Note: all cases below are taken directly from Caring for Patients From Different Cultures, 2nd edition. All names used are pseudonyms. I have purposely chosen examples of individuals who have not assimilated to a great degree and whose beliefs and behaviors deviate from those expressed in the American health care system. It should not be inferred that all or even most members of these groups will act in the manner described. The ones who are most Westernized do not generally present problems. It is those who adhere to traditional ways that are most likely to, hence their inclusion in this section. It should be remembered, however, that assimilation occurs in unpredictable stages. Individuals may be quite Westernized in some areas but traditional in others. These are meant to represent generalizations, rather than stereotypes.
Stereotype
vs. Generalization
Mrs. Mendez,
a sixty-two-year-old Mexican patient, had just had a femoral-popliteal
by-pass graft on her right leg. She was still under sedation when she
entered the recovery room, but an hour later, she awoke and began screaming,
"Aye! Aye! Aye! Mucho dolor! (much pain). " Robert, her nurse, immediately
administered the dosage of morphine the doctor had prescribed. This, however,
did nothing to diminish Mrs. Mendez's cries of pain. He then checked her
vital signs and pulse; all were stable. Her dressing had minimal bloody
drainage. To all appearances, Mrs. Mendez was in good condition. Robert
soon became angry over her outbursts and stereotyped her as a "whining
Mexican female who, as usual, was exaggerating her pain. "
After another hour, Robert called the physician. The surgical team came on rounds and opened Mrs. Mendez's dressing. Despite a slight swelling in her leg, there was minimal bleeding. However, when the physician inserted a large needle into the incision site, he removed a large amount of blood. The blood had put pressure on the nerves and tissues in the area and caused her excruciating pain.
She was taken back to the operating room. This time, when she returned and awoke in recovery, she was calm and cooperative. She complained only of minimal pain. Had the physician not examined her again and discovered the blood in the incision site, Mrs. Mendez would have probably suffered severe complications.
Despite the fact that Mexicans are generally expressive of their pain, it does not mean that every Mexican patient will be, or that there is not a legitimate basis for their cries. The generalizations on this website are meant to be only generalizations; beware the dangers of stereotyping ã it can have disastrous consequences.
Prejudice
and Discrimination
John Harris, a sixty-eight-year-old African American male was scheduled
to have his cancerous prostate removed at a government hospital. Two days
after scheduling the procedure, he called Karen, his nurse, in panic.
He had spoken to several friends about his upcoming surgery, and now wanted
to know about various forms of alternative treatments. Karen spent about
an hour on the phone with him and gave him a great deal of information
as well as phone numbers he could call to learn about other options. She
realized that he was probably overwhelmed and frightened about his diagnosis.
Right before hanging up, Mr. Harris said, "You know I trust you, Karen; I just don't know if I trust the hospital to take care of me. I have older friends who were subjected to government studies without knowing it back in the 1940s and 1950s." Karen suddenly realized it wasn't just the cancer he feared, but what a white institution might do to him, a Black man. The experiments done with syphilitic Black men who were left untreated in order to study the course of the disease are infamous.
It is no wonder that many African Americans are distrustful of hospitals and white institutions in general. Prejudice and discrimination are real. Not surprisingly, if you have been a frequent victim of discrimination, you are likely to come to expect it.
Values
Linh Lee, a sixty-four-year-old Chinese woman hospitalized for an acute
evolving heart attack. At discharge, her physician suggested that she
come back in two weeks for a follow-up examination. She agreed to do so,
but never returned. It is likely that she never intended to do so but
agreed because he was an authority figure. Chinese are taught to value
accommodation. Rather than refuse to the physician's face and cause him
dishonor, Mrs. Lee agreed. She simply did not follow through, sparing
everyone embarrassment.
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Informed
Consent/Interpreters
An Hispanic woman, Graciela Mendoza, had to sign an informed consent form
for a hysterectomy. Her bilingual son served as the interpreter. When
he described the procedure to his mother, he appeared to be translating
accurately and indicating the appropriate body parts. His mother signed
willingly. The next day, however, when she learned that her uterus had
been removed and that she could no longer bear children, she became very
angry and threatened to sue the hospital. What went wrong?
Because it is inappropriate for an Hispanic male to discuss her private parts with his mother, the embarrassed son explained that a tumor would be removed from her abdomen and pointed to that general area. When Mrs. Garcia learned that her uterus had been removed, she was quite angry and upset because an Hispanic woman's status is derived in large part from the number of children she produces. When dealing with anything remotely sexual, it is best not to use family members; if necessary, at least make every effort to use same-sex family members.
Touching
The Orthodox Jewish husband of a patient refused to shake the nurse's
hand when she held it out to him. At the time, she thought he was being
rude. He wasn't; he was merely following the Jewish prohibition against
touching between members of the opposite sex. The same rule holds true
for Muslims. Whenever possible, same-sex caregivers should be assigned
to Orthodox Jews and Muslims, and opposite-sex touching should be avoided.
Attitudes
Toward Pain Medication
Cecilia was a Filipino nurse in one of my classes. One day we were discussing
the tendency of Filipino nurses to undermedicate their pain patients.
If the physician prescribes a range of dosages, they will often administer
the lowest dose. When asked about this, Filipino students have given a
number of explanations: pain medication is scarce in the Philippines,
so they are trained not to use too much; addiction is highly feared; stoicism
is valued; and, for Catholic Filipinos, there is virtue in suffering.
After a few
minutes, I noticed tears falling from Cecilia's eyes. When I asked her
what was wrong, she explained that a year earlier her mother had died
of cancer. The doctor had prescribed high dosages of pain medication in
the months before her death. Cecilia administered the medication to her
mother, but out of habit had cut each dosage in half before giving it
to her mother. She did not want her mother to become addicted, she explained.
