This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Transcultural health care practice: Foundation module

Section two:

Essential aspects of care

Introduction

In the everyday care of patients, we are involved in interactions and interventions that assist and enable our patients to achieve the satisfactory outcomes that are essential to their recovery and well-being. The patient and significant others are encouraged to play an active part in the care process. In caring for the patient/client, the involvement and participation of family members and friends contributes to the understanding of their needs and expectations. The active participation of patients and their relatives in care makes the relationship between them and health care professionals much more of a partnership.

In the drive to improve the quality of care and patient experience, and to demonstrate its commitment to the nursing, midwifery and health visiting strategy (Making a Difference, DoH, 1999), the Department of Health has added to its wide ranging publications 'The Essence of Care' (Department of Health, 2001). The Essence of Care was developed through the active participation of practitioners and users of services. Its purpose is to support quality improvement and facilitate contributions to clinical governance at local level. The toolkit focuses on core and essential aspects of care, and provides a basis for advancing best practice in areas that are crucial to the quality of care. The eight fundamental aspects of care it addresses are: Personal and Oral Hygiene, Privacy and Dignity, Food and Nutrition, Safety of people with Mental Health needs, Record Keeping, Principle of Self Care, Pressure Ulcers and Continence and Bladder and Bowel Care. Not all of these will be covered in this section of our resource but it will be worth looking up the toolkit to extend your knowledge on what is offered here.

In this resource, the theme 'Essential aspects of care' is chosen to represent those aspects of care that are fundamental to the holistic care of the individual, in both health and illness, and even in birth and in death. They are thought of as essential to personal safety, comfort, and a sense of well-being, and embrace the dimensions of personal, physiological, psychological, social, and spiritual needs. The delivery of the essential aspects of care require different levels of skills and competence together with sensitivity and respect. Although caring exists in all cultures, the interpretation and relevance of culturally acceptable care are viewed according to the beliefs, values, social norms and taboos prevalent in that culture (see Holland and Hogg, 2001; MacLachlan, 1997). Our effort to understand and acknowledge the care needs of clients from the cultural perspective reduces barriers and enhances effectiveness.

The essential aspects of care introduced here are:

  • Communication
  • Personal hygiene needs
  • Dying, death and bereavement.

Before we examine these essential aspects of care, we perhaps ought to briefly visit some of the fundamental principles that may be general considerations when caring for others but assume greater significance in the cross-cultural context of care. The values we hold are an integral part of us, and determine how we think, feel and behave in respect to ourselves and towards others. In professional practice, we become aware of the accentuation of these values, and the associated personal and professional conflicts that may arise as a consequence of our own experiences. Values and philosophies are assimilated and become internalised by us through the socialisation process. Values have cultural determinants, and are influenced by religious beliefs and life experiences. When caring for people who are not of the same ethnic/cultural background as ourselves, we need to be aware of and sensitive to the values of others. In addition we all need to be cognisant of our cultural relativism or ethnocentric positions. Some of the values that are important to explore are concerned with dignity, trust, confidentiality, privacy, modesty, respect, truth and justice. Cultures vary in their philosophical worldviews that shape their visions and actions. Professional cultures are no different.

Observations

Caring for people from diverse ethnic communities is presenting us with new challenges. Our encounters with people who are different to us in ethnic and cultural backgrounds often point to gaps in our knowledge and skills when dealing with them. Our knowledge may often be limited in respect to:

  • who people are
  • how they live
  • their cultural and religious values and beliefs
  • their family relationships
  • how they perceive health and illnesses
  • their responses to illness
  • how they seek help and the barriers that may prevent them from doing so
  • their care needs.

This may be due in part to the fact that much of what is taught about health, diseases and care may be from an ethnocentric perspective. Historically, knowledge generation in the modern context has been predominantly from a 'western' scientific perspective. Texts and illustrations have predominantly featured examples from the white European perspective.

The knowledge that is derived and handed down may, for example, engender confidence in recognising pallor in a person who is white. We may then ask whether we can observe pallor with equal ease in a person of Black Caribbean or African ancestry (Scenario 3). Similarly, whether we can always communicate equally effectively with a child (Scenario 2) or adult (Scenario 4) from a different cultural and/or different linguistic background or a different background than our own? All of these issues concerning competence in caring for people from different backgrounds are equally important for black and minority ethnic students as well as for white students.

Developing Observational Skills

During your course you will be required to develop observational skills in an incremental way and achieve a competent level of practice. Observational skills help us make sense of everything we perceive.

Taking accurate observations, and recording and making meaningful interpretations of the information gathered are central to delivering congruent care. Nursing interventions are based on the assessment of needs through the analysis of information gathered and the subsequent identification of related problems. We then engage in an active process of planning the appropriate interventions, and explore the options and resources that are required for a satisfactory nursing outcome to be achieved. The implementation of the care and its evaluation provide further information on the progress of the patient and the quality of the care that has been administered. In the delivery of care to people from diverse cultural groups, other health professionals or agencies with specific responsibilities and expertise may be also involved during this process. Observations are therefore the foundation blocks on which we build the care process.

