Cultural and Spiritual Health Beliefs

Question 1

Culture and Nursing (Cultural Competence)

Answer 1

• improves pt satisfaction and pt safety (e.g., by reducing medication-related errors)

To provide culturally competent care, the APRN must develop knowledge, skills, and positive attitudes about diverse cultures and work individually and within the healthcare system to promote care that is respectful of all cultures
- If a cultural practice has ad an adverse effect on a pt’s health, then the NP needs to explain to the pt in a sensitive manner the reason for not following the practice

Ex: A female pt tells NP that her shaman (curandero in Spanish) “told me not to take my medicine but to drink herbal tea instead” or “told me not to drink water for 2 days”.” The NP respectfully explains to the pt why the practice is harmful to her health.

Question 2

Culture and Nursing: Leininger’s Theory of Cultural Care Diversity and Universality

Answer 2

Madeleine Leininger is recognized as the founder of transcultural nursing and credited w/ the construct of “culturally congruent care”
- defines culture as “the specific pattern of behavior that distinguishes any society from others and gives meaning to human expressions of care

Leininger’s Sunrise Model is likely the most frequently used to frame culturally competent nursing care and research
- The Sunrise Model recognizes that care is influenced by many cultural features (e.g., technology, religiosity or spirituality, kinship, and social structures, cultural values and beliefs, and practices, legal and policy systems, economics, and education); all of which shape one’s world view

Question 3

Cultural and Spiritual Awareness

Answer 3

“Being knowledgeable about one’s own thoughts, feelings, and sensations, as well as the ability tor effect on how these can affect one’s interactions with other
- Consult w/ the pt and family to understand their unique interpretations and practices

• Each person interprets and implements their cultural and religious beliefs/practices uniquely; therefore, the clinician should make NO assumptions and assess as needed —> talk to the pt and actively listen and verify what is being said
• Religious practices often influence behavior around birthing, marriage, child rearing, illness, death, burial, and mourning; pt beliefs and practices should be honored, provided they do not cause harm

Question 4

Cultural and Spiritual Awareness: African Americans

Answer 4

• often use religious coping—typically Christian (e.g., prayer, gospel music, Bible reading, engagement w/ faith community)
• Christian pastors and preachers are held in high esteem
• Church congregations and religion may be important sources of emotional and tangible support
• some pts may feel that their illness is caused by lack of faith or by sin
• many families have a female head of household (matriarchal)

Question 5

Cultural and Spiritual Awareness: Latinos/Hispanics

Answer 5

• have a strong matriarchal element; the mother is an important source of strength and solace ins times of illness
• people from various Latino cultures may consult folk healers

Susto - a cultural illness (also means “fright”)

Mal ojo (or mal de ojo) - the “evil eye” is a folk illness (usually of a baby/child)
- caused by an adult who stares w/ envy at the child
- similar to the belief in an “evil eye” among some Muslim and Mediterranean cultures
- hex can be broken if the person staring at the child touches the child
- another way to break the hex is to pass an egg over the child (w/ prayers) and then place the egg under the bed overnight

Generally, Hispanic families enjoy public affection
- Extended family are treated like immediate family
- Multigenerational households are common

Question 6

Cultural and Spiritual Awareness: American Indians

Answer 6

• There are 574 federally recognized Indian Nations (aka tribes, villages, bands, pueblos, ranchers as, or communities) and Alaskan Native tribes in the US
• they have differing cultural practices and beliefs, but most traditionally view illness as “punishment” by the spirits for wrongful actions
• healing is done by shamans using prayers, dance, fasting, smudging, and sometimes ingesting hallucinogenic plants (peyote)
• Smudging is the ritualistic burning of an herb (w/ prayer) to help cleanse a person/place
• Some groups use medicine pouches, tied to the pt by a string, to help cure the illness
• have the lower health status compared w/ other Americans
• life expectancy is 5.5 years less than the US all-races population
• die at a higher rate than other Americans from chronic liver ds/cirrhosis, diabetes, accidents, assault/homicide, self-harm/suicide, and chronic lower respiratory disease
• ~16% of persons (all age) are considered in fair/poor health
• the leading cause of death: heart ds! - among men and women 18+ years, ~20% are smokers
• American Indian women have the highest rates of rape and assault in the US; they are 2.5x more likely to experience sexual assault and rape compared w/ other ethnic groups in the US
• The Indian health Service, a federal agency, is charged w/ delivery of healthcare to this population

