NCLEX: Cultural Practices Influencing Nursing Care

Terms you’ll need to understand:
Culture
Ethnicity
Heritage
Religion
Time orientation
Tradition
Value

Nursing skills you’ll need to master:
Knowing differing cultural and religious beliefs and how these affect response to disease, treatment of diseases, childbearing, death, and dying
Knowing and applying principles learned in nursing school to facilitate communication with those who do not speak English

Cultural Diversity and Its Effect on Healthcare
Cultural practices and beliefs are passed down from generation to generation. The United States has always been a melting pot of varying cultural groups. Today more than ever, nurses must be aware of traditional medicine practices and cultural beliefs that influence healthcare. Migration trends indicate that one in three Americans is an ethnic minority. The NCLEX® Exam has changed to reflect these differences in client populations. This guide explores cultural differences including environmental, social, religious, communication, space, and time differences among varying populations. We cover these differences as they affect healthcare practices and discuss how you as a nurse can utilize knowledge of these beliefs in nursing practice.

Cultural Assessment
The nurse must be able to assess the client for differences in beliefs and utilize the knowledge gained to plan care for the client. It is critical that you know about your client’s beliefs to effectively treat him and not engage in acts that might be considered offensive to him.

Understanding Client Beliefs

As you assess the cultural background and beliefs of your client, you should remember that beliefs can be considered beneficial, neutral, or maladaptive. An example of a beneficial belief, or one that is helpful to the nurse, in planning care for the client would be a Hispanic client who believes in the use of garlic with his antihypertensive medication to lower blood pressure. Because garlic has been linked to lowering cholesterol and triglyceride levels, this is beneficial. If, however, he refuses his blood pressure medication and uses only the garlic, this would be considered a maladaptive consideration. A neutral consideration is one that is neither helpful nor harmful to the client.
Folk medicine is used by many groups. It involves the use of nonprofessional healthcare providers such as medicine men and midwives. These practitioners often use remedies that are not found in the local pharmacy. Herbs and potions are often used to treat fevers, pain, and upset stomach.

Working with Clients Who Speak Different Languages
The nurse might not be able to speak the language of the client he is trying to help. For this reason, it is useful to be able to use other techniques to communicate during teaching sessions. The following are 10 tips to use if you do not speak the client’s language:
1. Sit down next to the client. Regardless of language differences, the client will understand a calm, caring tone in your voice.
2. Respect the client’s personal space and watch her body language for cues that you are getting too close or touching her inappropriately.
3. If a client is from a different culture from your own, don’t treat her dif- ferently from other clients because she does not speak English. Do not talk to her as if she were deaf. Speaking loudly will not help her understand you.
4. Use an interpreter when one is available. Many hospitals have individu- als employed in other areas of the hospital who can help with translation. Investigate these possibilities before the client arrives for the visit.
5. Explain medical and nursing terms simply and clearly. Ask the client to demonstrate when possible. Remember that demonstration is the best indicator that the client understands your teaching.
6. Involve the extended family when possible. In most cultures, family is an important part of the client’s healthcare.
7. Be careful not to offend members of the family by asking them to per- form duties that are not allowed or preferred in their culture. For example, in Hispanic culture, the father might not want to bathe his child. When you are unsure, always ask—and do not assume.
8. Be careful if you do not have a thorough knowledge of the language. Many words have an entirely different meaning when pronounced incorrectly.
9. Use the title Mr. or Mrs. unless you know the person well. Not using these titles is often seen as disrespectful.
10. Do not assume that the client is angry if she speaks more loudly. Do not assume that the client is disinterested if she does not make eye contact.

Healthcare of Hispanics/Latinos
The fastest growing minority in the United States is the Hispanic/Latino population. Some Hispanic people believe that disease is caused by an imbalance in hot and cold. They also believe that health is maintained by preventing exposure to extreme temperatures. A 'hot' disease is treated with a 'cold' remedy.
Some examples of 'hot' conditions are diabetes, hypertension, pregnancy, and indigestion. These problems are treated with cold compresses and cold liquids.
Some examples of 'cold' conditions are menstrual cramps, colic, and pneumonia. These problems should be treated with hot liquids such as broths, hot tea, or hot coffee. Warm baths can also help relieve these conditions.
Hispanics/Latinos use herbals to treat most illnesses and maintain health.
Examples of the use of herbals are garlic to treat hypertension and cough; chamomile to treat nausea and anxiety; and a laxative tea combined with stomach massage to cure anorexia, stomach pains, or diarrhea. Peppermint is also used to treat dyspepsia. Manzanilla is another herb used as a tea to treat stomach and intestinal pain, and anise (a star-shaped seed) is used to treat nausea and colic and to increase breast milk.
A healer is often used to provide herbal remedies or to delivery babies. These santero/santera are well-respected in the community and should be considered as part of the health team. Several differences exist between the modern American healthcare provider and the traditional healer that you should be aware of.

