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All of this information was takn froman article about Transcultural Nursing, I am posting this for information and not generalizing or labeling any culture in any way..
The Basic Concepts of Transcultural Nursing
Transcultural Nursing - A humanistic and scientific area of formal study and practice in nursing which is focused upon differences and similarities among cultures with respect to human care, health, and illness based upon the people's cultural values, beliefs, and practices, and to use this knowledge to provide cultural specific or culturally congruent nursing care to people ... Leininger
Leininger (1991) notes the main goal of transcultural nursing is to provide culturally specific care. But before transcultural nursing can be adequately understood, there must be a basic knowledge of key terminology such as culture, cultural values, culturally diverse nursing care, ethnocentrism, race, and ethnography.
Culture refers to norms and practices of a particular group that are learned and shared and guide thinking, decisions, and actions.
Cultural values the individual's desirable or preferred way of acting or knowing something that is sustained over a period of time and which governs actions or decisions.
Culturally diverse nursing care an optimal mode of health care delivery, refers to the variability of nursing approaches needed to provide culturally appropriate care that incorporates an individuals cultural values, beliefs, and practices including sensitivity to the environment from which the individual comes and to which the individual may ultimately return.
To be culturally competent the nurse needs to understand his/her own world views and those of the patient, while avoiding stereotyping and misapplication of scientific knowledge. Cultural competence is obtaining cultural information and then applying that knowledge. This cultural awareness allows you to see the entire picture and improves the quality of care and health outcomes.
Adapting to different cultural beliefs and practices requires flexibility and a respect for others view points. Cultural competence means to really listen to the patient, to find out and learn about the patient's beliefs of health and illness. To provide culturally appropriate care we need to know and to understand culturally influenced health behaviors.
In our society, nurses don't have to travel to faraway places to encounter all sorts of cultural differences, such as ethnic customs, traditions and taboos. The United States provides plenty of opportunities for challenges stemming from cultural diversity. To be culturally competent the nurse needs to learn how to mix a little cultural understanding with the nursing care they offer. In some parts of the United States culturally varied patient populations have long been the norm . But now, even in the homogeneous state of Maine where we reside, we are seeing a dramatic increase in immigrants from all over the world. These cultural differences are affecting even the most remote settings.
Since the perception of illness and disease and their causes varies by culture, these individual preferences affect the approaches to health care. Culture also influences how people seek health care and how they behave toward health care providers. How we care for patients and how patients respond to this care is greatly influenced by culture. Health care providers must possess the ability and knowledge to communicate and to understand health behaviors influenced by culture. Having this ability and knowledge can eliminate barriers to the delivery of health care. These issues show the need for health care organizations to develop policies, practices and procedures to deliver culturally competent care.
list five essential elements that contribute to an institution’s or agency’s ability to become more culturally competent. These include:
1. valuing diversity;
2. having the capacity for cultural self-assessment;
3. being conscious of the dynamics inherent when cultures interact;
4. having institutionalized cultural knowledge; and
5. having developed adaptations of service delivery reflecting an understanding of cultural diversity.
These five elements should be manifested at every level of an organization, including policy making, administration, and practice. Further, these elements should be reflected in the attitudes, structures, policies, and services of the organization.
Developing culturally competent programs is an ongoing process, There seems to be no one recipe for cultural competency. It's an ongoing evaluation, as we continually adapt and reevaluate the way things are done. For nurses, cultural diversity tests our ability to truly care for patients, to demonstrate that we are not only clinically proficient but also culturally competent, that we CARE..
Meyer CR.(1996) describes four major challenges for providers and cultural competency in healthcare. The first is the straightforward challenge of recognizing clinical differences among people of different ethnic and racial groups (eg, higher risk of hypertension in African Americans and of diabetes in certain Native American groups). The second, and far more complicated, challenge is communication. This deals with everything from the need for interpreters to nuances of words in various languages. Many patients, even in Western cultures, are reluctant to talk about personal matters such as sexual activity or chemical use. How do we overcome this challenge among more restricted cultures (as compared to ours)? Some patients may not have or are reluctant to use telephones. We need to plan for these types of obstacles. The third challenge is ethics. While Western medicine is among the best in the world, we do not have all the answers. Respect for the belief systems of others and the effects of those beliefs on well-being are critically important to competent care. The final challenge involves trust. For some patients, authority figures are immediately mistrusted, sometimes for good reason. Having seen or been victims of atrocities at the hands of authorities in their homelands, many people are as wary of caregivers themselves as they are of the care.
As individuals, nurses and health care providers, we need to learn to ask questions sensitively and to show respect for different cultural beliefs. Most important, we must listen to our patients carefully. The main source of problems in caring for patients from diverse cultural backgrounds is the lack of understanding and tolerance. Very often, neither the nurse nor the patient understands the other's perspective.
Ethnocentrism the perception that one's own way is best when viewing the world (Geiger & Davidhizar, 1991). Our perspective is the standard by which all other perspectives are measured and held to scrutiny.
Ethnic relates to large groups of people classified according to common traits or customs .
Race Though many definitions exist, there appears to be no established agreement on any scientific definition of race. What we do find though, is the general belief among the scientific community that race has no biological or natural basis. For more information click here
Ethnography is the study of a culture. The methodological approach of ethnographic research central to the nurse's ability to develop a heightened awareness of culturally diverse needs of individuals, is to define a field for observation for study of the environment and its people, as well as the reciprocal relationship that exists between the two.
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The Hispanic American Community
Members of the Hispanic American community have their origins in Cuba, Central and South America, Mexico, Puerto Rico, and other Spanish speaking countries.
The majority of Hispanics are Catholic, with an increasing presence of Pentecostals. Health is a gift from God and should not be taken for granted. The prevention of illness is an accepted practice that is accomplished with prayer, the wearing of religious medals, or amulets, and keeping relics in the home. Visiting shrines, offering medals and candles, offering prayers and the lighting of candles is a frequently observed practice. Many homes have shrines with statues and pictures of Saints. The candles are lit here and prayers are recited.