Question 7

Cultural and Spiritual Awareness: Asians, in general

Answer 7

East Asians (Chinese, Vietnamese, Cambodian, Korean, Japanese)
- highly value college education and have high regard (respect) for doctors
- listening quietly w/out questioning is considered a sign of respect
- some think that asking questions or disagreeing w/ the treatment plan shows lack of respect
- Kinship ties are very important
- several generations may live in the same household
- elderly are held in high esteem; their opinion is highly respected
- some Asian cultures have a form of “ancestor veneration” practices
- In china, the male child is expected to take care of parents when they age

• Prolonged direct eye contact w/ males or strangers is considered rule by some cultures (e.g., Asians, female Muslim)

Question 8

Cultural and Spiritual Awareness: Asians - Vietnamese

Answer 8

• may stop taking prescription medicine when sx resolve or may think that only one visit is needed to “cure” an illness
• often save large quantities of leftover prescription drugs
• may fear blood tests and surgery d/t belief that blood loss worsens illness
• may believe that Western medicine will put the body out of balance

Question 9

Cultural and Spiritual Awareness: Asians - Buddhists

Answer 9

• Majority come from Asian (e.g., Cambodia, Thailand, Bhutan, Japan, Laos, Vietnam, Taiwan, Tibet)
• Main deity is Buddha; they believe that physical suffering is an inevitable part of life and believe in karma (“good deeds” create happiness and “bad deeds” create pain in the future)
• the cycle of rebirth (reincarnation); some dying Buddhists may experience anxiety about being reborn into a lower form or less desirable life
• may be vegetarian
• May practice regular meditations; Buddhists value clarity of mind and may refuse narcotics or meds that alter consciousness

Question 10

Cultural and Spiritual Awareness: Asians - Traditional Chinese Medicine

Answer 10

• Practitioners believe life energy (chi or qi) imbalance or blockage is the cause of ds
• Yin is the female, Yang is the male
• believe acupuncture and cupping correct energy imbalance

Ex:
- Cupping
- Coining
* Both may produce lesions that may be misinterpreted as signs of abuse; the NP should question how a child received such lesions before reporting the lesions as abuse

Question 11

Cupping

Answer 11

• create large round reddened marks or bruises on back (after 24 hrs)

Question 12

Coining

Answer 12

• when a coin is rubbed vigorously on skin to create welts

Question 13

Culture and Spiritual Awareness: Sikhs

Answer 13

Baptized Sikhs (Khalsa) and some others will obey a code of conduct that stipulates one wears 5 symbols of Sikh identity:
- uncut hair
- a sword
- shorts
- hair comb
- iron wrist ring

These symbols should NOT be removed unless negotiated w/ pt

• will not consume meat, alcohol, or stimulants
• Adult male Sikhs may wear a large turban-like head covering (usually white)
• Most come from southern/Southeast Asian, India, Canada, UK, and US

Question 14

Cultural and Spiritual Awareness: Hindus

Answer 14

• a central belief is the doctrine of karma, the law of cause and effect, which can affect decision0making regarding healthcare
• all illness may be seen as result of karma
• Hinduism encourages the acceptance of pain and suffering as part of the consequences of karma
• pts may not be forthcoming about pain and may prefer to accept it as a means of progressing spiritually
• they believe that all illnesses have a biological, psychological, and spiritual element —> Tx that do NOT address all 3 causes may not be considered effective by a Hindu pt
• many Hindus attach a stigma to mental illness and cognitive dysfunction
• Hindus believe that the time of death is determined by one’s destiny and accept death and illness as part of life
• Most Hindus do not eat beef/pork, and many follow a vegetarian diet
• Fasting is an integral part of Hinduism and is seen as means of purifying the body and the soul
• may wear a talisman that should not be cut or removed
• countries w/ highest percentage of Hindus are Nepal, India, and Mauritius

Question 15

Cultural and Spiritual Awareness: Muslims

Answer 15

• Traditionally, Sharia law (Islamic law) is followed
• Modesty is paramount!
• garments of adolescent females and women should cover arms, legs, and head

A hijab is a head scarf (hides hair, ears, and neck); the burqa or abaya is the full veil/robe that covers the body
- the left hand is reserved for bodily functions (considered unclean)
- shake the pt’s hand by using your right hand

