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Psychiatric-Mental Health Nursing

8.1 Understanding Cultural Differences

Psychiatric-Mental Health Nursing8.1 Understanding Cultural Differences

Learning Objectives

By the end of this section, you will be able to:

  • Identify cultural influences on beliefs regarding health and illness
  • Recognize health disparities among different cultural groups
  • Describe various types of healing in different cultures
  • Explain how to recognize and address unconscious or implicit bias

Nurses encounter clients from a variety of backgrounds; therefore, it is essential that nurses provide culturally appropriate care. Cultural competence, in the context of nursing care, does not assume mastery. It means being open to learn and grow and practicing toward success. The skill of applying evidence-based nursing care in agreement with the cultural values, beliefs, worldview, and practices of clients to produce improved client outcomes is called cultural competency. It is one component of providing client-centered, holistic nursing care.

A nurse who provides holistic care to clients will focus on healing the person as a whole, rather than on one specific problem. Holistic care means to think about and care for physical, cognitive, social, emotional, and spiritual health. When an individual’s cultural beliefs are integrated into their health care, it is called culturally responsive care. Culturally responsive care is required for a trusting, effective relationship with the client, and this skill begins with cultural awareness. Throughout care delivery, nurses partner with clients and families to become aware of their preferences and values. This awareness can come through structured interviews, therapeutic interactions, and inclusion of the clients’ significant others in care, as permitted.

Cultural Influences on Health and Illness

The United States is a country of various ethnic and cultural groups that grows more diverse every day. The set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group is called culture. Some cultures have beliefs that explain what causes illness, how illnesses can be treated or cured, and who should be involved in the process. Culture also affects how people communicate with health-care team members in terms of language or eye contact, or what can be discussed in terms of the person’s body, health, or illness. A person’s culture affects everything from how they think and feel about health and illness, to how receptive they are to treatment recommendations, to how, when, and from whom they receive care.

Clinical Safety and Procedures (QSEN)

Competency: Client-Centered Care

Definition: Recognize the client as a full partner in control of all decisions when providing compassionate and coordinated care based on respect for the client’s preferences, values, and needs.

Knowledge: Describe how diverse cultural, ethnic, and social backgrounds function as sources of client, family, and community values.

Skill: Communicate client values, preferences, and expressed needs to other members of the health-care team.

Attitude: Respect and encourage individual expression of client values, preferences, and expressed needs.

Best practice standards include the nurse providing competent, effective care with each client interaction. Conducting a cultural assessment is one way to ensure meeting the client’s preferences and cultural needs.

(QSEN Institute, n.d.)

Individualism versus Collectivism

One main psychological distinction between cultures that affects how people think and make decisions is individualism versus collectivism. Cultures that follow individualism focus on the individual. They are encouraged to make choices for their own benefit with an emphasis on independence and self-reliance, and health care tends to be viewed as a personal responsibility. Most Western countries, such as the United States, United Kingdom, and other parts of Western Europe are considered to have individualistic cultures (Fatehi et al., 2020).

In contrast, cultures that follow collectivism emphasize community and cooperation. Decisions are made for the benefit of the collective. These cultures believe that it is best for society when everyone works together as a group, and the needs of the individual come secondary to the needs of the greater good. A client from a collectivistic culture might defer treatment decisions to their family, for example. Some countries that practice cultural collectivism include China, Japan, Indonesia, and several other Eastern Asian or South Asian countries.

Cultural Influences on Pain

Pain management can be a challenging task and can be made more complex by the cultural considerations particular to each client. Different cultures have varying views on pain, including how to express it, how to treat it, and what it means. Pain is a universal physical experience, but it also involves emotions and behaviors that are colored by the client’s cultural viewpoint (Givler & Bhatt, 2022). For instance, Black, Japanese, Hispanic, and East Asian cultures tend to appear stoic about pain and may keep an unexpressive face or believe that requesting pain medication is a sign of weakness (Givler & Bhatt, 2022). This does not mean that they are not experiencing pain, or that they have a higher pain tolerance than people who may appear more emotional when experiencing pain. Others, such as those who are part of Muslim or Christian communities, can view pain as the plan of a higher power. Chinese clients may view pain as an imbalance between yin and yang (Perreira et al., 2019). Take care to avoid misunderstandings about pain due to cultural differences because they can result in overtreatment or undertreatment of the client’s pain.