Elders have a prestigious status in the Hispanic family because of their experience. Family members look to elders for advice. An individual who becomes sick will turn first to family members, especially elders, for support, comfort and advice. They may recommend safe, simple home remedies.
In the traditional household, the man is the head of the family and makes all major decisions. There is a strong sense of Paternalism what most Westerners call "Male Dominance", but the females role is equivalent and she is the Maternal powerhouse in her home. The truth is women are sacred and revered, often protected, not because she can't handle herself or has no voice, but because the solidarity of the family unit depends on her well being.
Hispanics are far more emotionally expressive. They expect to be pampered when ill, it is one way the family shows love and concern. This is a present oriented society, and as such they may neglect preventive health care, and may also show up late, or not at all, for appointments.
Most Hispanics are Catholics, and birth control methods other than rhythm are unacceptable.
Most Latin Americans see thinness as a problem and plumpness as the ideal. Advice that a patient lose weight might not be followed because it would create a negative body image.
Hispanics are not accustomed to the profession of social workers, and rely on their families, other relatives and close friends for support and help.
Curanderismo is defined as a medical system. It is a coherent view with historical roots that combine Aztec, Spanish, spiritualistic, homeopathic , and scientific elements. The curandero is a holistic healer; the people who seek help from him do so for social, physical, and psychological purposes. Since the curandero has a religious orientation, much of the treatment includes elements of both the Catholic and Pentecostal rituals and artifacts: offerings of money, penance, confessions, lighting candles, wooden or metal offerings in the shape of the afflicted anatomic part and laying on of hands.
Personal matters should be handled only within the family. Modestly is valued in Hispanic culture, and not just for women. The area between the waist and knees is considered particularly private.
Typically, Hispanics look down on people who are mentally ill. Patients with mental health concerns do not like to share this information with their relatives or friends and are shy of seeking professional help.
To attend a woman during delivery is a woman's job, ideally the job of her mother and midwife. Cultural tradition dictates that a husband not see his wife or child until the delivery is over and both have been cleaned and dressed. In general, Hispanic women prefer that their mothers attend them in labor.
Latin American women practice the custom of postpartum lying -in period. This period is designed to give a woman the period of rest between childbirth and returning to work. In these cultures women traditionally did not return to office work, but to physical labor in the fields.
1- A Hispanic woman had to sign an informed consent form for a hysterectomy. The patient spoke no English and the hospital staff relied on her bilingual son to serve as the interpreter. When the son explained the procedure to the mother, he appeared to be translating accurately and indicating the proper body parts. His mother signed the consent form willingly. The next day, however, when she learned that her uterus had been removed and she could no longer bear children, she became very angry and threatened to sue the hospital.
Because it is inappropriate for Hispanic male to discuss her private parts with his mother the embarrassed son had explained that a tumor would be removed from her abdomen and pointed to the general area. The woman became quite angry and upset because a Hispanic woman's status is derived in large part from the number of children she produces.
Even speaking the same language is not always sufficient. Cultural rules often dictate who can discuss what with whom. In general, it is best to use a same sex interpreter when translating matters of a sexual or private nature.
2- A 36 year old Mexican man with second degree burns on his hands and arms. The skin grafts had healed, and there was now a danger that the area would stiffen and the tissue shorten. The only way to maintain maximum mobility was through regular stretching and exercise. The nurses explained to the wife that feeding himself was an essential therapeutic exercise. She seemed to understand the nurses' explanation yet continued to cut her husband's food and put it in his mouth.
When one of the nurses, observed this, she took the fork out of the wife's hand and told the patient to feed himself because he needed to exercise his arms and hands. The wife appeared skeptical but did not argue. When the nurse returned later, she saw the wife once again cutting her husband's food and putting it in his mouth. The nurses were irritated by the wife's assistance with tasks the patient could do himself. Fortunately a Cuban nurse on staff explained to the nurses that Hispanic men expect to be waited on. Having the patient's wife available to care for him most of the time also eased their burden.
Failure to care for oneself is common in cultures that emphasize the family over the individual (almost all cultures other than Anglo-American). In many cases, Americans' ethnocentrism blinds them to the fact that life in a typical Hispanic household may be different than in the normal Anglo home. Hispanic cultures emphasize family interdependence over independence. For them self care is not an important concept, where someone is usually at home to care for the patient.
In this situation, it is of greater importance that when a family member is ill, love and concern are demonstrated through care and attention. The nurses might have instructed the wife to help her husband in ways not to hinder his rehabilitation. For example, show her how to massage lotion on his hands.
3- A home health nurse, received an angry call from a Mexican American woman after visiting her house the day before. Her infant had been crying and feverish the next morning and the woman recalled the nurse had remarked the child was adorable. The nurse's compliment and the fact that she had not touched the child, led her to concluded that the nurse had given him the evil eye.
In Mexican culture, babies are considered weak and very susceptible to the power of an envious glance. A simple compliment without touching the child, can bring on the evil eye. Touching the person while complimenting him or her, neutralizes the power of the evil eye.
Not all Mexicans adhere to this belief, so it is important to pay close attention to non-verbal clues from the mother.
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The Middle Eastern Community
The "Arab World" includes 22 countries in the Middle East and North Africa, with a population of 180 million. Arabs are inhabitants of the Arab World who speak various dialects of the Arabic language and share the values and beliefs of the Arab culture.
Religion : The majority of Arabs are Muslims. There are a large number of Arab Christians in Lebanon, Syria Palestine, Iraq and Egypt. Many Muslim Arabs who are conservative in their religious beliefs do not eat pork or drink alcohol. They observe a fast in the daytime during Ramadan. Some Muslim women wear long dresses and scarves to cover the body.
We as nurses should recognize that there are over 7 million Muslims in America, and over 1.5 billion world wide all of whom must observe prayer 5 times a day.
