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Clients vary according to age, gender, race, health status, education, religion, occupation,
and economic level. Culture, the focus of this chapter, is yet another characteristic that
contributes to client diversity. Nurses have always cared for clients with differences of some
sort. Despite cultural differences, the traditional tendency has been to treat clients as
though none exist. Although equal treatment may be politically correct, many nurses now
believe that ignoring differences contradicts the best interests of clients. Consequently
there is a movement toward eliminating acultural nursing care (care that avoids concern
for cultural differences) and promoting culturally sensitive nursing care (care that respects
and is compatible with each clients culture). This chapter provides information about
cultural concepts, cultural variations among different ethnic and racial groups, and
intercultural communication. Although components of culture are specific to a particular
group of people, individual clients within each cultural group may deviate from the
collective norm. Therefore, nurses are advised to always consider cultural needs from an
individuals perspective. Every human being is in some ways like all others, like some
others, and like no other (Andrews, 1999).

Culture (values, beliefs, and practices of a particular group; Giger & Davidhizar, 1999)
incorporates the attitudes and customs learned through socialization with others. It
includes, but is not limited to, language, communication style, traditions, religion, art, music,
dress, health beliefs, and health practices. A groups culture is passed from one generation
to the next. According to Smeltzer and Bare (2000), culture is (1) learned from birth; (2)
shared by members of a group; (3) influenced by environment, technology, and availability
of resources; and (4) dynamic and ever changing. Although the United States has been
described as a melting pot in which culturally diverse groups have become assimilated,
that is not the case. People from various cultural groups have settled, lived, and worked in
the United States while continuing to sustain their unique identities (Table 6-1).


Cultural groups tend to share biologic and physiologic similarities. Race (biologic variations)
is a term used to categorize people with genetically shared physical characteristics. Some
examples include skin color, eye shape, and hair texture. Despite wide ranges in physical
variations, skin color has traditionally been the chief, albeit imprecise, method for dividing
races into Mongoloid, Negroid, and Caucasian. Skin color is just one of a variety of inherited
traits. More importantly, nurses should not equate race with any particular cultural group.
To do so leads to two erroneous assumptions: (1) all people with common physical features
share the same culture and (2) all people with physical similarities have cultural values,

beliefs, and practices that differ from those of Anglo-Americans (U.S. Caucasians who trace
their ancestry to the United Kingdom and Western Europe).


The term minority is used when referring to groups of people who differ from the majority
in terms of cultural characteristics such as language, physical characteristics like skin color,
or both. Minority does not necessarily imply that there are fewer group members in
comparison with others in the society. Rather, it refers to the groups status in regard to
power and control. For example, men of European ancestry are the current majority in the
United States. Slightly more women than men are in the United States, yet women are
considered a minority. By the year 2020, the number of Latinos and Asian Americans living
in the United States is expected to triple, and the number of African Americans will double
(Andrews, 1999). Until these groups acquire more political and economic power in society,
they will continue to be classified as minorities.


Ethnicity (bond or kinship a person feels with his or her country of birth or place of ancestral
origin) may exist regardless of whether or not a person has ever lived outside the United
States. Pride in ones ethnicity is demonstrated by valuing certain physical characteristics,
giving children ethnic names, wearing unique items of clothing, appreciating folk music and
dance, and eating native dishes (Fig. 6-1). Because cultural characteristics and ethnic pride
represent the norm in a homogeneous group, they tend to go unnoticed. When two or more
cultural groups mix, however, as often happens at the borders of various countries or
through the process of immigration, unique differences become more obvious. One or both
groups may experience cultural shock (bewilderment over behavior that is culturally
atypical). Consequently many ethnic groups have been victimized as a result of bigotry
based on stereotypical assumptions and ethnocentrism.