Clinicians of the same gender preferred
- some male pts may be uncomfortable receiving healthcare from a female health provider
- an unmarried woman needs her father’s permission to see a clinician
- a married woman needs her husband’s permission
- women are not allowed to be alone/to visit w/ men who are not family members
- if a woman is seen by a male health provider, her husband or another male family member must be present in the rom; the female pt may refuse to undress (examine w/ the gown on)

The Qur’an (Koran) forbids drinking alcohol, eating pork, or eating meat not slaughtered in the “halal” manner
- the holy month of Ramadan is observed by 30 days of fasting
- it is forbidden to eat or drink fluids/water during the day time, but one can eat/drink from sunset to before sunrise
- If possible, schedule PO meds after sunset
- Those who are sick may be exempted (pregnancy women, physical/mentally ill people)
- children are not expected to fast until puberty

• Muslim women who refuse to wear a gown can be examined through their clothing (modified or partial physical exam)

Question 16

Cultural and Spiritual Awareness: Jews

Answer 16

Orthodox Jews (Hasidic Jews) prefer clinicians of the same gender
- Male Hasidic Jews may refuse to shake a female clinician’s hands
- Female wear a wig to cover their hair
- Shabbat (Sabbath) is observed from sundown Friday to sundown Saturday as a holy day that forbids any form of work
- Some believe the electricity is a form of work and may stop using light switches or any electronic equipment during Shabbat; may have to turn on the light switch for the pt
- Some observant Jews do not drive or use cell phones or other personal electronics at this time
- If possible, avoid accessing unnecessary health services on the Sabbath and avoid scheduling follow-up visits or tests on the Sabbath

• may keep their kosher dietary laws (kashruth; e.g., not mixing meat and dairy products within specified time frame, eating only meaty foods certified as kosher)
• families may have 2 separate kitchens at home: kosher and non kosher
• each kitchen has its own utensils, pots, and plates (not allowed to mix because kosher items will become contaminated)
• Orthodox Jewish pts may refuse to touch anything powered by electricity (e.g., light switch, call light, electronic pumps, cellphones) from sunset Friday to sunset Saturday (Sabbath); do NOT schedule visits during the Sabbath
• if you cal during this time, observant pts will not answer the phone

Question 17

Cultural and Spiritual Awareness: Jehovah’s Witnesses

Answer 17

• refuse to donate blood, store blood, or accept own blood (autologous transfusions) but accept non blood plasma expanders and blood components w/out red blood cells (RBCs; albumin, cryoprecipitate, clotting factors, immunoglobulins)
• if a blood transfusion is needed to save the life of a child, parents may refuse (may require a court order)
• believers do not celebrate civil holidays, birthdays, Christmas, Easter, and others
• Healthcare providers should encourage believers to carry an advance directive or medical release form stating their convictions; such a card is available from the church
• In urban locations, a hospital liaison from the church may be available to support believers w/ decision-making
• Jehovah’s Witnesses do not accept blood transfusion (including autologous) but some may accept blood components w/out RBCs (e.g., cryoprecipitate, immunoglobulins)

Question 18

Cultural and Spiritual Awareness: Seventh-Day Adventists

Answer 18

• often vegetarians
• abstain from tobacco, alcohol, and caffeinated beverages
• believe the human body is a temple of God that serves care (healthy lifestyle)
• they observe Sabbath (sundown Friday to sundown Saturday) as a holy day for rest from work/school and spiritual nursing
• if possible, avoid accessing unnecessary health services on the Sabbath

Question 19

Cultural and Spiritual Awareness: Amish/Mennonites (Old Order)

Answer 19

• believers do not participate in Medicare or Social Security or go to war
• the individuals’s community pays for healthcare (no health insurance)
• use folk practitioners and folk/alternative medicine (common)
• if surgery or an expensive test is needed, permission from church elders is required
• believers may speak German dialect
• they avoid modern technology, such as telephones and electricity
• uses horses and buggies for transportation
• large families, traditional roles for women, and agricultural work are characteristic
• Amish prefer giving birth (using midwives) and dying at home
• these closed communities have higher rates of some genetic cds such as maple syrup urine disease, Crigler-Najjar syndrome, a type of dwarfism (Ellis-van Creed syndrome), and cystic fibrosis, as well as certain metabolic disorders

Question 20

Cultural and Spiritual Awareness: Church of Latter-Day Saints (Mormons)