Health practices : Some people wear amulets for protection against the evil eye or will burn incense to keep the evil eye away from the sick. Such practices are declining and are used primarily to avoid illness and harm to a healthy person. Also, prayers and reading from Al Quran or the Bible help give comfort to patients and family members and enhance the patient's recovery.
Arab culture and Islamic religion emphasize maintaining good health, especially through personal hygiene practices and a healthy diet. They place a high value in modern Western medicine and have confidence in the medical profession.
Patient and family will not wait long to seek professional help and are usually anxious to receive a medication as soon as possible. They will answer questions, will listen carefully to the health care provider's advice, explanations and warnings, and will follow the provider's directions carefully. Once symptoms have improved, many patients will stop taking the prescribed medication or will not return for a scheduled follow-up appointment.
An Arab patient seeing a doctor expects relief from pain and to receive a medication on the first visit. Patients like doctors to explain the reasons for not getting medications and for all laboratory testing. Nurses are perceived as helpers, not health care professionals, and their suggestions and advice are not taken seriously. Doctors may need to explain the nurse's role to the patient. Arabs are not accustomed to the profession of social workers. They rely on their families, other relatives and close friends for support and help.
Generally, both male and female Arab patients and their children prefer to be seen by male doctors. For pregnancy or gynecological needs, women prefer a female doctor, however. In Arab culture, women are reluctant to discuss these concerns with men. It is common for the family member to stay with the patient and to help answer questions about the patient's health. In Arab countries, patients are told only the good news about their disease. In severe cases, the doctors generally report the seriousness of the illness and its likely consequences to a selected family member.
Arabs believe that recovery from illness has to do with seeking a professional treatment and submission to God's will. They consider death to be a destiny decided by God. Family members need to be with the body until it is ready to be removed from the hospital. Muslims prefer to bury the body on the day death occurs.
Social customs : Elders have a prestigious status in the Arab family because of their experience. Family members look to elders for advice. An individual who becomes sick will turn first to family members, especially elders, for support, comfort and advice. They may recommend safe, simple home remedies.
When a patient is admitted to the hospital, it is a social obligation for friends and family to visit and bring presents such as flowers, cookies or chocolate.
In the Arab Culture there is a strong sense of Paternalism what most Westerners call "Male Dominance". What is so important to the balance of the subject is to understand that the females role is equivalent and she is the Maternal powerhouse in her home. Men by culture give orders, but by the faith of Islam they are the "protectors" of their families. They do take orders from their womenfolk but within the construct of the family for it would be disrespectful to do so socially. 1
Maternal and child health : Most Arabs consider childbirth to be a female issue only. A woman in labor is usually surrounded by female relatives and friends. Fathers are not admitted to the labor room. Midwives play an important role in prenatal care, delivery and post delivery consultation and are held in high regard in society and in the medical profession. Arab women prefer to breasted their newborns. Arabs in general do not approve having an abortion.
It is an Arab tradition to circumcise newborn boys.
Privacy : Some Arabs are reluctant to disclose detailed information about themselves and their families to strangers. They tend to give as little information as possible and may not give enough for a proper diagnosis. Being conservative, they may be embarrassed by questions about their sexual relationships and other personal questions.
Sexual problems and venereal diseases are difficult for Arab patients to deal with. Women are shy to talk about their private lives and may feel more comfortable with women doctors.
Typically, Arabs look down on people who are mentally ill. Patients with mental health concerns do not like to share this information with their relatives or friends and are shy of seeking professional help.
Diet : Diet may be an issue for Muslim patients. During Ramadan, many patients resist taking medications or eating during the daytime. Since Muslims do not eat pork, patients may not eat all hospital meals. Some eat only Halal meat (meat from animals slaughtered according to Islamic tradition). Because of shyness, fear of rejection, or lack of knowledge, many Arab patients will not ask for different meals.
1- A 27 year old Arab man refused to allow a male lab technician to enter his wife's room to draw blood. She had just given birth. The staff finally convinced the husband of the need, he reluctantly allowed the technician in the room. However, he took the precaution, of making sure his wife was completely covered. Only her arm stuck out from beneath the covers. For Arab families, honor is one of the highest values. Since family honor is dependent on female purity, extreme modesty and sexual segregation must be maintained at all times. Male nurses should not be assigned to female Muslim patients. In many parts of the world, female purity and modesty are major values.
In this instance his sense of responsibility and need to protect her modesty from very much an "intrusive" health care experience for the most part could be curbed by a simple sign placed on the door that says "Please Knock before entering, this pt. observes modest dress and requires the announcement of your presence." This would help communicate to the pt. and her husband that
we understand and wish to honor your modesty. This is empowering for the family. The rudeness or sense of oppression of the pt. the nurses might have felt would be understandable. However, when ever patients. or their families are rude or pushy we only need ask ourselves .... What is the underlying motive behind rudeness .... The answer is fear.
2- When the nurse entered the room of her Iranian patient, she found the patient huddled on the floor, mumbling. At first she thought the patient had fallen out of bed, but when she tried to help her up the patient became visibly upset. She spoke no English and the nurse had no idea what the problem was. The patient had been praying.
She was practicing her religion in the traditional manner. Since she was scheduled for surgery the next day, she thought it was especially important to pray.
Devout Muslims believe they must pray to Mecca, the Holy Land, five times a day. Traditionally, they pray on a prayer rug placed on the floor. If the nursing staff had some understanding of Muslim customs, they could have arranged to provide the patient some privacy during certain times of the day so she could pray.
3- A nineteen-year-old Saudi Arabian woman had just given birth. Her husband moved into the hospital room with his wife immediately after she gave birth. He kept the door to the room shut, and questioned everyone who entered, including the nurses. The nurses were not happy but felt they had no choice but to comply.
Although the patient could speak some English, the only time she would speak directly to the nurses was when her husband was out of the room. Otherwise, he answered all questions addressed to her. He also decided when she would eat and bathe. As leader of the family, he felt it was his role to act as intermediary between his wife and the world.