Underpinning the philosophy of individualised patient care is the idea of respect for the individual. It is worth noting here the following section from the United Kingdom Central Council for Nursing and Midwifery (UKCC) Code of Conduct:

Recognise and respect the uniqueness and dignity of each patient and client, and respond to their need for care, irrespective of their ethnic origin, religious beliefs, personal attributes, and the nature of their health problems or any other factor.

(UKCC, 1992, cl. 7)

There is an element of cross-referencing between each of the essential aspects of care and the corresponding scenarios.

Further Reading

  • Department of Health. (2001) The Essence of Care: Patient-focused benchmarking for health care practitioners London: Department of Health
  • Holland K and Hogg C (2001) Cultural awareness in Nursing and Health Care: An introductory text London: Arnold
  • McLachlan M (1997) Culture and Health: Psychological Perspective, Problems and Practice Chichester: John Wiley and Sons
  • United Kingdom Central Council for Nursing Midwifery & Health Visiting (1992) Code of Conduct London: UKCC

Cultural Assessment

Introduction

Each one of us is unique. Any assessment should reflect that uniqueness. Cultural assessment has been defined as "a systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values, and practices to determine explicit nursing needs and intervention practices within the context of the people being evaluated" (Leininger, 1978, p.85-86 cited by Andrews and Boyle, 1999, p.24). The process of cultural assessment should demonstrate the attitudes and skills that value the individual. The interview process should be 'open-ended, flexible, and holistic in approach' (Rosenbaum, 1997, p.280). The content should focus on information that reveals the unique set of needs of the individual and emphasise not only signs and symptoms of disease but explore cultural beliefs and practices, including healing and alternative therapies.

Cultural assessment can be designed to elicit culture-specific beliefs, values and practices and can facilitate the planning of care that is congruent to needs. The assessment frameworks outlined by Andrews and Boyle (1999, Table 10-1, p.322; Appendix A, p. 539-544), Giger and Davidhizar (1999, Figure 1-3, p. 10-12), Purnell and Paulanka (1998, Box 2-1 through to Box 2-12, p.15-48) cover similar issues but use different categories or domains. Papadopoulos, Tilki and Taylor (1998) provide examples of exercises that may facilitate knowledge and skills development.

For details of the types of questions that may assist in eliciting information during the interview, look up the above authors.

Hofstede's Dimensions Of Cultures

Hofstede (1980, 1984) reported in detail the findings of an international collaborative study. The databank of two multinational companies with subsidiaries in 66 countries and questionnaires were used to gather information. The countries involved spanned industrialised as well as developing economies. The study focused on work- related values of all grades of employees. Through empirical analysis of questionnaires, Hofstede identified four dimensions: power/distance, individualism-collectivism, femininity-masculinity and uncertainty avoidance. To these he added a fifth dimension, time orientation, after examining the data of other researchers. Hofstede's (1980, 1984) dimensions of cultures have been found to be particularly useful in the attempt to distinguish between cultures, and the sub-culture of work.

MacLachlan (1997) has reviewed the theories underpinning our current understanding of cultures and has related these to explanations of health and illness.

The power/distance dimension describes the relationship between people of different ranks and the level of dependence or interdependence. Hofstede (1984) has distinguished societies on the scale of low power/distance - high power/distance, with low power/distance societies demonstrating interdependence between people of different ranks. In contrast, in high power/distance societies, subordinates in occupational groups show more dependence on their bosses. Hofstede (1984, p. 79) concluded that 'Class differences in Power Distance scores are particularly high in Great Britain and Germany. Such differences are low in India and Mexico because in these countries power distances are large for everyone, regardless of class'.

The individualism-collectivism dimension describes the 'relationship between the individual and the collectivity' in human societies. Individualism-collectivism reflects the values and significance placed on the individual's goals in societies or in direct contrast, the goals of groups. Individualistic societies are characterised by expectations that individuals will look after themselves and their immediate families, have autonomy, being taught to stand on one's own feet, and that personal relationships are specific and few. Collectivist societies are characterised by strong bonds between the individual and the group to which he/she belongs. There is an expectation that the individual will put the group's goals before his/her own. Loyalty to the collectivity is a lifelong commitment. Hofstede (1984, p.149) goes on to suggest that 'The relationship between the individual and the collectivity in the human society is not only a matter of ways of living together, but it is intimately linked with societal norms…It therefore affects both people's mental programming and the structure and functioning of many other types of institutions besides the family: educational, religious, political, and utilitarian'. Examples of societies that are seen as individualistic are Britain and America. Collectivistic characteristics are found in the cultures of Greece, Pakistan and Portugal.