Now, in class, she realized that she had allowed her mother to suffer
needlessly. She was dying; what would it matter if she became addicted
to the medication? The important lesson here is that caregivers must examine
their own attitudes toward the use of pain medication and not let them
affect the way they administer it to patients.
Blood
Transfusions
Susi, a thirty-seven-year-old woman with two children, was horseback riding
one day when a snake startled her horse. She was thrown off and landed
on a stump, resulting in massive internal injuries. She was rushed to
the hospital, where the surgical team discovered that there was a large
amount of blood in her abdomen and that she needed to have a kidney removed.
Susi had a medical alert card identifying her as a Jehovah's Witness and stating that under no circumstances was she to receive blood. Her physician knew this, but felt impelled by his oath to save lives to give her a blood transfusion. The hospital was unable to locate SusiÐs husband, so Dr. Andrews decided to transfuse her.
His actions saved Susi's life; however, Susi was not grateful. She sued her doctor for assault and battery, and won a $20,000 settlement! In a study done of Jehovah's Witnesses in the 1980s, two-thirds of those polled said they would sue if transfused against their will. A physician in a position like that of Dr. Andrews' should realize the possible ramifications (including legal ones) of violating the patients' express wishes in order to fulfill his own beliefs (Hippocratic oath) and make a conscious, fully informed decision.
Sometimes a Jehovah's Witness will reconsider at the last minute. For example, a twenty-seven-year-old woman who began bleeding heavily several days after giving birth required a hysterectomy. After the operation, she urgently needed blood but refused it. Two days later, when she developed acute respiratory distress and had to be placed on a respirator, she agreed to the blood transfusion. It saved her life.
Many health care professionals have strong moral difficulty in respecting the Jehovah's Witness position. The conflict lies in two areas: values and world view. The Jehovah's Witnesses believe that when Armageddon comes 144,000 of those who have followed God's laws (as interpreted by the Jehovah's Witnesses) will rise from the dead to spend eternity in heaven. Those who have followed GodÐs laws but do not go to heaven will spend eternity in a paradise on earth. All those who have violated God's laws (e.g., had a blood transfusion, placed themselves above God by celebrating their own birthdays, or worshipped idols by saluting the American flag) are doomed to spend eternity in nothingness.
Suppose for a moment that they are correct. Choosing to have a blood transfusion can be interpreted as giving up the chance to spend eternity in heaven or paradise in exchange for a few more years on earth. In this scenario, it is not very rational to have a blood transfusion. Few health care professionals are Jehovah's Witnesses. They do not believe that the fate of their soul rests on whether they have a blood transfusion. Thus the world view of Jehovah's Witness patients comes into direct conflict with that of most health care professionals.
Most health care professionals value the life of the physical body. In refusing blood, the Jehovah's Witness is valuing the life of the soul over that of the physical body. The question is, Does any group have the right to impose its values and beliefs on others? Can we be so arrogant and ethnocentric as to be sure we are right and they are wrong?
The issue is most difficult when children are involved. Do their parents have the right to choose for them? This question is not easily answered. In an extreme case, parents abandoned their child after he had been given a blood transfusion under court order.
Finally, there are social issues. If an individual who is a member of a very tightly knit, conservative group of Jehovah's Witnesses accepts blood, the act might lead to rejection by his or her entire social network. A few more years of life may not be worth that price.
Why do some members change their mind and accept blood at the last minute? Obviously, not all members of a religion are equally devout. Many people have doubts about their beliefs. When it is a matter of life and death, faith is often not strong enough to dictate the giving up of life.
Dealing with a Jehovah's Witness patient can be very difficult if the need for a blood transfusion arises. Doctors and nurses often feel helpless and frustrated. They value life so strongly that they find it hard to understand why some people willingly choose to give it up. Perhaps they should try to see the situation from the emic perspective and consider the possibility that the Jehovah's Witnesses are right.
Drawing
Blood
Saelee Mui Chua, a forty-two-year-old Mien gentleman, arrived at the clinic
with his twelve-year-old son, who acted as interpreter. The son explained
that his father had seen a traditional healer the previous week, but he
had been unable to cure his father's symptoms: weakness, fatigue, increased
urination, and thirst. The symptoms suggested diabetes to the physician,
and he ordered a blood glucose test. When Shawnee, the nurse, came to
draw the blood, Mr. Saelee fearfully yelled, "No!" His son told Shawnee
that his father refused to have his blood drawn. When she asked for an
explanation, all he would say is, "My father does not want the test."
The staff assumed that Mr. Saelee was afraid of the needle. However, it is more likely that he was concerned about having his blood drawn. There is a Mien legend about an evil bird that brought bad fortune and death by drinking a personÐs blood. This is probably connected to the Mien belief that losing blood saps strength (Mr. Saelee was already feeling weak) and may result in the soul leaving the body.
The staff tried to "educate" Mr. Saelee about the procedure of drawing blood, and explained its importance in diagnosing his symptoms, but their efforts were to no avail. He would not give his permission for the procedure and simply left the hospital.
What could have been done? While there are no guarantees that any intervention could have changed Mr. SaeleeÐs mind, they might have explained that the amount of blood needed was extremely small, and that new blood would be made to replace it. If possible, perhaps the traditional healer could have been involved in the procedure. They might have also spent more time explaining why the tests were so necessary. The connection between his symptoms and his blood is not immediately obvious.