A Comparison of Hispanic/Latino Traditional Healers to Modern Medicine Traditional Healers:


The 'evil eye' (mal de ojo) is thought to cause fever, crying, and vomiting in the infant. It is believed to be brought on by a person with a strong eye who looks at the baby in an admiring manner. The treatment for the evil eye is to sweep the body with eggs, lemons, and bay leaves.
Susto, or fright sickness, is brought on by an emotional trauma. Any traumatic event can bring on a susto. The result is a fever, vomiting, or diarrhea.
The treatment involves brushing the body with ruda, a rough object, for nine consecutive nights.
Bilis is a disease of the intestinal tract brought on by anger. If untreated, bilis can cause acute nervous tension and chronic illness.
Empacho is a disease that can affect children. It is caused by food particles being trapped in the intestine. To manage this illness, the client lies face down with his back bare. The healer pinches a piece of skin at the waist, listening for a snap as the skin is released. This is repeated several times to dislodge the material. Prayer should accompany these rituals. Many Puerto Rican parents believe that an amulet pinned to the baby’s shirt will protect her from evil. Jabon de la mano milagrosa is a soap used by a miracle man to clean and protect a person from evil spirits. Many also believe that candles should be burned to ward off evil spirits. The nurse should consider the strong religious beliefs of many in the Hispanic culture. Often a priest is the spiritual advisor and should be notified in the case of birth, illness, or death.

Time Considerations
The Hispanic population often views time differently from Americans. Time is viewed in generalities, so the nurse must be aware that the client might view time as present, past, or future. This difference can also affect the teaching plan. If the nurse tells the client to take the medication two times per day, the client might not understand the need to take the medication every 12 hours.

Use of Nonverbal/Verbal Communication
Most Hispanics speak Spanish or a dialect of Spanish as their primary language. They also might speak English. It is an untrue assumption that, if the client does not speak English, he is less intelligent. Many drug companies now provide written material in both Spanish and English. The nurse should use a translator when needed and should allow time for the client to respond to teaching. Eye contact is often avoided out of respect. The nurse should not assume that the client is disinterested or bored if he avoids eye contact.
A handshake is often used to communicate agreement or understanding.

Intimate zones are reserved for family and close friends. A distance of 1 1/2'–4' should be reserved for personal distance, and a distance of 4'–12' should be observed for social distance. The nurse should respect this spatial territory when providing healthcare.

Childbirth and Pain Response
It is very important for the nurse to be aware that the Hispanic client might not complain of pain. Watching the client’s nonverbal cues will help to prevent complications. During labor, the woman might remain stoic. She will often not ask for pain medication until late in the labor process, if at all.
Female relatives are often present for the birth of the infant.
Hispanic women might go into a 40-day period of rest after the birth of the infant. During this time the woman is placed on a regimen of dietary and restricted activity. An abdominal binder might be used to prevent air from entering the uterus and to promote healing. Filipino and Pacific Islanders might also perform this practice. Many in the Hispanic culture practice baptism of the infant by sprinkling. These clients do not believe that colostrums is good for the infant, so the nurse should consult with the mother and father before placing the baby to the breast in the delivery room. Modesty must be maintained during breast feeding.

Native Americans and Alaskan Natives
Native Americans are considered those whose ancestors inhabited North America and Alaska. There are 170 North American tribes, and Eskimos are also included in this group.
Native Americans believe in the need to be one with nature and hold in reverence animals such as the eagle, buffalo, and deer. This group, like the Hispanic population, uses medicine men. In the Native American culture this person is called a shaman. Native Americans believe that evil spirits and devils are responsible for illness, so masks are worn to hide from the devil. A. amulet called a thunderbird is worn for good luck and protection. Navajo medicine men are often called on to use sand painting to diagnose ailments.
Some Native Americans conduct sacred ceremonies that rely on having visions and using plants and objects that symbolize the individual or the illness that is being treated. Chanting, prayer, and dancing are also used to treat illness and drive off the evil spirits. Sweat lodges are used by some groups to help in the treatment of fever. Herbals, corn meal, and medicine bundles are used in the Indian population to treat most illness.
Although herbals are used, most Native Americans will take medications prescribed by the physician. Decisions regarding healthcare should be directed at the male members of the family.