The truth is Labor hurts like hell, and technology is scary as hell, the idea of an epidural is often misunderstood, and many women fear it therefore don't opt for it. In the faith of Islam, heaven rests beneath the feet of mothers .....Strange isn't it for a male dominated society. The truth is women are sacred and revered, often protected, not because she can't handle herself or has no voice, but because the solidarity of the family unit depends on her well being.
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F.F. a twenty four year old female, was admitted to the labor and delivery department of Eastern New Mexico Medical Center. F.F. had labor pains five minutes apart. F.F. was accompanied by her husband, M.A. , and N.F. her sister. Mr. M.F. translated for F.F. because her English was limited. Mrs. N.F. was able to communicate with the health care providers on behalf of the couple (F.F. and M.F.). It is customary to address people from Arabia and most Muslim countries by Mr. or Mrs. followed by the first name (Andrews, Boyle, 1999 p 169).
The family is from Jiddah, a city on the western coast of Saudi Arabia, and had been in the United States for three years. Mr. M.F. was attending the Oil Field Training School at Eastern New Mexico University in Roswell. Their plan had been to return to Saudi Arabia for the birth but it appears the family was unaware the time of birth was so close. Mrs. F.F. expected her term to last for another month. It is desirable for a baby of Saudi decent to be born in the homeland (Fahd.1990). Mrs. F.F. has two children living, ages four and six, and one spontaneous abortion two years ago. The two children are male and are healthy except for the youngest that has frequent ear infections since coming to the United States. Mr. M.F. stated Mrs. F.F.'s siblings and parents had no medical problems. The nurse should be aware, most Arabians do not believe disclosure of family medical history is necessary. In fact, Arabian people believe such disclosure is private. They expect physicians and other healthcare providers, because of their expertise, to select necessary treatments (Purnell, Paulanka, p. 155). Mrs. F.F.'s sister, the family mid-wife, came from Saudi Arabia to be a companion in the home while Mr. M.F. was in school.
Cultural Sanctions and Restrictions
The two women did not leave the house without Mr. M.F. Muslim custom dictate that all females do not go into public without a male member of the family as an escort. It is the custom in Saudi Arabia that the sister or mother tend to the needs of a pregnant woman and to continue the care for forty days after the birth of the baby. The custom assures the new mother will have time to recuperate.
Health-Related Beliefs and practices
It is customary for females to care for females and males to care for males. A male who is not the spouse is not allowed to see an Arabic woman uncovered in Saudi Arabia. Mr. M.F. stated that his wife would prefer that no male except for family be allowed in her room. F.F. wanted her husband to remain in her room during her hospital stay in order to host any visitor (Fahd, 1990).
The physician was able to convince Mr. M.F. to allow the physician to perform physical exams at least monthly on Mrs. F.F. The physician allowed Mrs. N.F. (Midwife) to perform most of the physical examinations in his office. The physician wanted to monitor Mrs. F.F.'s blood glucose levels because diabetes mellitus is one of the major health problems in people from Saudi Arabia. Other diseases prominent in the Arab countries include glucose-6-phosphate dehydrogenase (G-6-PD), sickle cell anemia, and the thalassemias a hereditary hemolytic anemia (Purnell, Paulanka), cutaneous leishmaniasis, a variety of visceral and superficial infections caused by protozoan parasites of the genus Leishmania, and filariasis which is a n infection of a filiform nematode which is a member of the superfamily Filarioidea.(Geissler p.240).
Mrs. F.F.'s prenatal term had been unremarkable. F.F. had visited a local physician three months ago. The physician was sensitive to the customs of the Arab couple and agreed to allow Mrs. N.F. to follow through with the parental course. F.F. and M.F. wanted a female to deliver the baby. The physician agreed to stand by Mrs. N.F. when the baby was born. The physician wanted to be close in case of complications. The physician was careful not to go into detail about possible complications. Communicating a grave diagnosis is often viewed as cruel and tactless because it deprives the client of hope (Purnell, Pulanka, p. 155).
The husband is the family leader and decision maker. A woman cannot sign an operative consent form. The man may answer questions directed to his spouse. He may decide when the wife should eat and bathe, or the wife may decide basic care patterns such as when to bathe, eat, and breast-feed. The nurse will want to ask Mr. M.F. if he or Mrs. F.F. will decide when she will eat and bathe. (Fahd, 1990).
Mr. M.F. did not want to be present for the delivery. He remained at his wife's bedside until she was ready to move to the delivery room. It has been traditional for men to leave the matters of birthing to the women. Recently, the younger generation of Muslims have chosen to remain with the wife during labor. The choice is left to the father (Fahd, 1990).
Cultural Aspects of Disease Incidence
The Physician assisted Mrs. N.F. in the delivery of a healthy six pound ten ounce male with an apgar of nine. The newborn's abdomen was wrapped with a white cloth to prevent cold or wind from entering the baby's body (Purnell, Paulanka. p 151).
The Physician and the nurse were careful not to say anything that would be interpreted as praising or admiring the infant. The newborn was placed in a crib in F.F.'s room. Newborns are particularly susceptible to the evil eye and expressions of congratulations may be interpreted as envy. It is believed those who envy the wealth, success or beauty of others causes adversity by the gaze, which transmits malignant radiating energy and upsets the victims natural balance. Protection from the evil eye is afforded by wearing amulets such as blue beads or figures involving the number five, reciting the Quar'an, or invoking the name of Allah. (Purnell, Paulanka. p.156).
A nurse entered the room and found Mr. M.F. on the floor bowing in prayer. She left the room bewildered and asked if anyone understood the customs of the couple. I was on the unit and was able to answer questions because I had spent time with two Saudi families. I explained that I had leaned much about their customs while visiting in the Saudi's homes. The Saudis had been very generous in their instruction and answers to my questions about the customs of Saudi Arabia.