Sacred
Symbols
A Cambodian infant was brought into the hospital diagnosed with dehydration
5 percent. Mona, the nurse, examined the child's extremities, looking
for a vein in which to start an intravenous line. She found one on the
baby's arm. At that point, she noticed several strands of dark brown strings,
about one-half inch wide, on both wrists. Mona prepared to cut the strings
with scissors. Mrs. Tep, the baby's mother, walked in at that moment,
looked horrified at what Mona was about to do, and began speaking loudly
in her native tongue. Mona assumed she was upset because the infant was
crying. But Mrs. Tep kept pointing to the strings; it was obvious that
she did not want them cut. Mona did not understand what the problem was,
but communicated through gestures that she would not cut the strings.
She then started an intravenous line in the infant's scalp. When the baby's parents saw this, the mother began to cry. While it is distressing for any parent to see intravenous lines put into a sick child's scalp, for many Southeast Asians, it is especially traumatic. As the Teps explained through an interpreter, the head is thought to be the seat of life. By introducing holes into it, the nurse had made an easy exit for the childÐs soul.
What was the problem with the strings? They are known as baci. It is a tradition believed to have originated with the Lao culture, but is practiced by the Mien and Cambodians as well. The strings are tied around a person's wrists at important occasions such as birthdays, promotions, weddings, and so forth. They are believed to "tie in the soul" so it doesn't get lost. They should never be cut off; they simply wear off in time. If Mona had cut the strings, she would have jeopardized the infant's life from the Tepses' perspective.
The
Garment
Grace Kettering, a Mormon woman, was admitted to the hospital for facial
surgery. Before entering the operating room, she was told to remove all
her clothes except the hospital gown. She refused to remove her long underwear,
and the surgeon refused to operate unless she did.
Devout Mormons who have attained adult religious status in the church wear "the garment." It resembles short-sleeved long underwear and ends just above the knee. While most Mormon patients will probably have no trouble removing it for surgery, having to remove the garment associated with God's protection might be very distressing for some, as it was for Mrs. Kettering.
Eventually, Mrs. Kettering's surgeon relented. In such cases, an understanding attitude and a discussion of the options beforehand are advisable. For example, the lower half of the garment could be pulled down to the patient's ankles in the event of abdominal surgery.
Evil
Eye
Sue Ramis, a home health nurse, received an angry call from Juanita Garcia,
a Mexican-American woman whose house she had visited the day before. As
Sue was leaving, she innocently remarked that Mrs. Garcia's child was
adorable. The next morning, the infant was crying and feverish. When Mrs.
Garcia recalled Sue's compliment and the fact that she had not touched
the child, she concluded that Sue had given him the evil eye. Being Anglo,
Sue had no knowledge of evil eye. She was innocent, except in the mind
of Mrs. Garcia.
Americans are raised to believe that germs cause disease. Mothers are uncomfortable when people get too close to their infants. Mexican mothers, in contrast, may worry when strangers admire their babies without touching them. The very act that is believed to protect a child from illness in one culture is thought to cause illness in another.
Each culture that believes compliments can cause the evil eye also has ways to neutralize them. Putting a bit of saliva on one's finger and making the sign of the cross on a child's forehead when giving a compliment can prevent the evil eye in some (but not all) parts of the Philippines. In Ethiopia, spitting on a child while remarking on its good looks will prevent an inadvertent casting of the evil eye. Not all Mexicans, Filipinos, or Ethiopians adhere to the belief, however, so it is important to pay close attention to nonverbal cues from the mother. Does she appear uncomfortable when you compliment her child? If so, she may believe in the evil eye.
Soul
Loss
Melissa was working in a busy pediatric intensive care unit the day she
inadvertently jeopardized Jimmy Hosea's life. Jimmy was a twelve-year-old
post-op, Navaho patient. The day he transferred into Melissa's unit, the
staff had just been given a new Polaroid camera. She gathered together
Jimmy and two other children for a photo. Because her attention was on
the two others who happily mugged for the camera, Melissa never noticed
the look of horror on JimmyÐs face until she saw the photo. He had disappeared
while it was developing.
When Melissa found him, Jimmy was sitting on the edge of his bed, gazing at the floor and looking as though he were ready to die. When she asked him what had happened, he carefully responded, "I've lost my soul." Melissa had no idea what he was talking about. He explained that pictures took the soul out of the face captured on the photograph. Melissa was astounded. How could he believe that?
She told him how sorry she was and offered him the photograph. He took it, saying that his family could help him get his soul back with a "sing," a religious ceremony.
This case is a good example of how important it is to know about the spiritual beliefs of those for whom you are caring. While it is obviously unrealistic to expect to know everything about every culture, just having an awareness that your patients' beliefs may be different from your own may help you to be more sensitive and aware. Melissa certainly is.
Hair
Raj Singh, a seventy-two-year-old Sikh from India, had been admitted to
the hospital after a heart attack. He was scheduled for a heart catheterization
to determine the extent of the blockage in his coronary arteries. The
procedure involved running a catheter up the femoral artery, located in
the groin, and then passing it into his heart where special x-rays could
be taken. His son was a cardiologist on staff and had explained the procedure
to him in detail.
Susan, his nurse, entered Mr. Singh's room and explained that she had to shave his groin to prevent infection from the catheterization. As she pulled the razor from her pocket, she was suddenly confronted with the sight of shining metal flashing in front of her. Mr. Singh had a short sword in his hand and was waving it at her as he spoke excitedly in his native tongue. Susan got the message. She would not shave his groin.
She put away her "weapon," and he did the same. Susan, thinking the problem was that she was a woman, said she would get a male orderly to shave him. Mr. Singh's eyes lit up again as he angrily yelled, "No shaving of hair by anyone!"
Susan managed to calm him down by agreeing. She then called her supervisor and the attending physician to report the incident. The physician said he would do the procedure on an unshaved groin. At that moment, Mr. Singh's son stopped by. When he heard what had happened, he apologized profusely for not explaining his father's Orthodox Sikh customs.