Time Considerations
Most Native Americans and Alaskan Natives are relaxed in their view of time and view life in the present. An appointment time for a clinic visit might be ignored or the client might arrive late. The nurse should consider this factor when making clinic appointments.

Use of Nonverbal/Verbal Communication
Many Native American Indians and Native Alaskans speak English as their primary language. However, some still speak the native language of their forefathers, especially when communicating with one another. The nurse might have difficulty understanding the native language because several dialects exist. The nurse might have problems understanding the client because he will probably speak in a low tone. These clients expect the listener to be very attentive during the discussion. Eye contact often is considered disrespectful.

Childbirth and Pain Response
Native Americans tend to be very quiet. The nurse must be aware of nonverbal cues that indicate understanding of teaching. Some nonverbal clues are nodding positively or negatively or the client complying with the nurse’s request. The client might be in a great deal of pain before the nurse realizes that she needs medication.

The family is extremely important to the well-being of the client during childbirth; the extended family typically attends the birth. Use of village women to assist with childbirth is also a part of their culture. Women might not complain of pain during the labor and birth. In the Navajo Indian culture, the umbilical cord in given to the family after the birth of the child to be buried near a tree so the child will grow strong and wise.

Asian-Americans
Asian Americans have come to the United States from more than 20 countries and speak more than 100 languages. Since 1965, their population in the United States has grown from 1 million to more than 10.9 million. The nurse dealing with this large minority must consider the variations in healthcare beliefs to promote the well-being of the client and family.
Asian medicine includes therapies such as acupuncture, acupressure, herbals, and dietary supplements. Clients might be reluctant to use herbals because they fear that Western doctors or nurses will disapprove of traditional remedies. Asian clients often believe in the yin (cold) and yang (hot) theory. They believe that illness is caused by a disruption in this environment. 'Hot' foods include beef, chicken, eggs, fried foods, red foods, and foods served hot.
'Cold' foods include pork, most vegetables, boiled foods, foods served cold, and white foods. Noodles and soft rice are considered neither cold nor hot.

To maintain fluid balance, Chinese Americans prefer hot tea to ice water.
Some Chinese believe that illness is a result of moral retribution by the gods and rituals must be performed to satisfy the gods and restore balance. A poor combination of the stars with the birth order can also lead to disharmony.
Some Cambodians practice cupping, pinching, coining, or rubbing an ill person’s skin to treat illnesses. Usually the forehead or abdomen is used, depending on the type and location of the illness. With the practice of cupping, a hot cup is placed on the skin. As it cools, the cup contracts and the skin is pulled into the cup, leaving a circular mark or blister on the skin. It is believed that this practice draws the evil spirit into the cup. Pinching is the practice of pinching the skin between the thumb and index finger to the point of producing a contusion on the chest, on the neck, on the back, at the base of the nose, or between the eyes. Coining is the rubbing of the skin with the side of a coin, causing bruising. The nurse should be careful not to assume child abuse if she witnesses this practice. However, teaching regarding the dangers to the infant should be included in the plan of care.

If the client is Hindu, Sikh, or Buddhist he might have beliefs that affect medical treatment. Hinduism accepts modern medicine but believes that illness is caused by past sins. Because life and death are part of an unending cycle, efforts to prolong life are discouraged and CPR might be forbidden.
Sikhism clients might accept healthcare but refuse certain aspects of treatment. Female clients often refuse being examined by a male, and removing the undergarments might be very traumatic for the client.
Buddhist clients will probably refuse treatment on holy days. They believe that spirits invading the body cause illness and will ask for a priest in times of birth and death. They also believe body should pass into eternity whole, which forbids organ donation and performance of an autopsy. When death is imminent the priest is called. He will tie a thread around the neck or wrist to ensure that the person will pass into eternity in peace—the nurse should not remove this string. The priest will then pour water in the client’s mouth and place the dying client on the floor. After death, the family washes the body before cremation. Some Buddhists might refuse to move the body because they believe that it takes time for the spirit to leave. In the Shinto religion, the body is wrapped in a white kimono and straw shoes are applied. Because reincarnation is a primary belief of this group, insulin produced from beef or materials containing gelatin are forbidden.

Time Considerations
Asian-Americans live in the present. Many of them believe in reincarnation and that, if they die, they go immediately to paradise. For this reason the nurse might encounter difficulty in teaching regarding preventive care.
Literature should be given to the client in his own language when available. Many hospitals and healthcare facilities provide interpreters when needed.

