1. CULTURAL CONCERNS IN NURSING
Presented by:
Jade Kaniowski, Lacey Kelley, Heather Kyle, Laura Lindsey, Kimberly Peters

2. Cultural Concerns in Nursing
Being aware of or inquiring about a person's
cultural or religious beliefs with respect to
medical care can help nurses avoid causing
cultural pain to patients. These concerns must
be a priority when caring for patients and must
be respected in order to gain a patient’s trust
and to be able to holistically care for them.
Caring for patients not only focuses on the
physical aspect of health, but must also include
the mind and spirit as well.

3. Culture
Shared system of beliefs, values, and behavioral
expectations that provide social structure for
daily living.

4. Cultural Diversity
It is the cultural variety and differences that
exist in the world, a society or an institution. It
is having a group of diverse people in one place.
People working or living together that have
different cultures.

5. Cultural Sensitivity
Being aware that cultural differences and similarities
exist and that they can have an effect of
behavior, values and learning. It also means to be
aware and tolerant of these differences and
acknowledging them when interacting with others.

6. Stereotyping
Categorizing individuals or groups of people into an
oversimplified or standardized image or idea. It’s
when you assume that a belief or characteristic is
shared by all in one class, culture or ethic group.

7. Cultural bias
To give an advantage to one cultural over
another. To ignore the differences between
cultures and impose understanding based on
the study of one culture to other cultures. To
think one culture has precedence of the other.

8. Cultural Influences on Healthcare
• Physiologic Characteristics
• Psychological Characteristics
• Reactions to Pain
• Gender roles
• Language and communication
• Orientation to space and time
• Food and nutrition
• Socioeconomic Factors

9. Physiologic Characteristics
Certain racial groups are more prone to specific diseases
and conditions.
Examples include:
• Keloids
• Lactase deficiency and lactose intolerance
• Sickle cell anemia

10. Psychological Characteristics
In most situations, a person interprets the
behaviors of another person in terms of her or
his own familiar culture.

11. Reactions to Pain
Healthcare researchers have discovered that many of the expressions
and behaviors exhibited by people in pain are culturally prescribed.
Nursing care for patients in pain should be individualized, but
important culture-sensitive considerations include the following:
• Recognize that culture is an important component of individuality
and that each person holds various beliefs about pain
• Respect the patient’s right to respond to pain in whatever manner
is culturally and individually appropriate
• Never stereotype a patient’s perceptions or responses to pain
based on the persons culture

12. Gender roles
In many cultures either the man or woman is the
dominant figure and generally makes decisions for
the family.
Knowing who is the dominant member of the family
is an important consideration when planning
nursing care.

13. Language and communication
• To avoid misinterpretation of questions and answers, it
is important to use an interpreter who understands the
healthcare system.
• When caring for culturally and ethnically diverse
patients it is important to perform a transcultural
assessment of communication.

14. Orientation to space and time
• Personal space is the area around a person regarded as
part of the person. This area, individualized to each
person and to different cultures and ethnic groups, is
the area others should not intrude during personal
interactions.
• Different cultures vary in being future, present, or past
oriented.

15. Food and nutrition
Food preferences and how foods are prepared
are often related to culture. Patients in a
hospital or long term care often do not have a
choice in foods. This can be a cause for weight
and health changes in a patient.

16. Socioeconomic Factors
Research suggests that both physical and mental
health are associated with Socioeconomic
status(SES). In particular, studies suggest that lower
SES is linked to poorer health outcomes. Poor
health may in turn decrease an individual’s capacity
to work, thus reducing their ability to improve their
SES.

17. CULTURALLY COMPETENT NURSING CARE
Providing culturally competent care means that
care is planned and implemented in a way that is
sensitive to the needs of individuals, families, and
groups from a diverse populations within society.
• Cultural assessment
• Guidelines for care

18. Cultural assessment
When caring for patients from a different
culture, it is important to find out how they
want to be treated based on their cultural values
and beliefs. An effective way to identify specific
factors that influence a patient’s behavior is to
perform a cultural assessment.