Devout Muslims believe they must pray to Mecca, the Holy Land, five times a day. Traditionally, they pray on a prayer rug placed on the floor. If the nursing staff had some understanding of Muslim customs, they could have arranged to provide the patient some privacy during certain times of the day so the couple could pray.
People from Saudi Arabia are Muslims and are of the Islamic faith. Much of their life and customs center around their religion. Islam is based on the teachings of Mohammed, who is called the Prophet. The Arabic word Islam literally means "one who submits," (Andrews, Boyle, 1999 p 421) but as a religious term in the Koran, it means "to surrender to the will or law of Allah (God)." A Muslims duty is that of five daily prayers. The first prayer is offered before sunrise, the second in the very early afternoon, and the third in the late afternoon, the fourth immediately after sunset, and the fifth before retiring and before midnight (Fahd, 1990).
Ramadan is that time of year when Muslims recharge their spiritual batteries. For a whole month they fast from dawn to sunset, and offer additional prayers at night. Eid, a day of thanksgiving begins after the end of Ramadan. On this day Muslims thank God for His guidance and grace in helping them to control their baser, et al. desires and fulfill their spiritual needs (Abalati, 1998).
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The next day was the time of Ramadan. Since it is the time of Ramadan, the offer should be made to have food brought to the room after sunset and before sunrise each day. It may be necessary for food trays to be prepared during the day and left in a refrigerator. At night the supervisor would have the trays brought to the floor. Extra snacks should be made available to the couple during the night. This would be a proper time to ask if Mrs. F.F. would like to have food and drink during the day. The Quar'an says anyone who is ill may forgo the fasting. The husband will most likely want his wife to eat for the health of the baby, because she will be nursing the baby.
Mr. M.F. moved into the hospital room with his wife immediately after she gave birth. Mr. M.F. kept the door to the room shut, and questioned everyone who entered, including the nurses. The nurses were not happy but felt they had no choice but to comply. The nurses stated they knew they needed to learn about the customs of this couple.
Although the patient could speak some English, the only time she would speak directly to the nurses was when her husband was out of the room. Otherwise, he answered all questions addressed to her. Mrs. N.F. helped with the translation for Mr. M..F. who would decided when Mrs. F.F. would eat and bathe. As leader of the family, his role is to act as intermediary between his wife and the world.
Cultural Aspects of Disease Incidence
Mrs. F.F. will not nurse the infant until the third day after birth, as is the custom of Islam. It is believed the colostrum is not healthy for the infant. Supplemental feedings are given to the mother to feed to the baby until mother's milk begins (Fahd, 1990).
The nurse assigned to Mrs. F.F. brought tea to the room for the couple and herself to develop rapport with the couple. It is important to make the couple feel comfortable with the nurse. The conversation was kept to a discussion of the weather locally and what the weather must be like in Saudi Arabia at the moment. This is the time to show a relaxed cordial side being careful not to give non-verbal cues of being in a hurry. At this time, the nurse may ask Mr. M.F. what time of day he would like food trays delivered to the room.
A Saudi husband will show hospitality to visitors by serving them refreshments or coffee and chocolate. Friends and relatives will be frequent visitors. When a woman has a new baby, her relatives, friends, and neighbors visit her to congratulate her and to present her with gifts. Relatives, friends and neighbors visit the father of the new baby to congratulate him. The mother of the new baby will usually spend the first 40 days after the delivery in her family home, where she will be taken care of by her mother and/or sisters. When a visitor comes to visit the following will usually be said by him. "Yetrabba Be Ezzekum, Waa Allah Yajaluhoh Min El Thorriah Al Salehah": May he/she (the new baby) be raised in your goodness and may Allah (God) make him/her be a good son/daughter (Al-Sabt).
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Alteration in self concept related to American Nurses lack of understanding of the cultural diversity of the Saudi Arabian people.
Mr. M.F. refused to allow a male lab technician to enter his wife's room to draw blood. The staff finally convinced the husband of the need. He reluctantly allowed the technician in the room. However, he took the precaution, of making sure his wife was completely covered. Only her arm stuck out from beneath the covers. For Arabian families, honor is one of the highest values. Since family honor is dependent on female purity, extreme modesty and sexual segregation must be maintained at all times. Male nurses should not be assigned to female Arabic patients. Female purity and modesty are major values, in many parts of the Islamic world.
Mrs. F.F. had several gold chains in her luggage. The nursing staff attempted to persuade the F.F. and M.F. to take the gold home or, for safety, place it in the hospital safe. Mr. M.F. insisted the gold would be safe while he remained in the room. Gold is a Saudi woman's insurance. It is the only possession she owns. Separation from her gold would have been very stressful for Mrs. F.F. (Fahd, 1990). In recent years women of Saudi Arabia have been know to own property and business.
When you explicitly admire a possession of an Arabian, he/she might feel obligated to offer it to you even if it is of special value. Admiring something should not be prolonged. When Arabians receive gifts, it is a custom not to open it in front of the giver. The same is expected when they give someone else a gift (Fahd, 1990). At this point it is wise to drop the subject. The nurses were wise to forgo their judgment of the situation.
The Arabian culture is a non-confrontational one, which seeks the least conflict possible. A concept called "save face" is a way to solve conflicts and avoid embarrassing or discomforting the parties involved. Saving someone's face or dignity involves using maneuvers or holding one's reactions to give the other party a way to exit the situation with minimal discomfort or harm to their dignity. It involves compromise, patience, and sometimes looking the other way to allow things to get back to normal. The "save face" concept is looked at as a behavior of high quality ethics and manners. The Arabian culture encourages people to act humbly and with sensitivity to a person's dignity, especially when that person's dignity and self respect is endangered (Abalati, 1998)
Nutrition Aspects Related to Religious Teachings.
In Arabian and Islamic countries alcohol and pork is forbidden (Andrews, Boyle, 1999 p 423). Clients in hospitals and other health care settings may need assistance in identifying foods that have been prepared using animal shortening or pork seasonings. They should avoid regular gelatin made with pork, marshmallow and other confections made with pork. Avoid medicines containing alcohol such as some cough suppressants. Avoid extracts such as vanilla and/or lemon that contain alcohol (Andrews, Boyle, 1999 p 351).