The Sikh religion forbids cutting or shaving any bodily hair. Orthodox Sikhs always carry a dagger with them, lest someone try to force them to do something against their religion - as Susan had. The dagger is considered one of the five "outer badges." The others are wearing hair and beard unshorn; wearing a turban; wearing knee-length pants; and wearing a steel bracelet on the right wrist. These badges reflect the Sikhs' military history.
Many of the procedures medical professionals consider necessary are not; when they conflict with patients' religious beliefs, they can be worked around. The doctor might have been willing to make compromises in Mr. Singh's case only because his son was a member of the staff. All patients should be treated with the same respect.
Dietary
Practices: Hot and Cold
Nonreligious food restrictions can also create problems. Mina Asami, a
sixty-seven-year-old Pakistani woman, was hospitalized with tuberculosis.
When Rachel, her nurse, noticed that Mrs. Asami's appetite was poor, she
became concerned. Wanting to make sure her patient received enough protein,
she made a concerted effort to feed her meat and potatoes with gravy.
Mrs. Asami, however, was uncooperative, eating only fruit and jello.
When Mrs. Asami's son Davi came to the hospital, he provided information that resolved the problem. Rachel, it appears, was trying to feed Mrs. Asami foods that Pakistanis normally avoid during the summer. Foods are either hot or cold. These are qualities, not temperatures. In the summer, Pakistanis avoid hot foods like beef because they "make our insides hot." In winter, they avoid cold foods that make their insides cold. Beef, pork, potatoes, and whiskey are all considered hot foods and are avoided in summer; in winter, Pakistanis refrain from eating cold foods such as chicken, fish, fruit, and beer. Once Rachel understood this, she ordered the appropriate foods for Mrs. Asami, who suddenly developed a much heartier appetite.
It is best to ask about food preferences during the admission interview.
.........
Self-Care
Tome Tanaka, a Japanese man in his sixties, was a patient in the rehabilitation
unit. A stroke had left him with significant weakness on his left side.
Self-care was an important part of his therapy. He had to relearn to feed
himself, dress, shave, use the bathroom, and do other daily activities.
Kathy, his nurse, spent a great deal of time carefully explaining to Mr.
Tanaka how the staff would work with him on these tasks. The patient and
his wife listened passively; his children and grandchildren appeared more
interested. Several hours later, when Mr. Tanaka's children and grandchildren
left, Kathy came into the room and discovered Mrs. Tanaka waiting on her
husband as though he were an invalid.
She was not alone in impeding his progress, however. He refused to do anything for himself and continually barked commands at her. Rather than use the toilet, he insisted that she hold the bedpan for him. He refused to brush his teeth, shave, or dress, demanding that his wife do everything for him.
Mr. Tanaka attended physical therapy and occupational therapy sessions each day and did quite well. He learned to walk with a cane. He needed minimal assistance with self-care activities. Despite his progress in therapy, however, as soon as his wife or one of his children arrived, he regressed. He was discharged after four weeks, almost as dependent as when he first came.
Kathy and the other nurses were frustrated over Mr. Tanaka's dependency, especially when they saw that he was capable of taking care of himself. They took his "failure" personally, as though they were not doing their jobs properly. What might the nurses have done differently? First, they needed to understand that patients and their families do not always share the same goals as health care personnel. Second, they might have allowed the family to observe Mr. Tanaka during physical and occupational therapy sessions. Unlike most hospitals, this one barred families from such sessions because of the potential distraction for the patient. In this case, the rule might have been waived.
Failure to care for oneself is common in cultures that emphasize the family over the individual - in other words, almost all cultures other than Anglo-American. Self-care is important to Americans in part because we value independence so highly. In contrast, Asian cultures emphasize family interdependence over independence. For them, self-care is not an important concept.
In many cases, Americans' ethnocentrism blinds them to the fact that life in a typical Asian or Hispanic household may be different from that in the normal Anglo home. Self-care may be a practical necessity in the Anglo home, where there may be no one to help the former patient with such tasks. In contrast, many Asians live in large extended family households, where someone is usually at home to care for the patient.
Another significant factor is the difference between egalitarian and hierarchical cultures. In an egalitarian culture such as our own, everyone is theoretically equal. And, theoretically, no one in the family is considered subservient to anyone else. In hierarchical Asian cultures, some members of the family are clearly dominant (males and elders) while others are clearly subordinate (females and children). The case study illustrates the proper roles of wife and children in hierarchical cultures. It is their duty to obey and care for the dominant family member - the husband and father.
Control may also play a role in the failure to care for oneself. Mr. Tanaka comes from a culture which clearly acknowledged his power and authority. He was, however, reduced to a state of physical weakness by his medical condition. Ordering people around and having them wait upon one's every need are ways of demonstrating dominance. It may masquerade as helplessness, but it is a way of maintaining control.
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Informed
Consent
A twenty-six-year-old Mexican woman named Rosa Gutierrez brought her two-month-old
son to the emergency room. Rosa was concerned because he had diarrhea
and had not been nursing. The staff discovered that he was also suffering
from sepsis, dehydration, and high fever. The physician wanted to perform
a routine spinal tap, but Rosa refused to allow it. When asked why, she
said she needed her husband's permission before anything could be done
to the baby. The staff tried to convince her that this was a routine procedure,
but Rosa was adamant. Nothing could be done until her husband arrived.
Although legally Rosa could have signed the consent, culturally she lacked the authority. In the traditional Mexican household, the man is the head of the family and makes all major decisions. Rosa was unwilling to violate that norm. Fortunately, her husband soon arrived and signed the informed consent.