19. Guidelines for Care
Cultural competency is a process and takes time. It involves developing
awareness, acquiring knowledge, and practicing skills. As defined by
Campinha-Bacote (2003), the nurses should answer the following
questions when caring for culturally diverse patients:
• Am I aware of my personal biases and prejudices toward cultural
groups different from mine?
• Do I have the skill to conduct a cultural assessment in a sensitive
manner?
• Do I have knowledge of the patient’s worldview?
• How many encounters have I had with patients from diverse
cultural backgrounds?
• What is my genuine desire to be culturally competent?

20. Assessment Tool
Andrews/Boyle Transcultural Nursing
Assessment Guide
This is an example of an assessment guide that is intended to
help the learner as he or she strives toward cultural competency.

21. Andrews/Boyle Transcultural Nursing Assessment Guide
Cultural Affiliations
With what cultural group(s) does the client report affiliations
(e.g., American, Hispanic, Navajo, or combination)?
To what degree does the client identify with the cultural group
(e.g., “we” concept of solidarity or as a fringe member)?
Where was the client born?
Where has the client lived (country, city) and when (during
what years)? Note: If a recent relocation to the United
States, knowledge of prevalent diseases in country of origin
may be helpful. Current residence? Occupation?

22. Andrews/Boyle Transcultural Nursing Assessment Guide
Values Orientation
What are the client’s attitudes, values, and beliefs about developmental life events such as birth and
death, health, illness, and healthcare providers?
Does culture affect the manner in which the client relates to body image change resulting from illness
or surgery (e.g., importance of appearance, beauty, strength, and roles in cultural group)?
Is there a cultural stigma associated with the client’s illness (i.e., how is the illness or client condition
viewed by the larger culture)?
How does the client view work, leisure, education?
How does the client perceive change?
How does the client perceive changes in lifestyle relating to current illness or surgery?
How does the client value privacy, courtesy, touch and relationships with individuals of different
ages, social class (or caste), and gender?
How does the client view biomedical/scientific health care (e.g., suspiciously, fearfully, acceptingly)?
How does the client relate to persons outside of his or her cultural group (e.g., withdrawal, verbally or
nonverbally expressive, negatively or positively)?

23. Andrews/Boyle Transcultural Nursing Assessment Guide
Cultural Sanctions and Restrictions
How does the client’s cultural group regard expression of emotion and
feelings, spirituality, and religious beliefs? How are dying, death, and
grieving expressed in a culturally appropriate manner?
How is modesty expressed by men and women? Are there culturally
defined expectations about male-female relationships, including the
nurse-client relationship?
Does the client have any restrictions related to sexuality, exposure of
body parts, certain types of surgery
(e.g., amputation, vasectomy, hysterectomy)?
Are there any restrictions against discussion of dead relatives or fears
related to the unknown?

24. Andrews/Boyle Transcultural Nursing Assessment Guide
Communication
What language does the client speak at home? What other languages does the client speak or read? In what
language would the client prefer to communicate with you?
What is the fluency level of the client in English—both written and spoken use of the language? Remember
that the stress of illness may cause clients to use a more familiar language and to temporarily forget some
English.
Does the client need an interpreter? If so, is there a relative or friend whom the client would like to interpret?
Is there anyone whom the client would prefer did not serve as an interpreter (e.g., member of the opposite
sex, a person younger/older than the client, member of a rival tribe or nation)?
What are the rules (linguistics) and modes (style) of communication? How does the client prefer to be
addressed?
Is it necessary to vary the technique of communication during the interview and examination to accommodate
the client’s cultural background (e.g., tempo of conversation, eye contact, sensitivity to topical taboos, norms
of confidentiality, and style of explanation)?
How does the client’s nonverbal communication compare with that of individuals from other cultural
backgrounds? How does it affect the client’s relationship with you and with other members of the healthcare
team?
How does the client feel about healthcare providers who are not of the same cultural background
(e.g., black, middle-class nurse and Hispanic of a different social class)?
Does the client prefer to receive care from a nurse of the same cultural background, gender, and/or age?
What are the overall cultural characteristics of the client’s language and communication processes?
Health-Related Beliefs