Stereotypes (fixed attitudes about all people who share a common characteristic) develop
with regard to age, gender, race, sexual preference, or ethnicity. Because stereotypes are
preconceived ideas usually unsupported by facts, they tend to be neither real nor accurate.
In fact, they can be dangerous because they interfere with accepting others as unique
Generalization (supposition that a person shares cultural characteristics with others of a
similar background) is different than stereotyping. Stereotyping prevents seeing and

treating another person as unique, whereas generalizing suggests possible commonalities

that may or may not be individually valid. Assuming that all people who affiliate themselves
with a particular group behave alike or hold the same beliefs is always incorrect. Diversity
exists even within cultural groups. A generalization provides a springboard from which to
explore a persons individuality. For example, when a nurse is assigned to care for a
terminally ill client whose last name is Vasquez, the nurse may assume that the client is
Roman Catholic because Catholicism is the religion of most Latinos. Before contacting a
priest to assist with the clients spiritual needs, however, the nurse understands that the
generalization concerning religion may not be accurate. A culturally sensitive nurse strives
to obtain information that confirms or contradicts the original generalization.


Ethnocentrism (belief that ones own ethnicity is superior to all others) also interferes with
intercultural relationships. Ethnocentrism is manifested by treating anyone different as
deviant and undesirable. This form of cultural intolerance was the basis for the Holocaust
during which the Nazis attempted to carry out genocide, the planned extinction of an entire
ethnic group (in this case European Jews). Ethnocentrism continues to play a role in the
ethnic rivalries between Bosnians and Serbs in Eastern Europe, Arabs and Jews in the Middle
East, Tutsis and Huntas in West Africa, and other regions where culturally diverse groups
live in close proximity. Similar conflicts also occur among U.S. ethnic groups.


The U.S. culture can be described as Anglicized, or English-based, because it evolved
primarily from its early English settlers. Box 6-1 provides an overview of some common
characteristics of U.S. culture. To suggest that everyone who lives in the United States
embraces the totality of its culture, however, would be foolhardy. Although it is a gross
oversimplification, four major subcultures (unique cultural groups that coexist within the
dominant culture) exist in the United States. In addition to Anglo-Americans, there are
African Americans, Latinos, Asian Americans, and Native Americans (Table 6-2). The term
African Americans (those whose ancestral origin is Africa) is used here instead of Black
Americans to avoid any association based only on skin color. Latinos (those who trace their
ethnic origin to Latin or South America) are sometimes referred to as Hispanics, a term
coined by the U.S. Census Bureau, or Chicanos when speaking of people from Mexico.
Asian Americans (those who come from China, Japan, Korea, the Philippines, Thailand,
Cambodia, Laos, and Vietnam) make up the third subculture. Native Americans (Indian
nations found in North America including the Eskimos and Aleuts) include approximately 2.3
million American Indians and Alaskan Natives belonging to 545 federally recognized tribes in
the United States (U.S. National Library of Medicine, 1999). Although Anglo-American
culture predominates in the United States, those of African, Asian, Hispanic, and Arabic
descent outnumber those who trace their ancestry to the United Kingdom and Western
Europe. As the population becomes more diverse, the need for transcultural nursing is
becoming increasingly urgent.

BOX 6-1 Examples of U.S. Cultural Characteristics
a. English is the language of communication.
b. The pronunciation or meaning of some words varies according to regions within the United States.
c. The customary greeting is a handshake.
d. A distance of 4 to 12 feet is customary when interacting with strangers or doing business (Giger and Davidhizar,
e. In casual situations, it is acceptable for women as well as men to wear pants; blue jeans are a common mode of
f. Most Americans are Christians.
g. Sunday is recognized as the Sabbath.
h. Government is expected to remain separate from religion.
i. Guilt or innocence for alleged crimes is decided by a jury of ones peers.
j. Selection of a marriage partner is an individuals choice.
k. Legally, men and women are equals.
l. Marriage is monogamous (only one spouse); fidelity is expected.
m. Divorce and subsequent remarriages are common.
n. Parents are responsible for their minor children.
o. Aging adults live separately from their children.
p. Status is related to occupation, wealth, and education.
q. Common beliefs are that everyone has the potential for success and that hard work leads to prosperity.
r. Daily bathing and use of a deodorant are standard hygiene practices.
s. Anglo-American women shave the hair from their legs and underarms; most men shave their faces daily.
t. Licensed practitioners provide health care.
u. Drugs and surgery are the traditional forms of medical treatment.
v. Americans tend to value technology and equate it with quality.
w. As a whole, Americans are time oriented and, therefore, rigidly schedule their activities according to clock hours.
x. Forks, knives, and spoons are used, except when eating fast foods, for which the fingers are appropriate.