Women
and Authority
An Iranian mother and father admitted their thirteen-month-old child,
Ali, to the pediatrics unit. After three days of rigorous testing and
examination, it was discovered that Ali had Wilms tumor, a type of childhood
cancer. Fortunately, the survival rate is 70 to 80 percent with proper
treatment.
Before meeting with the pediatric oncologist to discuss Ali's treatment, Mr. and Mrs. Mohar were concerned and frightened, yet cooperative. Afterward, however, they became completely uncooperative. They refused permission for even the most routine procedures. Mr. Mohar would not even talk with the physician or the nurses. Instead, he called other specialists to discuss Ali's case.
After several frustrating days, the oncologist decided to turn the case over to a colleague. He met with the Mohars and found them extremely cooperative. What caused their sudden reversal in behavior? The fact that the original oncologist was a woman.
Even though the Mohars had described themselves as "Americanized," the Iranian tradition of male authority was still strong. They could not accept a woman making life-and-death decisions for their son. Ali's treatment was too important to be decided by a woman.
Several weeks later, it became necessary to insert a permanent line into Ali to administer his medication. The nurse attempted to show Mrs. Mohar how to care for the intravenous line, but Mr. Mohar stopped her. "It is my responsibility only. You should never expect my wife to care for it." Throughout each encounter with the hospital staff, Mrs. Mohar remained silent. She deferred to her husband.
Interestingly enough, the nurses had few problems with the Mohars. They were treated with respect because, as Mr. Mohar stated, they were functioning under the direction of the physician. Their only problem was in understanding why the Mohars initially refused treatment for Ali. They had assumed that since both parents were educated in American universities and had described themselves as Americanized, they really were. The stress of their son's illness, however, had made them revert to traditional ways.
Authority
Figures
Tony Romano, the eight-year-old son of Gypsy parents, was afflicted with
Guillain-Barré syndrome. He had lost control over all his muscles,
including those of his respiratory system. Whenever the male physician
asked to speak with the parents, the paternal grandmother and two aunts
insisted that he speak with them instead. The grandmother said she did
not want the parents to see the child. When the issue of signing informed
consent forms came up, the grandmother said they would have to wait until
her husband arrived.
Shortly thereafter, a meeting was called with the physician, the two grandfathers, a great-grandfather, and a few uncles. The parents were excluded from the conference by the elder males, who later had the father sign the consent form. The grandmothers were excluded without discussion. It was assumed that only the elder males would take part.
Family members did not allow the Romanos to see their child until two days after his admission, when his condition had stabilized. When his mother finally saw Tony, she became hysterical. The group forbade her to see him again for a while. Family members frequently asked the staff for information about the child's condition, but all decisions were made by Tony's grandfather.
One of the nurses finally asked Tony's grandmother why the boy's parents were not allowed to see him or talk with the physicians. She explained, "They are too young. They are just babies." Tony's father was twenty-eight, his mother twenty-four.
Gypsy marriages are often arranged when the couple are in their mid-teens. After marriage, they usually live with the husband's parents and are sheltered from adult responsibilities and decisions for many years. Wisdom is thought to come with age. The Romanos were still considered children despite the fact that they were parents.
This attitude was very difficult for the nurses to accept. Anglo American culture expects parents to assume full responsibility for their children, no matter what their age. Legal consent for medical procedures may be given only by the parents. Information regarding a child's condition is given only to the parents. In some cases, only the parents are allowed to visit the child. It was very disconcerting for the nurses to have all the rules changed, but the Gypsies insisted on doing things their own way.
The fact that all the important decisions were made by the men, with no input from the women, is also cultural. Gypsies have a male dominated (and age-dominated) society. Women are not allowed to interrupt men's conversations, let alone join them in making decisions.
In general, knowing who holds the position of authority can help resolve difficult situations. Nurses who have worked with Gypsies have said that if they can gain the cooperation of the king, they can maintain some control.
Female
Modesty
A twenty-eight-year-old Arab man named Abdul Nazih refused to let a male
lab technician enter his wife's room to draw blood. She had just given
birth. When the nurse finally convinced Abdul of the need, he reluctantly
allowed the technician in the room. He took the precaution, however, of
making sure Sheida was completely covered. Only her arm stuck out from
beneath the blankets. Abdul watched the technician intently throughout
the procedure.
Another time, the toilet in Sheida's room overflowed. Abdul flew into a rage when three men from engineering and housekeeping were about to enter the room after knocking. He refused to allow them in. The toilet went unrepaired until the couple left the next day.
Both incidents stem from the fact that among Arabs family honor is one of the highest values. Since family honor is tied to female purity, extreme modesty and sexual segregation must be maintained at all times. Hospitals that do not have female physicians on staff should have a referral system so one can be found when needed. Female housekeepers should clean the rooms of Middle Eastern females. Male nurses definitely should not be assigned to female Muslim patients. Same-sex staff should be used whenever possible.
Female
"Circumcision"
aka Female Genital Mutilation
An Egyptian woman in labor presented an unusual problem for the nursing
staff. Her vagina was severely deformed, and they were unable to find
any of the appropriate "landmarks." The entire area appeared to have been
badly burned, yet no other parts of her body showed evidence of fire.
The doctor and nurses were mystified. They did not realize that the woman
had been "circumcised."
One way "female purity" is maintained in the Middle East is by keeping the woman covered and veiled. Another method, used in some remote regions, and particularly in parts of Africa, is "female circumcision" ("female genital mutilation" in the human and women's rights literature). It is believed that the practice reduces women's sexual desire, and that without it, women might be unable to control their exceptionally strong libido, and family honor might be lost.
