A growing realization that the United States is not a “melting pot” in which immigrants assimilate into the mainstream culture, but a country of many cultures has led to a growing appreciation of different ethnocultural groups. As a result, many health care professionals are concerned with providing culturally sensitive patient education. However, it is a daunting task for nurses and other health care providers to become familiar with the cultural dynamics of all the various ethnocultural groups in the United States. Rather than taking on the virtually impossible task of learning about multiple cultures, it is more practical and helpful for nurses to use a generic approach in doing a cultural assessment.
Data obtained from a cultural assessment will help the patient and nurse to formulate a mutually acceptable, culturally responsive treatment plan. The basic premise of the cultural assessment is that patients have a right to their cultural beliefs, values, and practices, and that these factors should be understood, respected, and considered when giving culturally competent care. The first step in cultural assessment is to learn about the meaning of the illness of the patient in terms of the patient’s unique culture. Table 15 shows questions to ask during a cultural assessment.
|Questions to Ask During a Cultural Assessment|
By asking the patient and family these questions you can obtain valuable information needed for a teaching plan. It is important to remember that the patient’s personal interpretation of the illness experience is more significant than your view of the disease. Health care providers should teach from a position of mutual understanding and collaboration rather than trying to impose traditional Western medical practices that are unlikely to be effective.
The next step in cultural assessment is to determine how embedded the patient is in his or her traditional culture. Cultural embeddedness refers to how aligned the patient is with the native culture. The extent of the patient’s cultural embeddedness has a major influence on health care teaching. Table 16 shows some characteristics of cultural embeddedness.
|Characteristics of Cultural Embeddeness|
How recently the patient has immigrated to America, whether the immigration was voluntary or not, and whether the patient lived in intermediate countries are important to know. In general, the more recently the person has immigrated, the less acculturation will have occurred. If the person was forced to leave his or her native country and was detained in other countries, as has happened with many Southeast Asian immigrants, painful experiences may further delay acculturation. Many migrants from Haiti, El Salvador, and the Baltic States experienced physical and psychological terrorism in their own countries before migration. Such individuals often have had frequent moves or repeated changes before and after the migration-leading to physical and psychological rootlessness that can lead to physical manifestations of stress.
The nurse should also inquire about the process of immigration for the individual patient. For example, what country did the patient immigrate from and how different is the native culture from American culture? Does the patient associate with friends primarily or exclusively from his or her same ethnocultural group? Because moving to a new country and culture is stressful, it is common for newly arrived immigrants to associate only with people with whom they feel comfortable and secure-people who share their own native culture. It is important to remember than the greatest influences on reactions and responses to health care treatment and management may be very unfamiliar to nurses raised in the United States.
Frequently, when immigrants arrive in a new country, they live in an ethnically homogenous neighborhood with people from their same cultural group. Areas such as the Lower East Side of New York City are typical of immigrants to the United States. Within a generation, immigrants often move to other areas of a city. In the United States, it is possible for immigrants to remain in a community in which the native language is the primary language spoken and newspapers are in this language. A patient who is embedded in the original culture may not have much contact with the predominant cultural group and may present a greater challenge in patient teaching.
Does the patient have traditional dietary habits and wear traditional dress? Traditional dietary habits are often maintained for many generations, while traditional dress is usually given up sooner unless it is also closely associated with religious beliefs. For example, the dress of Muslim women represents their religious beliefs. Traditional dietary habits should be acknowledged, respected, and incorporated into patient teaching plans. Traditional dietary habits of native peoples are often healthier than U.S. eating habits because there is little use of processed foods or overuse of animal fats. In fact, modifying the patient’s native dietary pattern may make a disease like diabetes easier to manage than if the patient ate a typical U.S. diet.
Does the patient live exclusively within his own cultural neighborhood or does he venture out into the larger cultural American experience? Patients whose daily lives are spent within their own culturally defined neighborhoods are usually more culturally embedded than patients who leave the neighborhood are.
Does the patient use folk medicine or engage the services of a traditional healer? Is the patient from an urban or rural area in the country of origin? Immigration from a rural area is associated with less exposure to and knowledge about Western medical practices and the American health care system. This is especially true of rural immigrants from Asian, African, and South American countries.
Knowing the patient’s degree of cultural embeddedness helps the nurse to know where to start negotiating with the patient and his or her family to achieve health care goals. Patients who are highly embedded in the native culture are traditional individuals totally committed to their original cultures. People who are less embedded and more acculturated value open communication and ideas from both cultures. Bicultural individuals can move easily between both cultures.
The nurse may observe tension between acculturated children who want older members of the family to take advantage of Western medical practices and older members of the family who wish to follow traditional remedies. The challenge for the nurse in this situation is not to become involved in the transgenerational struggles, but to respect the two positions and allow opportunities for teaching that recognize the importance of both generations.2 The transgenerational impact of migration is illustrated in books such as The Joy Luck Club, The Kitchen God’s Wife, Rain of Gold, and Like Water for Chocolate.