Madeline Leininger coined the term transcultural nursing (providing nursing care within the
context of anothers culture) in the 1970s. Aspects of transcultural nursing include the
Assessments of a cultural nature
Acceptance of each client as an individual
Knowledge of health problems that affect particular cultural groups
Planning of care within the clients health belief system to achieve the best health
To provide culturally sensitive care, nurses must become skilled at managing language
differences, understanding biologic and physiologic variations, promoting health teaching
that will reduce prevalent diseases, and respecting alternative health beliefs or health

Cultural Assessment
To provide culturally sensitive care, the nurse strives to gather data about the unique
characteristics of clients.
Pertinent data include the following:

Language and communication style

Hygiene practices including feelings about modesty and accepting help from others
Special clothing or ornamentation
Religion and religious practices
Rituals surrounding birth, passage from adolescence to adulthood, illness, and death
Family and gender roles including child-rearing practices and kinship with older adults
Proper forms of greeting and showing respect
Food habits and dietary restrictions
Methods for making decisions
Health beliefs and medical practices
Assessment of these areas is likely to reveal many differences. Examples of variations
include language and communication, eye contact, space and distance, touch, emotional
expressions, dietary customs and restrictions, time, and beliefs about the cause of illness.

Language and Communication

Because language is the primary way to share and gather information, the inability to
communicate is one of the biggest deterrents to providing culturally sensitive care. Foreign
travelers and many residents in the United States do not speak English or they have learned
it as their second language and do not speak it well. Estimates are that 13.8% of those who
live in the United States speak a language other than English at home (Perkins et al., 1998).
Those who can communicate in English may still prefer to use their primary language
especially under stress.

Federal law, specifically Title IV of the Civil Rights Act of 1994, states that people with
limited English proficiency are entitled to the same health care and social services as those
who speak English fluently. In other words, all clients have a right to unencumbered
communication with a health provider. Using children as interpreters or requiring clients to
provide their own interpreters is a civil rights violation. The Joint Commission on
Accreditation of Healthcare Organizations requires that hospitals have a way to provide
effective communication for each client. The use of untrained interpreters, volunteers, or
family is considered inappropriate because it undermines confidentiality and privacy. It also
violates family roles and boundaries. It increases the potential for modifying, condensing,
omitting, or adding information or projecting the interpreters own values during
communication between client and health care provider. To comply with the laws and
accreditation requirements, health care agencies are strongly encouraged to train
professional interpreters. A competent trained interpreter demonstrates the skills listed in
Box 6-2.


BOX 6-2 Characteristics of a Skilled Interpreter


Learns the goals of the interaction

Demonstrates courtesy and respect for the client
Explains his/her role to the client
Positions himself/herself to avoid disrupting direct communication between the health care worker and client
Has a good memory for what is said
Converts the information in one language accurately into the other without commenting on the content
Possesses knowledge of medical terminology and vocabulary
Attempts to preserve the emphasis and emotions that both people express
Asks for clarification if verbalizations from either party are unclear
Indicates instances where a cultural difference has the potential to impair communication
k. Maintains confidentiality

If the nurse is not bilingual (able to speak a second language), he or she must use an
alternative method for communicating. See Nursing Guidelines 6-1 for more information.
Understanding some unique cultural characteristics involving aspects of communication may
ease the transition toward culturally sensitive care. It is helpful to be aware of general
communication patterns among the major U.S. subcultures. Native Americans tend to be
private and may hesitate to share personal information with strangers. They may interpret
questioning as prying or meddling. The nurse should be patient when awaiting an answer and
listen carefully because people of this culture may consider impatience disrespectful (Lipson,
Dibble & Minarik, 1996). Navajos, currently the largest tribe of Native Americans, believe
that no person has the right to speak for another and may refuse to comment on a family
members health problems. Because Native Americans traditionally preserved their heritage
through oral rather than written history, they may be skeptical of Anglo-American nurses
who write down what they say. If possible, the nurse should write notes after, rather than
during, the interview.