25. Andrews/Boyle Transcultural Nursing Assessment Guide
Health-Related Beliefs and Practices
To what cause(s) does the client attribute illness and disease (e.g., divine wrath, imbalance in hot/cold or
yin/yang, punishment for moral transgressions, hex, soul loss, pathogenic organism)?
What are the client’s cultural beliefs about ideal body size and shape? What is the client’s self-image vis-à-vis the ideal?
What name does the client give to his or her health-related condition?
What does the client believe promotes health (eating certain foods, wearing amulets to bring good
luck, sleep, rest, good nutrition, reducing stress, exercise, prayer, rituals to ancestors, saints, or intermediate deities)?
What is the client’s religious affiliation (e.g., Judaism, Islam, Pentecostalism, West African voodooism, Seventh-Day
Adventism, Catholicism, Mormonism)? How actively involved in the practice of this religion is the client?
Does the client rely on cultural healers (e.g., curandero, shaman, spiritualist, priest, minister, monk)? Who determines
when the client is sick and when he or she is healthy? Who influences the choice/type of healer and treatment that
should be sought?
In what types of cultural healing practices does the client engage (use of herbal remedies, potions, massage, wearing of
talismans, copper bracelets or charms to discourage evil spirits, healing rituals, incantations, prayers)?
How are biomedical/scientific healthcare providers perceived? How does the client and his or her family perceive
nurses? What are the expectations of nurses and nursing care?
What comprises appropriate “sick role” behavior? Who determines what symptoms constitute disease/illness? Who
decides when the client is no longer sick? Who cares for the client at home?
How does the client’s cultural group view mental disorders? Are there differences in acceptable behaviors for physical
versus psychological illnesses?

26. Andrews/Boyle Transcultural Nursing Assessment Guide
Nutrition
What nutritional factors are influenced by the client’s cultural background? What is the meaning of food and
eating to the client?
With whom does the client usually eat? What types of food are eaten? What is the timing and sequencing of
meals?
What does the client define as food? What does the client believe comprises a “healthy” versus an “unhealthy”
diet?
Who shops for food
? Where are groceries purchased (e.g., special markets or ethnic grocery stores)? Who prepares the client’s
meals?
How are foods prepared at home (types of food preparation, cooking oil(s) used, length of time foods are
cooked, especially vegetables, amount and type of seasoning added to various foods during preparation)?
Has the client chosen a particular nutritional practice such as vegetarianism or abstinence from alcoholic or
fermented beverages?
Do religious beliefs and practices influence the client’s diet (e.g., amount, type, preparation or delineation of
acceptable food combinations, e.g. kosher diets)? Does the client abstain from certain foods at regular
intervals, on specific dates determined by the religious calendar, or at other times?
If the client’s religion mandates or encourages fasting, what does the term fast mean (e.g., refraining from
certain types or quantities of foods, eating only during certain times of the day)? For what period of time is the
client expected to fast?
During fasting, does the client refrain from liquids/beverages? Does the religion allow exemption from fasting
during illness? If so, does the client believe that an exemption applies to him or her?

27. Andrews/Boyle Transcultural Nursing Assessment Guide
Socioeconomic Considerations
Who comprises the client’s social network (family, friends, peers, and cultural
healers)? How do they influence the client’s health or illness status?
How do members of the clients social support network define caring (e.g., being
continuously present, doing things for the client, providing material support, looking
after the client’s family)? What is the role of various family members during health
and illness?
How does the client’s family participate in the promotion of health (e.g., lifestyle
changes in diet, activity level, etc.) and nursing care
(e.g., bathing, feeding, touching, being present) of the client?
Does the cultural family structure influence the client’s response to health or illness
(e.g., beliefs, strengths, weaknesses, and social class)? Is there a key family member
whose role is significant in health-related decisions (e.g., grandmother in many African
American families or oldest son in Asian families)?
Who is the principal wage earner in the client’s family? What is the total annual
income? (Note: This is a potentially sensitive question.) Is there more than one wage
earner? Are there other sources of financial support (extended family, investments)?
What insurance coverage (health, dental, vision, pregnancy) does the client have?
What impact does economic status have on lifestyle, place of residence, living
conditions, ability to obtain health care? How does the client’s home environment
(e.g., presence of indoor plumbing, handicap access) influence nursing care?