The procedure is generally performed when a girl is seven or eight years old. Older women will come in the night, hold her down, and then start cutting. The most minor form involves cutting off the tip of the clitoris. The most severe, known as infibulation, is the removal of the entire clitoris, labia minora, and parts of the labia majora. The outer lips of the vagina are then held together with thorns, sutures, or a pastelike material. A small opening is left for urine and menstrual blood. The girl's legs are tied together for several weeks until she heals. As can be imagined, this practice often leads to a myriad urinary, menstrual, and intrapartum problems, apart from the risk of infection and death at the time.
In 1985, a world congress was held in Africa in an effort to reduce or eradicate the practice. Surprisingly, the greatest opposition to the elimination of the custom came not from men but from older women and young girls. The older women wanted to maintain tradition. The young girls were afraid that if they were not circumcised, they would be unable to find husbands. Circumcision is seen as the ultimate proof of purity; why would any boy marry a woman without a guarantee of her virginity? In the years since that world congress little, if any, progress has been made toward eradication of the custom. In fact, newspaper and magazine reports indicate that it is spreading, as African women move out of Africa. Anthropologists recognize that it is difficult, if not impossible, to merely eliminate a traditional cultural ritual; efforts would be better aimed at trying to promote the sunna form, which involves cutting only the tip of the clitoris, over infibulation.
Doctors and nurses caring for circumcised women should be especially sensitive to their needs and feelings. Female providers should be used whenever possible, and the patient should be kept draped for privacy. Physicians need to know how to handle labor and delivery, since the episiotomy must be done at an earlier stage. Above all, do not express any ridicule or judgment. You might, however, gently discuss the relationship between their infibulation and any health problems they may have experienced, so that they can make an informed choice for their own daughters. It might also be appropriate to let them know that the practice raises issues of illegality and child abuse in the United States.
Female
Virginity
The importance of female virginity and purity are unfortunately well illustrated
in the following case. Fatima, an eighteen-year-old Bedouin girl from
a remote, conservative village, was brought into an American air force
hospital in Saudi Arabia after she received a gunshot wound in her pelvis.
She had been shot by her cousin Hamid. Her family had arranged for her
to marry him, as was local custom, but she wanted nothing to do with him.
She was in love with someone else. An argument ensued, and Hamid left.
He returned several hours later, drunk, and shot Fatima, leaving her paralyzed
from the waist down.
Fatima's parents cared for her for several weeks after the incident but finally brought her to the hospital, looking for a "magic" cure. The physician took a series of x-rays to determine the extent of Fatima's injuries. To his surprise, they revealed that she was pregnant. Sarah, the American nurse on duty, was asked to give her a pelvic exam. She confirmed the report on the x-rays. Fatima, however, had no idea that she was carrying a child. Bedouin girls are not given any sex education.
Three physicians were involved in the case: an American neurosurgeon who had worked in the region for two years; a European obstetrics and gynecology specialist who had lived in the Middle East for ten years; and a young American internist who had recently arrived. No Muslims were involved. The x-ray technician was sworn to secrecy. They all realized they had a potentially explosive situation on their hands. Tribal law punished out-of-wedlock pregnancies with death.
The obstetrician arranged to have Fatima flown to London for a secret abortion. He told the family that the bullet wound was complicated and required the technical skill available in a British hospital.
The only opposition came from the American internist. He felt the family should be told about the girl's condition. The other two physicians explained the seriousness of the situation to him. Girls in Fatima's condition were commonly stoned to death. An out-of-wedlock pregnancy is seen as a direct slur upon the males of the family, particularly the father and brothers, who are charged with protecting her honor. Her misconduct implies that the males did not do their duty. The only way for the family to regain honor is to punish the girl - by death.
Finally, the internist acquiesced and agreed to say nothing. At the last minute, however, the reluctant physician decided he could not live with his conscience. As Fatima was being wheeled to the waiting airplane, he told her father about her pregnancy.
The father did not say a word. He simply grabbed his daughter off the gurney, threw her into the car, and drove away. Two weeks later, the obstetrician saw one of Fatima's brothers. He asked him how Fatima was. The boy looked down at the ground and mumbled, "She died." Family honor had been restored. The ethnocentric internist had a nervous breakdown and had to be sent back to the United States.
Doctor-Nurse
Relations
Dr. Fukushima, a Japanese physician, ordered Lisa to give a patient a
certain dosage of a medication. Lisa refused on the grounds that the dosage
might be harmful to the patient. Dr. Fukushima insisted, but she was adamant.
The interesting twist to this situation is that when Dr. Fukushima reported
Lisa to her supervisor, he suggested that she should have agreed to give
the medication, but simply not have done it.
Asians generally believe it is important both to avoid conflict and to show respect for authority. Rather than refuse directly, it is more appropriate to agree to the supervisor's face and then not follow through. Americans, in contrast, feel it is important to be direct and honest. Disagreement is not avoided. Assertiveness is valued, as is an egalitarian ideal. Dr. Fukushima's major complaint was not that the nurse disobeyed him, but that she disagreed to his face, thereby denying him proper respect.
It would be easy to suggest that nurses dealing with Asian physicians take that advice, but it is not that simple. Laws require nurses to follow through on orders they agree to. Nurses would be well-advised, however, to remember that Asian men are very concerned about their dignity and self-esteem. And, once again, hospitals should consider offering foreign-born physicians training in the role of nurses in American hospitals.
Gender
Role Conflict
Traditional dominant and subordinate roles can also create friction among
hospital staff. For example, Ikem Nwoye, a Nigerian male nurse assistant,
would have what one nurse described as a temper tantrum whenever a female
registered nurse asked him to do something. Other times he would sulk
and simply leave the room. What he would not do is take instructions from
a woman. In Nigeria, men are considered superior to women. Men tell women
what to do, not the reverse.
