinking at the bedside like in the US (Galanti, 2008).

Galanti (2008) recommends that foreign-born physicians be given a class on cultural diversity regarding American culture and nurses roles as well as nurse practice acts; when they come to practice in this country. By maintaining a culturally diverse workforce, this will comply with Standard 7 (Douglas et.al., 2011).

23Some Culture Profiles that can be helpful

Here are some tips given by Galanti (2008) in regards to varying cultures.I hope you find these helpful

24Discrimination and SlaveryReligion is very important. Be aware of giving privacy for prayer. Men are seen as the spokesperson for the family, but usually it is the woman who is really in charge.Visiting the sick is tradition; usually after church Sunday.There is a high tradition of the use of herbal remedies. Be aware of this when taking medication history.Some believe in voodoo and will seek voodoo practitioner for remedies for such illnesses of the GI tract or psychological disorders. (Galanti, 2008)

African American

Many African-Americans do not trust hospitals and doctors. The Tuskegee experiment with syphilis done in the 1950s where Black- men were not treated so that the symptoms of the disease could be studied. Because of the years of slavery, African-Americans can perceive unintended incidents as discriminatory. Be conscience of not using terms of gal or boy. Use respectful titles such Mr. or Mrs.

Most lower socioeconomic groups will be Present time oriented; thus they will not follow preventive medicine or follow up appointments. Explanation of medications and importance of adhering to diets need to be stressed and reiterated often.

25Middle and upper-class will often be well educated on their illness. Will use the internet to search for information.Independence and privacy are valued.Most will show emotional control; be stoic.Most husbands and wives will make decisions together. Usually will favor aggressive treatments to illness and will want to know diagnosis and prognosis.Stoicism is expected with dealing with death. Depending on socioeconomic status, patients will be either present time oriented (Lower) or future time oriented (middle to upper). (Galanti, 2008)

Anglo-Americans

As with any generalizations, be sure to understand that there will be variations to any generalization. Please make sure plans of care are individualized to reflect each patients beliefs, values, and desires..

26Value Family. Value sons. Is a hierarchical culture. Wives will let husbands make decisions. Tremendous respect for the elderly.Will agree with nurses or doctors, even if they do not understand or agree. Ask questions like what questions do you have instead of asking do you have questions.Are usually stoic with regards to pain. Offer pain medications when they might be needed and insist when appropriate.Believe in body hot/cold balance (or Ying-Yang).Herbal remedies are common. Be aware of this when taking medication history. The number 4 is seen as signifying death in the Korean, Japanese, and Chinese culture. (Galanti, 2008)Asian

Be aware that sons might be more valued than daughters. Family is very important in their lives, and most especially respect for the elderly.

Out of respect, Asian patients will not argue with doctors or nurses. They might not take information from female nurses, but be much more receptive to men/doctors giving the discharge teaching.

27Family oriented. Inquire about patients family. Are reluctant to discuss family issues outside of family.Sometimes the family might withhold fatal diagnosis from a patient for protection, upon admission ask family to whom information about condition should be given. Balance hot/cold foods. Might prefer to drink hot/warm fluids instead of iced.When complimenting a child, be sure to touch the child to avoid giving the child the evil eye. Being heavy (fat) is seen as healthy. Foods are high fat and salt. This will become an issue when dealing with diabetic patients.

Hispanic Culture

Pain, many will be expressive, but it has also been my experience that many are stoic as well. So, this will depend on personality and culture of the family. 28Male dominant culture.Might be loud and very expressive; especially at a death of a family member.Communication is seen as going both ways; if they share information, then you should as well.Psychological or emotional problems are dealt with within the family and may not be receptive to seeking outside help.Muslim is the dominant religion; but not the only religion within this group.Family will consider it an honor to care for elderly or ill family members. Both men and women care for family members just in different manners (Wehbe-Alamah, 2011). Middle-Eastern

As discussed in earlier slides, male dominant doesnt mean spousal abuse. Wives will often defer to husbands for decisions and as the spokesperson for her and her family.

In the Muslim religion, caring for others; community, animals, family, and the elderly is seen as an honor and to do Allahs will.Many will not make plans with regard to death or birth, these are events that are seen as in Allahs hands. To plan for these events is seen as challenging Allah (Wehbe-Alamah, 2011).

To not take care of yourself or others is not take care of Allah, so when a person is caring for oneself (no smoking, not being promiscuous, no drinking, fasting and observing prayers) then you are caring for Allah.

29Value family immensely.May be very stoic, especially with pain. Offer pain medication when appropriate. Patient may not say they are in pain, they may say that something isnt right. So be aware, they might not say anything again about it.Can expect long pauses when talking as the person is thinking on what to say. Might be quite expressive when a death occurs.Cutting of hair is done during times of mourning, so ask about cutting hair before doing it and ask if they want to keep the hair should it need to be cut.Traditional and western medicines are both used. Be aware of alternative healing practices that might be used.Native Americans

Another point to remember is that in the Navaho tribe, being loud is seen as a sign of aggressiveness.

Some might want to leave the window open at the time of death as to let the spirit be free to go.

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30References:American Nurses Association (2004) Nursings scope and standards of practice. Silver Spring, Maryland. Nursebooks.org.Clarke, P.N., McFarland, M.R., Andrews, M.M., Leininger, M. (2009). Caring: some reflections on the impact of the culture care theory by McFarland and Andrews and a conversation with Leininger Nursing Science Quarterly. 2009 22:233. doi.: 10.1177/089431409337020Douglas, M.K., Pierce, J.U., Rosenkoetter, M., Pacquiao, D., Callister, L.C., Hattar-Pollara,M., Lauderdale, J., Milstead, J., Nardi, D., Purnell, J., (2011). Standards of practice for culturally competent nursing care: 2011 update Journal of Transcultural Nursing. 2011 22:317Galanti, G.A. (2008). Caring for Patients from Different Cultures (4Ed.) Philadelphia, Pennsylvania. University of Pennsylvania. Michigan Census information retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml.Narayanasamy, A., and White, E. (2004) A review of transcultural nursing Nurse Education Today 2005 25,102-111.Nursing Theories; Transcultural Nursing retrieved from http://currentnursing.com/nursing_theory/transcultural_nursing_html on June 11, 2013. Site last updated on Jan. 26,2012.Nursing Theories: Roys Adaptation Model retrieved from http://currentnursing.com/nursing_theory/Roys_adaptation_model.html on June 11, 2013.Site last updated Jan. 26,2012.

References continued:

Smith, L.S., (2013). Research for cultural competence. Nursing 2013. Retrieved from Nursing2013.com on May 31, 2013..Quality & Safety Education for Nurses Competencies (2013). Retrieved from http://qsen.org/competenceis/prelicensure-lesas/ on June 15, 2013. Wehbe-Alamah, H. (2011). The use of culture care theory with Syrian Muslims in the mid-western United States The Online Journal of Cultural Competence in Nursing and Healthcare 1 (3).