One does not compliment an Arabian man about the beauty of his wife, sister or daughter (it is not a compliment). In Arabic culture, it is not proper to compliment women. Only Allah is admired. A female Saudi Arabian is held in high esteem and her virtue is most important but must not be placed above Allah. Only Allah can be complimented on beauty.
Mr. M.F. frequently summoned the nursing staff using the call light. He requested a ?pain shot? for his wife or requested extra blankets or asked that the bathroom be cleaned. The nursing staff asked Mrs. Fatima if she was in pain. Her answer was that she had only a little pain. Mr. Mohammad insisted that his wife be given the medication.
Family members indulge the individual and assume the ill person's responsibilities. The patient will usually down play her pain with the knowledge that her husband will assure that she will receive pain medication when she needs it. Although the patient may seem overly dependent and the family over protective by American standards, family members? vigilance and ?demanding behavior? should be interpreted as a measure of concern. It is a custom for Muslims to care for the ill (Purnelll, Paulanka). Giving birth is considered an illness.
Saudi Arabians believe that intrusive procedures such as injections and intravenous fluids are more effective that are those procedures that are not intrusive (Geissler, 1998). The nursing staff contacted the physician for orders for intramuscular pain medication. The physician ordered Ketorolac (Toradol) 30 - 60 mg I.M. with half the original dose in 6 hours. Toradol is a non-steroidal Anti-inflammatory drug (N.S.A.I.D.) and it has analgesic, anti-inflammatory and antipyretic effects. Unlike narcotics, which act on the central nervous system (C.N.S.), Ketorolac is primarily considered a peripherally acting analgesic. It does not have the sedative properties of narcotic analgesics. Relief has a rapid onset when given intravenously and peak plasma concentrations occur 50 minutes after intramuscular administration. Side effects to watch for are edema, hypertension, rash, itching, nausea, headache, dyspepsia, constipation, diarrhea, drowsiness and dizziness. Contraindications are hypersensitivity to aspirin (A.S.A.) and to other non-steroidal Anti-inflammatory drugs (N.S.A.I.D.). Precautions to watch for are: inhibits platelet aggregation and may prolong bleeding: gastrointestinal irritation and hemorrhage can occur, though probably not common in short-term pre-hospital use: use cautiously for patients with hepatic or renal disease.
It may be necessary to adjust dosages of medication because of a potential Arabian's response to drugs such as: lower dosages of antiarrhythmics, antihypertensives, psychotropics and neuroleptics, or increase dosages of opioids due to diminished ability to metabolize codeine to morphine (Andrews, Boyle, p. 62).
In an Arabian family, gender and age plays a big role in specifying responsibilities. The father is usually the head of the family and the provider for its needs, while the mother plays a major role in raising children and taking care of the house. This structure is not always the norm; in recent years, both the father and the mother provide for family needs, while household chores are taken care of by maids and servants. In the past the father made major family decisions, but now they make many decisions jointly (Al-Sabt, 1999).
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The Nursing Diagnosis of Alteration in self-concept related to American Nurses lack of understanding of the cultural diversity of the Saudi Arabian people indicates that nurses cannot always look for ways to change behavior of people. It may be necessary to simply honor the culture and customs of a person's country. One example is, when the nurse entered the room and found Mr. M.F. on the floor praying. If the nursing staff had some understanding of Muslim customs, they could have arranged to provide the patient some privacy during certain times of the day so the couple could pray.
Before taking this course, I had a concept that people of other cultures need to be honored and held in esteem. I have learned that understanding my own self-concept is important in order to get myself out of the way and to allow myself to learn about other cultures. Learning about cultures and customs is refreshing and rewarding.
The most important thing I have learned is: Cultural Competency is the ability of individuals and systems to respond respectfully and effectively to people of all cultures, classes, races, ethnic backgrounds and religions in a manner that recognizes, affirms, and values the cultural differences and similarities and the worth of individuals, families, and communities and protects and preserves the dignity of each. This concept is not new. This concept is bases on the results of research by Dr. Madeleine Leininger who published Cultural Care Diversity and Universality: A Theory of Nursing. In 1991.
I can never stop learning about other cultures. I have learned that I have a lot to learn about people. This can only mean I will continue to be surprised and refreshed with the new concepts I will learn in the future.
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The Deaf Culture
People with hearing loss form the largest disability group in this country. In addition to the 4000 to 5000 babies who are born deaf every year, countless numbers of people suffer injury or illnesses that cause deafness. As healthcare providers we view deafness as a disability and focus purely on the medical aspects of deafness. However Deaf people tend to find this view restrictive and limiting, because it fails to describe the sociological implications of deafness. Labels like "hearing impaired" "deaf and dumb" or "deaf mute", is considered undesirable because it refers to a presumed disability.
Deaf people prefer to view deafness not as a handicap but as a shared experience underlying their sense of community. As a symbol of pride and identity within this community the word Deaf is often capitalized when referring to this group. The Deaf community is a cultural group, sharing common experience, concerns, and language.
Since the primary binding force for this cultural group is its shared language, deaf people who do not use ASL (American Sign Language) are not considered part of the Deaf community. Conversely, some hearing people do belong to the Deaf community. The Deaf community now includes perhaps as many as half a million people throughout the United States.
These case studies were compiled from our personal experiences and interviews with members of the Deaf community.
Many (most, I fear) hearing impaired women do not realize that they are entitled to an interpreter during visits to their doctors. Seeing a doctor is an intimidating experience for many people, and if one must write out questions instead of signing, it is even more intimidating.
I know of a class through the New York Medical College which is taught by a deaf woman who is very much a patient advocate. The medical students are taught basic sign language at beginner, intermediate and advanced levels. They learn medical terms and also learn about deaf culture. (More medical schools and healthcare schools should follow this example.)