Nursing is a hierarchical profession in which orders are followed according to rank, not sex. The nurses thus expected the nurse assistant to do what they told him. As a Nigerian male, Ikem felt that he should not have to take directions from females, despite his lower professional ranking. Unless someone with this cultural disposition can be placed under the supervision of another man, it will be difficult to maintain a viable working relationship on the floor.
The
Role of the Nurse
Josepha DeLeon, a Filipino nurse, did not get along well with her coworkers.
The nursing staff on her unit was composed of two Anglo Americans, two
Nigerians, and Josepha. She felt her coworkers were taking advantage of
her, since they would ask for assistance whenever they saw her. Josepha
was angry over what she perceived as obvious discrimination. She cheered
herself by reminding herself that she was a better nurse than the others;
she could do her work without their help. In addition, she was not lazy
like they were. She took care of her patients; the other nurses insisted
that their patients take care of themselves.
One day, Rena, one of the Anglo nurses, was unusually friendly, so Josepha opened up to her. As they got to know each other better, Josepha shared her feelings of being taken advantage of. Rena explained that it was common procedure for the nurses to help each other with their work. Rena confided that the others thought Josepha was being snobbish and proud because she never asked for help. What Josepha had interpreted as laziness on the part of the others was seen by them as being team players. Rena also explained that American health care providers believe that independence is important and encourage self-care among their patients.
Josepha was stunned by Rena's revelations. Rena offered to help bridge the communication gap between Rena and her coworkers Rena explained to the others that Josepha was trying to save face by never asking for help; she didn't want them to think she couldnÐt do her job. Josepha began to teach her patients self-care and to ask her coworkers for assistance. Over time, the cross-cultural misunderstandings were resolved, and Josepha's coworkers became her best friends.
........
Postpartum
Lying In
Su Yong, a nineteen-year-old Vietnamese woman, returned to the hospital
with a high fever and abdominal pain twelve days after giving birth. During
her stay, she rejected most of the food and liquids prepared by the hospital,
refused to shower or wash her hair (despite increasingly strong body odor),
and would not get out of bed except to use the bathroom. When she insisted
on mounds of blankets in spite of her high temperature and sweating, the
nurses feared for her health.
Su Yong was practicing a version of the traditional Iying-in period observed throughout much of Asia and Latin America. For a period of time after a woman gives birth, her body is thought to be weak and especially susceptible to outside forces. The new mother is encouraged to avoid both exercise and bathing. These traditional practices come into direct conflict with Western health care, which promotes exercise and bathing for new mothers as soon as possible following childbirth.
The traditional practice in China is called "doing the month." It is important to keep the room warm, lest cold or wind enter the new mother's joints. Bathing is considered dangerous for similar reasons. No matter how hot the weather, the traditional Chinese woman will want the windows closed and the air conditioning off.
In Asia, health is believed to depend upon keeping the body in a state of balance. Pregnancy is generally thought to be a hot condition. Giving birth causes the sudden loss of yang, or heat, which must be restored. The most effective way to do this is to eat yang foods, such as chicken. Cold liquids should be avoided lest the system receive too great a shock.
Traditional Asian thought has it that the price for not "doing the month" is aches, pains, arthritis, and other ailments when one is old. Although practical circumstances may prevent a woman from observing the entire month, many want to practice at least a shortened version of it. This explains why the patients in the cases described above refused ice water in preference for hot, rejected bathing or exercise, insisted upon keeping extremely warm, and ate only certain foods.
Bonding
Maternal-infant bonding has become a major concern of Western health care
professionals in recent decades. Poor bonding has been associated with
failure to thrive, child abuse, and psychological problems. It is therefore
not surprising that doctors and nurses become concerned when they observe
cultural beliefs and practices that appear to reflect poor bonding. They
often do not. An example is the case of Thanh Vo, a Vietnamese woman who
came to the hospital to deliver her fifth child. After giving birth to
a son, she refused to cuddle him, although she willingly provided minimal
care such as feeding and changing his diaper. The nursery nurse, feeling
sorry for the "neglected" baby, picked him up, cuddled him, and stroked
the top of his head. Mrs. Vo and her husband became visibly upset. The
baby, who had jaundice, had to remain in the hospital for several days
after Mrs. Vo went home. She did not visit her baby even once during the
time he remained in the hospital.
In the past, nurses who worked in areas with a large Vietnamese population often referred these mothers to social services. Eventually, however, they came to understand that the apparently neglectful behavior did not reflect poor bonding, but instead indicated cultural belief and traditions.
Many people in the more rural areas of Vietnam believe in spirits. Since spirits are particularly attracted to infants and likely to "steal" them (by inducing death), it is important that parents do everything possible to avoid attracting attention to their newborn. For this reason, infants are not verbally fussed over. They are sometimes even dressed in old clothes to "fool" the spirits. The apparent lack of interest new parents demonstrate reflects an intense love and concern for the child, rather than the opposite.
Mrs. Vo and her husband were probably distressed over the nurse's attention to their baby for two reasons. First, they may have feared having attention drawn to their baby. Second, Southeast Asians view the head as private and personal. It is also seen as the seat of the soul and is not to be touched. Not only did the nurse risk attracting the attention of dangerous spirits, but she also stroked the child in a taboo area.
Why did Mrs. Vo not come to visit her son in the hospital after she was discharged? She was probably practicing Iying-in and was at home resting while her internal organs resumed their normal position in her body.
Healthcare providers can best deal with Vietnamese mothers by following their lead. If the parents do not fuss over the child, providers should not either. In any event, they should avoid touching the infant's head. And as long as a mother can feed and hold her baby properly, they should not be concerned about an apparent lack of interest. It is merely an illusion.
Breastfeeding
It is well known that the colostrum that fills a new mother's breasts
before her milk comes in is rich in antibodies that fight infections to
which newborns might be subject. Western doctors and nurses emphasize
the importance of feeding infants colostrum. Many ethnic groups, however,
refuse to do so.