Clinical Judgment Measurement Model

Take Action: Culturally Sensitive Nursing Interventions for Pain

Even though the ways in which clients experience and express pain are influenced by their cultural background, pain is an individual experience. It is important for the nurse to be aware of cultural differences so that they can treat the individual in a way that best suits their pain and their preferences. Culturally sensitive nursing interventions for pain include (Givler & Bhatt, 2022):

  • Providing an interpreter for clients with limited verbal or written English skills.
  • Asking the client about their ideas and understanding of the concept of pain. Their beliefs may be representative of their cultural background, or they may not—be careful not to make generalizations without listening to the client.
  • Providing thorough education to the client on pain assessment and the importance of reporting pain. Rely on these assessments rather than on behaviors.
  • Being sensitive to traditional healing remedies, such as prayer or use of certain foods. Allow the client to incorporate traditional remedies whenever possible. Make sure to gather a thorough history of all medicines, herbs, plants, and foods to avoid any possible interactions.
  • Assuring the client that the health-care team is there to help treat their pain in a way that is the most appropriate and suitable for them.
  • Adjusting the client’s care plan to reflect their cultural needs.

Health Disparities Related to Cultural Differences

The nonbiological factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life are called social determinants of health. Health outcomes that are influenced by these social determinants of health and therefore represent preventable differences experienced by underrepresented individuals are called health disparities.

Various factors contribute to health disparities among different cultural groups. Socioeconomic status, race, educational level, and physical proximity to health-care facilities are all factors that contribute to health disparities. For instance, distrust of mainstream Western medicine in Black and American Indian communities due to a long history of systemic discrimination can further health disparities by preventing community members from seeking preventative care. Black and American Indian populations experience increased stress levels of systemic discrimination and have higher rates of obesity, diabetes, hypertension, and heart disease when compared with White populations (Perreira et al., 2019; Weinstein et al., 2017). This represents one example of why it is important for the nurse to provide culturally sensitive care to all groups and foster a trusting relationship with the client.

Healer Variations among Different Cultures

Every culture develops its own ways of dealing with health and illness. Some use traditional healing, the various medicines and healing practices around the world that differ from the modern, Western health-care system (World Health Organization, n.d.) (Table 8.1). The term encompasses a vast range of traditions and practices that differ across different regions and cultures.

Traditional healing has long been used to promote health and fight disease and is still used today by many people around the world because traditional healers tend to be accessible, affordable, familiar, and knowledgeable of the language and culture. Some people rely on traditional healers instead of Western medicine, while others choose to incorporate traditional healing practices into Western medical care.

Healing Tradition Chief Characteristics
Traditional Chinese Medicine (TCM) Belief in the idea of balance as the root of health; based on concepts of qi and yin and yang; practices include acupuncture, cupping, herbs, tai chi
Ayurveda Hindu form of medicine from India, based on the idea that disease is caused by imbalance; seeks to cure imbalances using Ayurvedic medicine, including diet, herbal medicines, yoga, and meditation
African Traditional Healing Extremely diverse and varies by tribe; belief that ancestral spirits are closely involved in the lives of the living, offer spiritual education and care, and function as counselors and social workers
American Indian Traditions Belief in spiritual and physical health as intertwined; the healer’s role is to help the individual as they help themselves; ritual and ceremony have key roles in healing
Hispanic Traditions Curanderismo is a holistic practice rooted in beliefs that health is achieved through the right balance of mind, body, and spirit; healers focus not only on the individual’s physical health, but also on their mental health, diet, personal/social relationships, and more; use various healing methods, including prayer, oils, herbs, special diets, massage, and other spiritual rituals
Western European Traditions Role of client at the center of the client-healer relationship is crucial; strong foundation in using medicines created from natural elements, including herbs, plants, minerals, and animals
Table 8.1 Healing Traditions

Asian Traditions

Asian healing traditions are rooted in the concept of balance. Two of the more well-known traditions are Traditional Chinese Medicine and Ayurveda. Both Traditional Chinese Medicine and Ayurveda have become increasingly popular in recent years as complementary therapies to Western medicine.

Traditional Chinese Medicine (TCM) is an ancient practice based on the ideas of qi and yin and yang. Qi is the life force that runs through one’s body; yin and yang are the opposite qualities of qi that must be in balance for optimal health (Johns Hopkins Medicine, 2019b). TCM consists of such practices as acupuncture, acupressure, cupping, herbs, tai chi, and others (Figure 8.2). The Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) is a federally recognized organization that accredits schools in the United States that teach acupuncture and TCM.

A man measuring out herbs for use in Traditional Chinese Medicine.
Figure 8.2 Various herbs shown here are used in Traditional Chinese Medicine. ("Chinese prescriptions" by Tim Wilson/Flickr, CC BY 2.0)

Ayurveda is the traditional Hindu form of medicine from India that is based on the idea that disease is caused by an imbalance in the body. Ayurvedic medicine seeks to cure this imbalance through a combination of diet, herbal medicines, yoga, and meditation. In India, Ayurvedic medicine is considered equivalent to conventional Western medicine, and providers receive formal training, but there is no licensing process for Ayurvedic practitioners in the United States (Johns Hopkins Medicine, 2019a). Ayurvedic medicine consists of herbs, spices, minerals, and other substances that can interfere with conventional drugs; a thorough list of all medicines and supplements is an important part of the nursing assessment for this reason.