Use of Nonverbal/Verbal Communication
Direct eye contact is considered a sign of disrespect. The nurse should be aware of this difference in communication and should not consider a lack of eye contact as a sign of a lack of interest or difficulty hearing. The client might nod as a sign of compliance or understanding and respect. Shaking hands with a person of the opposite sex is considered forward and inappropriate.

Childbirth and Pain Response
Asian clients will probably be stoic and not complain of pain until it becomes unbearable. Childbirth is a time of celebration for the Asian-American family. The extended family is present and usually takes the infant after delivery, especially if the mother has had a Cesarean section. This allows the mother to rest and recover. This time is considered a 'hot' time.
After the birth, the postpartum period is considered a 'cold' time because the uterus is more open. The client might therefore refuse to shower or do peri-care in the traditional American manner; however, she might allow a heat lamp to be used to improve healing. The postpartal period is much longer in most Asian cultures: A length of 30–40 days is thought to provide time for healing. The family stays close during this time to provide emotional and physical support.
Most Chinese prefer to give birth side-lying because this position is thought to be less traumatic to the infant. Many in the Hindu religion believe that placing honey in the mouth of the infant ensures a sweet life. However, this practice is discouraged by healthcare providers in the United States because honey can carry botulism. Many in the Chinese culture believe that colostrum is not good for the baby. The mother is often given hot rice water to drink to restore the balance between the body and nature.

Arab-Americans
The term Arab is associated with people from a region of the Middle East extending from Northern Africa to the Arabian Gulf. The large majority of Arabs are members of the Islamic (Muslim) religion. Their cultural and religious beliefs direct most of their beliefs regarding healthcare. Prayer and fasting are a major part of the Muslim client’s day. Nurses should be willing to accommodate the client’s desire to pray, and the bed should be positioned facing toward Mecca. So, if the client is in the United States, the bed should face southeast. A sick client who is unable to fully kneel and touch his head to the floor might be allowed by his religious leaders to sit up while praying.
During Ramadan, Muslims must fast from sunrise to sunset. If the client has a life-threatening condition, accommodations can be made, but this fasting does pertain to IV therapy and most injections.
Cleanliness is very important to the Arab-American client. The left hand is used for toileting; therefore, the client will avoid using the left hand to eat or touch others. Food should be kept clean and free of odors. Because alcohol is forbidden, medications and liquids containing alcohol should be avoided.

Most Arab-Americans prefer to be treated by a healthcare worker of the same sex. When prescribing medications, pills and injections are preferred— suppositories should be avoided if possible.
In some countries, secluding women from men and restricting movement outside the home is practiced. Covering of the women in public is practiced and abuse is allowed.
The dying client must confess his sins to be taken to heaven. The body is washed and wrapped in a white cloth and the head is turned to the right shoulder. The body of the client who has died should be positioned facing east. A prayer called a Kalima is said.

Time Considerations
Arab-Americans live in the present, so many do not plan for retirement or save for future needs. Preventive medicine is a concept that is difficult for them to understand. This group, like many others, might be less aware of appointment times. Scheduling of office visits should allow for this cultural difference.

Use of Nonverbal/Verbal Communication

As with other cultures, nonverbal communication is used frequently in Arab cultures. Women are particularly prone to speaking softly and might not voice health concerns, especially to a male healthcare provider.

Childbirth and Pain Response
Response to pain differs with each individual. Some clients in this group will be stoic, but some might respond to pain by crying or moaning. It is generally believed that an injection of pain-killing medication works better than a pill. The nurse should assess changes in vital signs and other cues such as grimacing to be able to provide pain medication as needed. During childbirth, group prayer is used to strengthen the mother, and women assist the client during childbirth. At the time of birth, a prayer is said into the baby’s ear.
The mother is then secluded from the group for a period of time to allow for cleansing. Because blood is considered a pollutant, a ritual bath is performed before the woman can resume relations with her husband. In some African cultures, such as in Ghana and Sierra Leone, some women will not resume sexual relations with their husbands until after the baby is weaned.

Nursing Plan Dietary
Considerations Across Cultures
Dietary considerations play a part in the nursing plan of care for all cultural populations.

Dietary Practices of Various Cultural Groups

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Religious Beliefs and Refusal of Care Considerations
Various religious beliefs affect how the client is treated and can lead to a refusal of some traditional medicines. It is important for the nurse to understand these differences to assist the client with healthcare and teaching.

Religious Beliefs Affecting Healthcare and Death
Some religions, the treatments their practitioners might refuse, and how prayer plays a role in their medicinal views.

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