African Americans have good reason to mistrust the medical establishment, because they
have been uninformed subjects in past research projects and have sometimes been treated
as second-class citizens when seeking health care. The nurse must demonstrate
professionalism by addressing clients by their last names and introducing himself or herself.
He or she should follow up thoroughly with requests, respect the clients privacy, and ask
openended rather than direct questions until trust has been established. Because of their
experiences as victims of discrimination, African Americans may hesitate to give any more
information than what is asked. Latinos are characteristically comfortable sitting close to
interviewers and letting interactions unfold slowly. Many Latinos speak English but still have
difficulty with medical terminology. They may be embarrassed to ask the interviewer to
speak slowly, so the nurse must provide information and ask questions carefully. Latino men
generally are protective and authoritarian regarding women and children. They expect to be
consulted in decisions concerning family members. Asian Americans tend to respond with
brief or more factual answers and little elaboration, perhaps because traditionally they
value simplicity, meditation, and introspection. Asian Americans may not openly disagree

with authority figures, such as physicians and nurses, because of their respect for harmony.
Such reticence can conceal disagreement or potential noncompliance with a particular
therapeutic regimen that is unacceptable from their perspective.


Eye Contact

Anglo-Americans generally make and maintain eye contact throughout communication.

Although it may be nat-ural for Anglo-Americans to look directly at a person while speaking,
that is not always true of people from other cultures. It may offend Asian Americans or
Native Americans who are likely to believe that lingering eye contact is an invasion of
privacy or a sign of disrespect. Arabs may misinterpret direct eye contact as sexually
Space and Distance

Providing personal care and performing nursing procedures often reduce personal space,
which causes discomfort for some cultural groups. For example, Asian Americans may feel
more comfortable with the nurse at more than an arms length away. The physical closeness
of a nurse in an effort to provide comfort and support may threaten clients from other
cultures. It is best, therefore, to provide explanations when close contact during procedures
and personal care is necessary.


Some Native Americans may interpret the Anglo-American custom of a strong handshake as
offensive. They may be more comfortable with just a light passing of the hands. People from
Southeast Asia consider the head to be a sacred body part that only close relatives can
touch. Nurses and other health care workers should ask permission before touching this
area. Southeast Asians also believe that the area between a females waist and knees is
particularly private and should not be touched by any other male than the womans
husband. Before doing so, a male nurse can relieve the clients anxiety by offering an
explanation, requesting permission, and allowing the clients husband to stay in the room.
Emotional Expression

Anglo-Americans, in general, freely express their positive and negative feelings. Asian
Americans, however, tend to control their emotions and expressions of physical discomfort
(Zborowski, 1952, 1969) especially among unfamiliar people. Similarly, Latino men may not
demonstrate their feelings or readily discuss their symptoms because they may interpret
doing so as less than manly (Andrews & Boyle, 2003). The Latino cultural response can be
attributed to machismo, a belief that virile men are physically strong and must deal with
emotions privately. Because this behavior is atypical from an Anglo-American perspective,
nurses may overlook the emotional and physical needs of people from these cultural


a. Greet or say words and phrases in the clients

language, even if carrying on a conversation is
impossible. Using familiar words indicates a
desire to communicate with th1e client even if the
nurse lacks the expertise to do so extensively.
b. Use Web sites with the client that translate
English to several foreign languages and vice
and A computer with
Internet access provides sites with easy-to-use,
rapid, free translations of up to 150 words at a
c. Refer to an English/foreign language dictionary or
use appendices in references such as Tabers
Cyclopedic Medical Dictionary. Some dictionaries
provide medical words and phrases that may
provide pertinent information.
d. Compile a loose-leaf folder or file cards of
medical words in one or more languages spoken
by clients in the community. Place it with other
reference books on the nursing unit. A
homemade reference provides a readily available
language resource for communicating with others
in the local area.
e. Request a trained interpreter. If that option is
impossible, call ethnic organizations or church
pastors to obtain a list of people who speak the
clients language and may be willing to act as
emergency translators. Someone proficient at
speaking the language is more effective in
obtaining necessary information and explaining
proposed treatments than is someone relying on
a rough translation.
f. Contact an international telephone operator in a
crisis, if there is no other option for
communicating with a client. International
telephone operators are generally available 24
hours a day; however, their main responsibility is
the job for which they were hired.
g. When several interpreters are available, select
one who is the same gender and approximately
the same age as the client. Some clients are
embarrassed relating personal information to
people with whom they have little in common.
h. Look at the client, not the interpreter, when
asking questions and listening for responses. Eye