African Traditions

African healing traditions have their foundations in practices dating back thousands of years. Although specific religious traditions vary from tribe to tribe, traditional African healing is rooted in the idea that ancestral spirits are closely involved in the lives of the living, and act as “mediators” between the living and God (Mokgobi, 2014). As Christianity and Islam began to spread across the continent, many people converted from traditional religions, but continued the use of traditional practices while also using Westernized health care.

Different tribes have different types of healers; for example, the Bapedi tribe has diviners (Ngaka ya ditaola), Sanusi (or Sedupe), traditional surgeons, and traditional birth attendants. Diviners and Sanusi can diagnose and prescribe treatment for mental, physical, and spiritual afflictions (Zuma et al., 2016). Surgeons have been trained to perform circumcisions on boys, along with the duties of diviners and Sanusi. Older women who have experience assisting with births over many years become traditional birth attendants. African traditional healers do more than help with physical illness and injury, however. They also offer spiritual education and care and have special knowledge of traditional culture, which allows them to function as counselors and social workers.

Native American Traditions

In Native American and Alaska Native cultures, physical and spiritual health are interconnected. The belief is that in order for the body to heal, the soul must heal as well. Native American healers believe that the individual is the source of most of the healing, and is responsible for their own health, wellness, and behavior. The healer’s role is to help the individual as they heal themselves, although the individual’s family and community play an important part as well (National Institutes of Health (NIH), n.d.).

Ritual and ceremony hold a key role in traditional Native American healing. Purifying and cleansing the body, whether through sweating or purging, is an important practice in some Native American healing rituals. Smudging is another practice that involves cleansing a place or person with the smoke of certain sacred plants. Some healing ceremonies can involve whole communities. These ceremonies can include music, painting bodies, dancing, exorcisms, sand paintings, stories, and use of mind-altering substances. These ceremonies are a way to seek spiritual assistance and physical healing (NIH, n.d.). Researchers call for mentorship and outreach in nursing education to incorporate culture and tradition into academic programs (Moore, 2023).

Members of the Native American Church are legally allowed to use peyote, a hallucinogen, during religious ceremonies. It can cause hallucinations and alterations in perceptions of space, time, and self. Physical symptoms include nausea, vomiting, dilated pupils, increased heart rate, elevated blood pressure, perspiration, headaches, muscle weakness, and impaired motor coordination. In rare cases, large doses have been reported to cause bradycardia, hypotension, and respiratory depression (Department of Justice, 2020). Peyote has been used for centuries by American Indians and is considered a sacred plant.

Hispanic Traditions

Traditional Hispanic medicine is performed by healers called curandera (women) or curandero (men). The practice is called curanderismo, a holistic practice rooted in beliefs that health is achieved through the right balance of mind, body, and spirit. A curandero focuses not only on the individual’s physical health, but also on their mental health, diet, personal relationships, and more. Curanderos use various healing methods, including prayer, oils, herbs, special diets, and other spiritual rituals. They also act as counselors and social workers, listening to individuals talk about their problems and helping them build an emotional support network (Cruz et al., 2022).

Western European Traditions

The central role of the client in the healer-client relationship is foundational to modern Western European healing culture. There is also a strong emphasis on technology and scientific evidence of healing practices.

Traditional European medicine has a strong foundation in using medicines created from natural elements, including herbs, plants, minerals, and animals (Firenzuoli & Gori, 2007). Homeopathy and naturopathy both have roots in European tradition. Individuals who rely on herbal and plant-based remedies tend to either use them in conjunction with conventional Western medicine or view them as alternatives to harsher methods of treatment. Examples are discussed later in this chapter. Nurses should provide quality education to their clients about clinical evidence of the effectiveness of these complementary and alternative therapies (Leonti & Verpoorte, 2017).

Counteracting Implicit Bias

Everyone holds biases that reflect their own personal belief systems. One type of bias is called explicit bias, a consciously held set of beliefs about a particular group of people based on characteristics. Explicit bias is what we typically think of when we see or hear the word bias. A person might be openly biased against someone due to their age, gender, race, sexuality, or another reason. An overtly racist comment is an example of explicit bias (Sabin, 2022).

In comparison, implicit bias refers to unconscious biases. Implicit bias is an automatic reaction toward a group of people involving subconscious feelings, perceptions, attitudes, and stereotypes. People may hold conscious beliefs about equality and fairness while still having unconscious, implicit biases that contradict these beliefs.

Bias negatively affects the client-provider relationship, leading to poorer quality care and worse outcomes for certain groups. For example, research studies have shown that implicit bias regularly leads to the undertreatment of pain in Black individuals (Sabin, 2022). Implicit bias can be difficult to change. The first step in overcoming implicit biases is to become aware of them; training in diversity and inclusiveness can also help identify problematic feelings, thoughts, and behaviors.


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