Sofia Salgado, a Mexican American, gave birth to a son. The nurse wheeled the baby into Sofia's room and handed him to her to be nursed. Instead, Sofia pointed to her breasts and said, "No leche, no leche" (No milk, no milk). Pedro, her husband, explained to the nurse that Sofia would bottle-feed now and breastfeed when she returned home.
According to the nurse who related this example, most of the Mexican women who gave birth in a hospital near the Mexican border followed the same pattern - early bottle-feeding, later breastfeeding. Because colostrum is so important, this practice worries health care professionals.
Many Mexican women believe they have no milk until their breasts enlarge and they can actually see it. Some perceive colostrum as "bad milk" or "spoiled" and thus not good for a baby. Many do not realize that milk production is stimulated by nursing. Still others are very modest and are embarrassed to expose their breasts while nursing in the hospital.
The best way to deal with this situation is through education. Explain the importance of colostrum to the baby's health. If the mother's concern is to provide "real" milk for the baby, tell her that nursing on the colostrum will help it to come more quickly. The new mother should also be given privacy while nursing her infant.
Informed
Consent
Mrs. Hidalgo, an elderly Mexican woman, was dying of cancer. Her doctor
spoke with her family about receiving hospice care. They liked the idea
of having the hospice personnel provide her with medication to reduce
her pain; however, there was a problem. In talking with the hospice organization,
the family learned that before the hospice would accept Mrs. Hidalgo as
a patient, she had to sign informed consent, acknowledging that she had
a terminal condition and would die within six months. Since the family
would not allow Mrs. Hidalgo to see the form (and prognosis), hospice
care could not be given.
When dealing with dying patients, one should not be surprised to find the family insisting that the diagnosis be withheld from the patient. One way of dealing with this kind of situation is to discuss with the patient beforehand whom s/he wants information about his/her condition to be given. That way, the patient can choose whether to be told the truth or to let the family make the decision. (Check with your hospital regarding the legal aspects of the situation.) Sometimes, it will be the patient who tries to hide the seriousness of her condition from her family. Often, each may know the truth of the situation but try to hide it from the other. Sensitive health care providers will be open to discussing any concerns that the patient might raise when the family is not around, since the patient's impending death may not be a topic than can be openly discussed in the family's presence.
.........
Coining
A Korean man named Sung Kim was brought into the emergency room, unconscious.
His chest was covered with red welts. The family did not speak English,
and there was no interpreter available. The staff assumed that Mr. Kim's
lack of consciousness was related to the red welts, that both were symptoms
of the same condition. They were not. Unfortunately, by the time they
discovered what Mr. Kim was suffering from, it was too late to save him.
Had they known to ignore the welts, they might have saved his life.
Folk
Medicine/Fevers
An African American infant was brought into the hospital by his mother,
Mary, and grandmother Adele Wilson. The nurse explained that she would
put the naked infant in a cool mist tent and bathe him in cold water to
reduce his temperature. Mary was quiet, calm, and cooperative. She indicated
her concern by asking several questions about her son's condition.
Adele Wilson, however, did not appear to be listening. She got up from her chair, looked into the tent, and said, "You forgot to give him a blanket. That thing is real cold inside." The nurse again explained that she was keeping him cool because of his high temperature. Mary tried to calm her mother-in-law, seeing that she was becoming hostile. "Mama, it's okay." Mrs. Wilson responded, "What you talkin' 'bout? They got you believing in this foolishness too. I'm gonna put his blanket on him 'cause he is cold. I raised all my nine children and I never put one in no ice box. You know you need to wrap him so he can sweat the fever out. Hot chamomile tea would bring that fever down."
Most of the nurses dealt with the grandmother by avoiding her. They could not talk to her without arguing. How might they have handled the situation? They might have begun by asking her how she would have treated the child. They could have acknowledged her approach, which comes from years of use of natural remedies within the Black culture. They might also have incorporated her recommendation of chamomile tea. Mrs. Wilson's hostility may have been a reaction to what she perceived as racism on the part of the white nurses. A bit more respect on the part of the nurses might have helped.
Medications:
Improper Use
Florence, an African American nurse, was doing home care for a thirty-year-old
Mexican female named Lena Menendez who had recently had a cesarean section.
Mrs. Menendez spoke little English. Her mother, Gloria Flores, was staying
with her to help with the baby. During her first visit, she wanted to
make an assessment evaluation and change the dressing on the incision
site.
When Mrs. Menendez removed her underpants, the first thing Florence noticed was the absence of a pad or gauze covering the gauze inside the wound. When she looked more closely, she discovered a bloody white cheesy substance on the gauze and in the corners and edges of the wound. Florence had no idea what it was. In her mind, she considered the possibilities: semen? intestines? When she removed the old dressing, she was relieved to find that it was not her intestines. She could find no evidence of infection, and after cleaning the wound, decided it was just a dirty wound.
When Florence returned the next day, she noted more of the white, bloody, cheesy substance. This time, she asked Mrs. Menendez what it was. Her mother answered for her, replying, "Her medication, the one with the powder in it. The nurse said it was for infections." Florence was astounded. She explained that the medication was to be taken by mouth. Mrs. Flores said, "No, in my culture, we mix the powder and put it where the infection is. In order for the wound to heal, the powder goes in there." Florence then spent several minutes explaining to Mrs. Flores and her daughter the difference between American medicine and traditional Mexican medicine. It was unfortunate that the nurse who had given her the medication had neglected to explain how it is used. Moreover, Florence should have asked about it on the first visit.
Do not assume that a patient will understand how to take the medication prescribed. Medicines are used in different ways in different countries, and confusion can result.