I had an experience with a deaf woman who had a new baby. She had a translator who signed to the patient what the nurses said and then told the nursing staff what the patient said. As we spoke I kept talking to the interpreter and directed all of my communications to her. Finally, the interpreter told me to face the patient and speak directly to her. Not only can deaf people read lips, but we are basically leaving them out of the conversation if we do not direct our conversations to them. It was a big learning experience for me! Just thought this could be helpful for this site as an example! ( "Joseph RN" )
In a rural emergency department, a deaf patient had been waiting in the Emergency Department exam room behind closed doors for one and a half hours. The patients chief complaint was abdominal pain and no medical evaluation had been done. When asked why, the nurse simply replied ... "she is deaf and mute and we are waiting for the interpreter, it's a week end it will be a while before they arrive, we'll just have to wait. "
I communicated with the patient using ASL (American Sign Language) while the doctor evaluated her. The patient asked the doctor "why do you treat deaf people as if we were animals who can neither read nor write ? in spite of my university education I continue to experience this attitude. "
The degree of insensitivity toward deafness and deaf people displayed by the nurse and doctor is unfortunately very high and mainly due to ignorance rather than malice. The hearing assume that, thinking cannot develop without language. Language cannot develop without speech. Speech cannot develop without hearing. Conclusion, those who cannot hear cannot think. These assumptions and opinions have had a devastating impact on the lives of deaf people.
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Chinese medicine teaches that health is a state of spiritual and physical harmony with nature. A healthy body is in a state of balance. When it gets out of balance illness results. They view their bodies as a gift given to them by their parents and fore bearers. A person's body is not his personal property. It must be cared for and well maintained.
In Asia the balance is between yin and yang. All things in the universe are primarily either yin or yang, including diseases, which may result from excess yin or yang, deficient yin, or deficient yang. Yin and yang are generally translated as hot (yang) and cold (yin), these refers to qualities, not temperatures. 2
The Asian patient rarely complains about what bothers him. Often the only indication that there may be a problem is an untouched food tray and the silent withdrawal of a patient.
1- A middle-aged Chinese patient refused pain medication following cataract surgery. When asked, he replied his discomfort was bearable and he could survive without any medication. Later the nurse found him restless and uncomfortable. Again the nurse offered pain medication. Again he refused, explaining that her responsibilities at the hospital were far more important than his comfort and he did not want to impose. Only after she firmly insisted that the patients comfort was one of her most important responsibilities did the patient finally agree to take the medication.
Chinese are taught self-restraint. The needs of the group are more important than those of the individual. Another factor that may be involved in Asian's refusal of pain medication is courtesy. They generally consider it impolite to accept something the first time it is offered. The safest approach for the nurse is to anticipate the needs of an Asian patient for pain medication without waiting for requests. Nurses should be aware of Asian rules of etiquette when offering pain medication, food or other services. But if the patients continue to refuse medication, their wishes should be respected.
2- A Vietnamese woman was rushed to the hospital by her adult children. The emergency room personnel discovered dark red welts running up her arms, shoulders and chest, yet the only presenting complaint was dizziness. When questioned, her son explained that he had rubbed her body with a quarter.
A nurse becomes concerned when she finds an elderly Chinese patient rubbing him self with a quarter( she thought he was trying to hurt himself). When she took the coin away from the patient, he became very upset, grabbed it back from her and continued to rub his arms and legs, leaving dark red scratches.
A Vietnamese girl in her first year at an American elementary school, was not feeling well one morning, so her mother rubbed the back of her neck with a coin. When the school staff discovered the welts on the girls neck, they immediately assumed they were seeing a case of child abuse and reported the family to the authorities.
In each case the patient was practicing a traditional form of healing known as coin rubbing. There are several variations, including heating the coin, but they all involve vigorously rubbing the body with a coin. This produces red welts, which can distract medical staff from the real problem or be mistaken for child abuse. It is important to recognize and become familiar with this practice, and not to be distracted from the real problem or mistakenly make accusations of child abuse.
Asians rubbing their children with coins is not any more abuse than Americans having thin pieces of metal wrapped around their children's teeth and tightened until their teeth move out of place. Braces are usually applied for merely aesthetic reasons. Coin rubbing, at least, is an attempt to heal. Apparently, it often works, only the failures show up in the medical system.
3- A 24 year old Korean man, visiting family in the United States, became ill and was hospitalized. With a diagnosis of renal and respiratory failure, was put on strict bed rest because exertion would be dangerous. Conflict arose when the family would get him out of bed to squat over the bedpan on the floor. The nurse tried to explain that the bedpan was to be used in bed, but they spoke little English and became very upset.
In most Asian countries, traditional toilets are holes in the ground. To eliminate from the bowels, one squats over the hole. There is no other way to do it. Elimination is considered unclean and certainly should not be done in bed. The patient was trying to maintain standards of cleanliness and decency. He was using the bedpan in the only way he knew how. After a co-worker explained the patients behavior, the nurse called the doctor and had him rewrite the orders from strict bed rest to bathroom privileges as needed with assistance. The patient and family were much happier and more cooperative as a result.
4- A Vietnamese woman, after giving birth to a son, refuses to cuddle him but she willingly provided minimal care such as feeding and changing his diaper. The nurse feeling sorry for the baby, picked him up, cuddled him and stroked the top of his head. Both the mother and the husband became visibly upset.
This apparent neglectful behavior does not reflect poor bonding, but instead indicates a cultural belief and tradition. Many people in rural areas of Vietnam believe in spirits. They believe these spirits are attracted to infants and are likely to steal them (by inducing death). The parents do everything possible not to attract attention to their new born, for this reasons infants are not cuddled or fussed over. This apparent lack of interest reflects an intense love and concern for the child, not neglect.
Not only did the nurse attract attention to the infant but she touched him in a taboo area. Southeast Asians view the head as private and personal, it is seen as the seat of the soul and is not to be touched.