Answer 20

• church provide a strong social support network for the ill
• local ward bishop, elders, missionaries, home or visiting teachers, and/or lay people provide spiritual and temporal support
• pts may wear “temple garments” under hospital gown or clothing as a symbol of covenant they made in temple
• treat such undergarments w/ respect

Question 21

Cultural and Spiritual Awareness: Lesbian, Gay, Bisexual, Transgender

Answer 21

• Avoid assumptions regarding sexual orientation or gender identity
• facilitate disclosure while remaining respectful of an individual’s “coming out” process
• recognize and support the pt’s family of choice
• use gender-neutral language on forms and during history taking (e.g., “have you had sex w/ a male, female, both, or neither?”)
• respectfully ask how the pt wants to be addressed and what pronouns to use (e.g., he vs she
• many LGBT people have been mistreated by the medical community and are reluctant to obtain healthcare unless absolutely necessary
• organizations like the Yes Institute in Miami maintain lists of culturally competent LGBT healthcare providers
• The National LGBTQIA+ Health Education Center, a program of the Fenway Institutes, provides educational programs, resources, and consultation to healthcare organizations w/ the goal of optimizing quality, cost-effective healthcare for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minority people

Question 22

Cultural and Spiritual Awareness: Military Veterans

Answer 22

• conditions, such as PTSD and TBI are prevalent among US veterans
• Military personnel are accustomed to self-protect when exposed to certain sounds or experiences (e.g., hide under bed when helicopter is overheard)
• are socially stoic about pain or suffering and non questioning of authority figures
• important to include pt’s family in their care, they are aware of the military culture

Question 23

Factors that Affect Healthcare: Health Literacy

Answer 23

• Per Healthy People 2020, health literacy is the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”
• affects the person’s ability to learn about how to access healthcare, complete forms, respond to questions, implement recommended treatments, etc
• depends on communication and language, existing knowledge about health, culture, and numerical ability and skills, + demands of the situation and system w/in which the individual presents

Question 24

Factors that Affect Healthcare: Language Barriers

Answer 24

• even one misunderstood or misspoken word can affect a pt’s decision-making or implementation of a treatment
• strategies for communication b/w pts and providers who speak different langue’s include language access services (virtual, telephonic, or in-person interpreters) and handheld documents at point of service that present clinicians w/ pt information
• untrained staff and family members should not be used for interpretative services

Question 25

Factors that Affect Healthcare: Individualistic and Collectivistic Societies

Answer 25

• cultures are often categorized as individualistic or collectivistic

Individualist societies —> value the individual above the family, organization, or group

Collectivist societies —> consider the rights, needs, and wishes of the family or group over those of individuals

• ways these cultural differences may be observed during clinical encounters

Question 26

Cultural Differences in Healthcare: Individualistic Society Behaviors - US, Europe, Australia

Answer 26

• clinicians expected to tell pt the truth
• respect for pt autonomy
• pt makes health-related decisions
• needs of younger generations of family may take precedence over those of elders (e.g., elders are institutionalized in SNF)

Question 27

Cultural Differences in Healthcare: Collectivistic Society Behaviors - Asian, Africa, South America

Answer 27

• clinicians not expected to tell pt truth, instead share w/ family
• family shares (and may ultimately make) health-related decisions
• consultation w/ family is pivotal
• decisions will likely conform to family wishes
• familial piety, or honoring elders by providing the best care possible
• opposed to sending elders to long-term care facilities (nursing homes)

Question 28

Differing Interpretations of Illness - Illness Narrative (Questions for Assessment)

Answer 28

Medical anthropologist and psychiatrist Arthur Kleinman proposed that the culture-infused “illness narrative” is essential for any healing clinician to understand; in other words, things associated WITH the ds, NOT the ds itself, are important

Questions for assessment:
- What do you think has caused your illness? (Etiology)
- Why do you think it started when it did? (Onset of symptoms)
- What do you think your illness does to you? How does it work? (Pathophysiology)
- How severe is your illness? Will it last a short/long time? (Course of illness)
- What kind of treatment do you think you need? What results do you hope for? (Treatment)
- What are the biggest problems your illness has caused you?
- What do you fear most about your illness?

• Noncompliance and other problems are usually expected by a discrepancy b/w pt’s and professional’s interpretation of the t illness
• when explanatory models for the illness do not align, the clinician must seek to understand and negotiate them as “therapeutic ally” w/ the pt

Question 29

What is Ramadan?

Answer 29

A Muslim holiday that last for 30 days
- both fluids and food are forbidden from sunrise to sunset