28. Andrews/Boyle Transcultural Nursing Assessment Guide
Organizations Providing Cultural Support
What influences do ethnic/cultural organizations have on the client’s
receiving health care (e.g., Organization of Migrant Workers, National
Association for the Advancement of Colored People, Black Political
Caucus, churches such as African American, Muslim, Jewish, and
others, schools including those which are church-related, Urban
League, community-based healthcare programs and clinics)?
Educational Background
What is the client’s highest educational level obtained?
Does the client’s educational background affect his or her knowledge level
concerning the healthcare delivery system, how to obtain the needed
care, teaching-learning, and any written material that he or she is given in the
healthcare setting (e.g., insurance forms, educational literature, information
about diagnostic procedures and laboratory tests, admissions forms)?
Can the client read and write English, or is another language preferred? If
English is the client’s second language, are materials available in the client’s
primary language?
What learning style is most comfortable/familiar? Does the client prefer to
learn through written materials, oral explanation, or demonstration?

29. Andrews/Boyle Transcultural Nursing Assessment Guide
Religious Affiliation
How does the client’s religious affiliations affect health and illness
(e.g., life events such as death, chronic illness, body image
alteration, cause and effect of illness)?
What is the role of religious beliefs and practices during health and
illness? Are there special rites or blessings for those with serious or
terminal illnesses?
Are there healing rituals or practices that the client believes can
promote well-being or hasten recovery from illness? If so, who
performs these?
What is the role of significant religious representatives during health
and illness? Are there recognized religious healers (e.g., Islamic
Imams, Christian Scientists practitioners or nurses, Catholic
priests, Mormon elders, Buddhist monks)?

30. Andrews/Boyle Transcultural Nursing Assessment Guide
Cultural Aspects of Disease Incidence
Are there any specific genetic or acquired conditions that are more prevalent
for a specific cultural group (e.g., hypertension, sickle cell anemia, Tay
Sachs, G6PD, lactose intolerance)?
Are there socioenvironmental diseases more prevalent among a specific
cultural group (e.g., lead poisoning, alcoholism, HIV/AIDS, drug abuse, ear
infections, family violence)?
Are there any diseases against which the client has an increased resistance
(e.g., skin cancer in darkly pigmented individuals, malaria for those with sickle
cell anemia)?
Biocultural Variations
Does the client have distinctive physical features characteristic of a particular
ethnic or cultural group (e.g., skin color, hair texture)? Does the client have
any variations in anatomy characteristics of a particular ethnic or cultural
group (e.g., body structure, height, weight, facial shape and structure
[nose, eye shape, facial contour], upper and lower extremities)?
How do anatomic, racial, and ethnic variations affect the physical
examination?

31. Andrews/Boyle Transcultural Nursing Assessment Guide
Developmental Considerations
Are there any distinct growth and development characteristics that vary with
the client’s cultural background (e.g., bone density, psychomotor patterns of
development, fat-folds)?
What factors are significant in assessing children of various ages from the
newborn period through adolescence (e.g., expected growth on standard
grid, culturally acceptable age for toilet training, introducing various types of
foods, gender differences, discipline, socialization to adult roles)?
What is the cultural perception of aging (e.g., is youthfulness or the wisdom
of old age more highly valued)?
How are elderly persons handled culturally (e.g., cared for in the home of
adult children, placed in institutions for care)? What are culturally acceptable
roles for the elderly?
Does the elderly person expect family members to provide care, including
nurturance and other humanistic aspects of care?
Is the elderly person isolated from culturally relevant supportive persons or
enmeshed in a caring network of relatives and friends?
Has a culturally appropriate network replaced family members in performing
some caring functions for the elderly person?