Another Vietnamese tradition that is seen as a sign of poor bonding is the delay in naming the infant. The name is often decided on by the family in a naming ceremony that takes place at the parent's house with all relatives present. This custom emphasizes the infant's importance as a member of the family.
5- A 27 year old Vietnamese woman in the delivery room with very strong and closely spaced contractions. The baby was positioned a little high and there was some discussion of a possible c- section. Despite her difficulties, she cooperates with the doctor's instructions and labors in silence. The only signs of pain or discomfort were her look of concentration and her white knuckles.
Vietnamese women, as most Asians, believe that a woman must experience pain and discomfort as part of childbirth. To express these feelings, however, brings shame upon her. It might be very disconcerting for an Asian woman accustomed to controlling her emotions to labor next to a highly expressive Middle Eastern or Hispanic woman.
6- A Chinese woman in her mid-twenties, had just given birth. The nurses became concerned when she would not eat the hospital food and did not bathe. She would only eat foods her family brought to her. The patient later explained her custom prevented her from bathing for seven days after childbirth and permitted her only to eat certain foods.
This patient was practicing the traditional lying-in period observed in much of Asia and Latin America. It is believed that for a period of time after childbirth, the women's body is weak and susceptible to outside forces. New mothers are encouraged to avoid exercise and bathing (bathing could introduce organisms into the body and cause illness.)
Pregnancy is thought to be a hot condition. Giving birth causes a loss of yang, or heat, which must be restored. This is accomplished by eating yang foods such as chicken and avoiding cold liquids. The woman is to rest, stay very warm, and avoid bathing and exercise. The price for not observing these customs is aches, pains, arthritis and other ailments in later life.
Compromises can be made. The use of boiled water (removes impurities) may make a sponge bath more acceptable. Do not assume the patient will follow orders that would violate the traditions and wisdom's of her own culture.
7- In China there is a strong cultural aversion to donating blood. By tradition, giving ones blood is considered disrespectful to parents and ancestors. Blood is thought to contain qi, or life energy.
The Chinese believe the more blood in the body, the better. Health care workers there acknowledge the wasteful distribution of what is known as sympathy blood in hospitals. This practice occurs sometimes when a patient is about to die, a nurse will give him blood, just to make him feel better. While some wealthy Chinese request blood transfusions in hopes to improve the qi.
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Nursing in a third world country can be exciting, dangerous and conditions can be austere. But working in a third world country offers the opportunity to experience diverse cultures, grow personally and professionally, promote health and prevent disease, and feel that you're making a difference.
There are several types of nursing opportunities abroad. The most common are short term volunteer assignments. We usually pay for transportation to assignments as well as a fee that covers food and lodging. We often bring our own equipment, and pharmaceuticals. Many of these trips are sponsored by religious organizations or individual groups, and are coordinated as one to three-week assignments in which teams of volunteers travel daily to makeshift clinics These clinics can be located in the outskirts of a city or in remote villages.
Residents assemble at the designated site (sometimes after days of walking), where volunteers provide pediatric, adult and gynecologic care and dispense basic medications. Advance Planning doesn't always prepared you for what you may encounter, you'll need to adapt. Delivering babies in the living room, suturing lacerations by candlelight, removing bullet fragments and dodging bullets. You'll see things you only read about -neonatal tetanus, elephantitis, a measles epidemic and much more.
We travel on foot and by horseback, mule, and four wheel drive vehicle, up mountains and across rivers with no bridge. We sleep in churches, stables, and anywhere we could. You may be without electricity and an outdoor spigot as the only plumbing. The nearest phone may be hours away. You see bugs you never dreamed of and eat the same foods everyday -plantains, potatoes, yucca and cabbage.
The specific skills you will need depend on the work you will be doing. A strong medical surgical experience is essential. For primary care you need a strong emergency/critical care experience with some pediatric and obstetric experience. Critical - thinking skills and the ability to improvise are the most important and helpful.
Before you take the plunge consider the following
Familiarize your self with the customs, values, laws and health of the country you will work in.
Try the food, listen to the music and if possible talk with people of that culture before leaving home.
Learn the language, you can't provide adequate care if you can not communicate with your patients.
Learn about the organization under who you will work - purpose, goals, philosophy, policies
Remember you will be under other's rules, laws, value system, customs.
Can you cope with lack of structure, boredom, change and danger ?
The right experience may enrich your life immeasurably.
Be realistic and above all be informed.
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What is a Third World Country?
In most people's minds, countries in Africa and Latin America make part of the Third World, while advanced western states, such as Canada, the US, the UK, along with the rest of Europe, are seen as Non-Third World. The term "Third World" appears not to be universally accepted. Though some political correct would prefer other terms such as - non-industrialized countries, underdeveloped countries, emerging nations, the term "Third World" is probably the one most widely used in the media today.
The term 'Third World Country' was used in reference to the economically underdeveloped countries of Asia, Africa, Oceania, and Latin America, and were considered as an entity with common characteristics, such as poverty, high birthrates, and economic dependence on the advanced countries. Alfred Sauvy, the French demographer coined the expression ("tiers monde" in French) in 1952 in an analogy with the "third estate," the commoners of France before and during the French Revolution.
By the end of World War II the definitions, somewhat ambiguous, provided a reasonable framework. A First World Country was one that was industrialized and had generally accepted the concepts of capitalism and world trade, a Second World Country was an industrialized nation that had rejected capitalism, in favor of Communism or Marxism. The Third World Countries were those that did not fit either of these two. The key features used to define a Third World Country were its lack of industrialization, a very low GNP, a high population and a high level of poverty .
As time has passed and the world has advanced, these definitions have become somewhat meaningless, but unfortunately the concept of a Third World Country, and its association with third-rate status, has remained. Today the world generally consists only of Third World Countries, and Non-Third World Countries. Those termed Third World have; poor industrialization, a low GNP and lack of economic stability, over population and high poverty rates, and a lack of infrastructure (roads, healthcare and education.) The have's and have not's.