i. If the client speaks some English, speak slowly,

loudly, using simple words and short sentences. Leng
or complex sentences are barriers when communicat
with someone not skilled in a second language.

j. Avoid using technical terms, slang, or phrases wit

double or colloquia vernacular, especially if he or
learned English from a textbook rather t
conversationally. cAsk questions that can be answered
a yes or no. Direct questions avoid the need to prov
elaborate responses in English. If the client appe
confused by a question, repeat it without changing
words. Rephrasing tends to compound confusion beca
it forces the client to translate yet another group
unfamiliar words.

k. Give the client sufficient time to respond. The process

interpreting what has been said in English and t
converting the response from the native language b
to English requires extra time.

l. Use nonverbal communication or pantomime. B

language is universal and tends to be communicated a
interpreted quite accurately.
m. Be patient. Anxiety is communicated interpersonally
tends to heighten frustration.

n. Show the client written English words. Some non-Engl

speaking people can read English better than they
understand it spoken.

O. Work with the health agencys records committee

obtain consent forms, authorization for health insura
benefits, and copies of clients rights written in langua
other than English. Legally, clients must understand w
they are consenting to.

p. Develop or obtain foreign translations describing comm

procedures, routine care, and health promotion. O
resource is the Patient Education Resource Center in
Francisco, which provides publications in m
languages on numerous health topics. All clients
entitled to explanations and educational services.

contact indicates that the client is the primary

focus of the interaction and helps the nurse to
interpret nonverbal clues.


Dietary Customs and Restrictions
Basically food is a means of survival: it relieves hunger, promotes health, and prevents
disease. Eating also has social meanings that relate to communal togetherness, celebration,
reward and punishment, and relief of stress. Culture dictates the types of food and how
frequently a person eats, the types of utensils used, and the status of individuals such as who
eats first and who gets the most. Religious practices within some cultures impose certain
rules and restrictions such as times for fasting and foods that can and cannot be consumed
(Table 6-3). Nurses can jeopardize the compliance of clients with a therapeutic diet for
medical disorders if dietary teaching disregards cultural and religious food preferences.
Throughout the world, people view clock time and social time differently (Giger &
Davidhizar, 1999). Calendars and clocks define clock time, dividing it into years, months,
weeks, days, hours, minutes, and seconds. Social time reflects attitudes concerning
punctuality that vary among cultures. Punctuality is often less important to people from other
cultures than it is to Anglo-Americans. Tolerating and accommodating cultural differences
related to time facilitates culturally sensitive care.
Beliefs Concerning Illness
Generally people embrace one of three cultural views to explain illness or disease. The
biomedical or scientific perspective is shared by those from developed countries who base
their beliefs about health and disease on research findings. An example of a scientific
perspective is that microorganisms cause infectious diseases, and frequent handwashing
reduces the potential for infection. The naturalistic or holistic perspective espouses that
humans and nature must be in balance or harmony to remain healthy; illness is an outcome of
disharmony. Native Americans share this view. Another example is Asian Americans who
uphold the Yin/Yang theory, which refers to the belief that balanced forces promote health.
Latinos embrace a similar concept referred to as the hot/
cold theory. It implies that illness is an imbalance between components ascribed as having
hot or cold attributes.
Adding or subtracting heat or cold to restore balance also can restore health. Lastly there is
the magico-religious perspective in which there is a cultural belief that supernatural forces
contribute to disease or health. Some examples of the magico-religious perspective include
cultural groups that accept faith healing or who practice forms of witchcraft or voodoo.
Although nurses may disagree with a clients beliefs concerning the cause of health or
illness, respect for the person who believes them helps to achieve healthcare goals.
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