32. Andrews/Boyle Transcultural Nursing Assessment Guide
Retrieved from:
http://www.ons.org/clinicalresources/specialpopulations/Transcultural
/media/ons/docs/clinical/MulticulturalToolkit/tools-andrewsboyle.pdf
Source:
Transcultural Concepts in Nursing Care (3rd ed.) by M.M. Andrews and
J.S. Boyle, 1999, Philadelphia: Williams and Wilkins. Copyright 1999 by
Williams and Wilkins.
Validity: Transcultural theories, models, and
research studies
http://www.tcns.org/files/TransculturalConceptsin
NursingCareSummary.pdf

33. Nursing Interventions: Cultural Needs
• Respect patient autonomy and promote the good of the patient by being consistent with culturally
competent care/rationale: Leever (2011) states that one must be sensitive to the cultural
background by respecting the autonomy of the patient instead of forcing our own values or ways of
doing things upon our patients. Nurses should not assume that autonomy is linked to selfishness by
the patient, but that allowing for patient autonomy is intended to promote one’s own good.
Autonomy is individual liberty and allowing patients to make their own choices without coercion or
constraint.
• Communicate respect to achieve cross-cultural competent care by caring for all patients
equally, regardless of cultural background/rationale: Mackenzie (2011) states that culture has a
profound influence of the perception of respect and the ways respect can be communicated varies
across different cultures. Nurses must be aware of the cultural background of their patients and
know the proper ways to communicate to develop a respected relationship with their patients. It is
usually not just a single instance of perceived disrespectful communication that damages a
relationship, and often a relationship can still be established as the nurse learns the cultural
background of their patients.
• Be culturally aware and culturally sensitive of your own views and those of your patients by being
aware of your own culture, bias, and world wide views and how they influence your care delivery
and respect, accept, and value your own and other’s personal attitudes, values, beliefs, and
practices that reflect cultural background/rationale: Starr (2011) states that culturally congruent
care results from interactions between clients and their care providers. Perspectives from both
parties are need to develop and evaluate culturally congruent care.

34. Case Study
A female patient in her mid 40's comes into the hospital screaming while
holding her abdomen. She can not speak any English. Jane RN asks the
patient her name. She replies, “Maria”. Jane RN asks the patient her last
name. She again replied, “Maria”. Jane RN and her patient went through this
over and over. Jane RN could not speak any Spanish and the patient could not
speak any English.
After several minutes of her holding her abdomen and yelling at the Jane RN
in Spanish, The RN got out the over-the-phone interpreter. Jane RN was then
connected to a nice lady who interpreted everything she said. The interpreter
was very calming to the patient. Jane RN learned her patient’s name and that
she had been having horrible abdominal pain for 2 days. After doing some
tests, we found that she had appendicitis. She was very afraid and had a lot of
questions. We again communicated with the over-the-phone interpreter. Jane
RN learned a lot about her patient and her culture and the RN felt that she
bonded with her patient.
Since that patient, Jane RN has had several more Hispanic patients. She has
learned that Hispanic women often express their pain loudly. Jane RN has
seen other nurses that she works with become very annoyed at the way
Hispanics vocalize their pain. It is important not to generalize the way
patients should express themselves. We must accept them and become
familiar with their culture.

35. Case Study Questions
1.Based on Andrews/Boyle Transcultural Nursing
Assessment Guide what do you believe the number
one cultural consideration in the situation with Maria
should be?
2. Name one Nursing Diagnosis with Intervention for
the patient in this case study.
3. Do you feel the care givers in this case study were
culturally competent?

36. Links to Learn More…
• http://www.culturediversity.org/index.html
• http://www.apa.org/about/gr/issues/socioeco
nomic/ses-health.aspx
• http://www.barnesjewish.org/about/diversity

37. References
Fernandez, V. M., & Fernandez, K. M. (2011, November 05). Transcultural nursing: Basic
concepts and case studies. Retrieved from http://www.culturediversity.org/index.html
Davidhizar, R., & Giger, J. (2004). A review of the literature on care of clients in pain
who are culturally diverse. International Nursing Review, 51(1), 47-55.
Paniagua, C. T., & Taylor, R. E. (2008). The Cultural Lens of Genomics. Online Journal Of Issues In
Nursing, 13(1), 2.
Parikh, A. (2008). Cultural assessment manual. Retrieved from
http://www.dbhds.virginia.gov/2008CLC/documents/clc-Trn-AmieParikh-revis-cult-
assess.pdf
http://www.apa.org/about/gr/issues/socioeconomic/ses-health.aspx
Lillis, C., & Taylor, C. R. (2008). Fundamentals of nursing, the art and science of nursing care. (6th
ed.). New York, NY: Lippincott Williams & Wilkind.