The Masculinity-Femininity dimension attempts to distinguish between gender roles in societies. This dimension starts with the premise that 'The sex role distribution common in a particular society is transferred by socialisation in families, schools, and peers groups, and through the media. The predominant socialisation pattern is for men to be assertive and for women to be nurturing' (Hofstede, 1984, p.176). It is suggested that in different societies sex roles have particular significance. However, this may be a contentious issue in the context of both individualistic and collectivistic societies, given that equality between men and women is a goal in all societies. This dimension should not be dismissed without exploring its value in trying to understand cultures. Countries with a high masculinity index are Japan, Germany. Whilst Ireland and Great Britain are above average, France, Spain and Portugal are lower on the scale.

The low uncertainty avoidance and high uncertainty avoidance dimension reflects the level of threat that is perceived when there is uncertainty or when faced with the unknown. Low uncertainty avoidance is characterised by tolerance, lower stress, less showing of emotions, whilst high uncertainty avoidance cultures show higher anxiety and stress, the urge to work harder, concern with security in life and less tolerance (Hofstede, 1984, p.140). Ireland and Great Britain are characterised by low uncertainty avoidance, as is India. Countries that fall on the high uncertainty avoidance band include Greece, Portugal, Italy and France.

Time orientation is a significant feature across cultures. Hofstede (1991, p.164 cited in MacLachlan, 1997, p.53) suggests that the short-term orientation - long-term orientation dimension 'refers to a long-term versus short-term orientation in life'. The short-term relates to the past and the present, the current values and obligations that have to be fulfilled and preserved. The long-term on the other hand emphasises future goals and rewards, and stresses perseverance. How time is perceived, and the meanings attached to it, varies within cultures too. Countries scoring high on short-term orientation include Pakistan and Nigeria, whilst China and Hong Kong scored highly on long-term orientation.

These dimensions may be useful in comparing and contrasting cultures. However, when it comes to examining the values and beliefs of individuals from these cultures caution should be exercised in order not to generalise to the point of stereotyping.

The Problem Portrait Technique

MacLachlan (1997) has introduced an assessment tool called the Problem Portrait Technique that combines imagery and words in the process of assessing the person's health-related problems. The purpose of the Problem Portrait Technique is to provide as vivid and genuine a likeness as possible of the person's inner experiences and understanding of them. MacLachlan illustrates the use of this technique with particular reference to the explanatory models that people may hold when making sense of the causes and consequences of their illness.

The technique engages the patient/client and draws into the assessment his/her understanding and explanations. MacLachlan suggests that requests about the patient's/client's own rationale of causes assists in legitimising the beliefs that he/she holds but was previously unsure of expressing. This approach allows the patient to reveal his beliefs and allows comparisons to emerge. The explanations put forward by the patient may reveal the strength of beliefs and offer an insight into how willing the patient is to accept alternative explanations. In engaging the patient in this way, the Problem Portrait Technique facilitates assessment 'with a complex outline of causal factors which a more conventional approach to assessment would have overlooked' (MacLachlan, 1997, p.65). A comprehensive 'impression of the range of causal factors and their relative importance' can be gained.

The use of the Problem Portrait Technique can facilitate the comparison of ratings of beliefs held by patients and members of their community. This can further help with an understanding of the extent to which the patient's perception of his/her own cultural background is influencing his/her beliefs.

MacLachlan goes on to explain that the set of beliefs held about causation of illness also influence the beliefs about the appropriate course of action, intervention or treatment. MacLachlan describes as 'consequential treatments' those treatments that are pursued as direct result of beliefs about a particular cause. The 'actual treatment' that the patient has may include 'consequential treatments'. Faced with choices, patients may or may not take the treatment that is appropriate for the held causal belief and opt for something different. This may explain why some patients take both the traditional and the treatments offered by 'western' medicine, or one or the other.

MacLachlan concludes that 'Culture in this scenario is a problem to be overcome, a social construction to be deconstructed and outwitted, something which clouds the essential objective truth' (1997, p.71). Within the context of cultural assessment, this point may raise further issues for discussion about the processes of assessment.

When assessing an individual, MacLachlan (1997, p. 72-73) suggests that the

"individual must always be seen as the 'foreground' and the context they live in, including their culture, as the background".

The reason for this is that a greater emphasis on the cultural rather than individual characteristics may lead to stereotyping of the individual or attributing blame to a particular culture. Although various dimensions of cultures may have been identified (for example Hofstede, 1984), these dimensions do not always apply to each and every individual to the same extent in that culture. These dimensions are often identified, by studying large numbers of people in a given culture. Generalisations that are thus derived are then applied to the whole culture. Generalisations about cultural characteristics as identified by such studies provide useful insights about cultures but we must guard against any risk of stereotyping individuals. Hence, the cautionary note from MacLachlan.

Examples Of Cultural Assessment Items

Examples of two domains, the individual and communication are outlined below:

Unique Individual

  • Are there any culture-specific issues one has to be aware of prior to engaging with the individual?
  • Where was the person born? When?
  • How does the person identify himself/herself in relation to his/her cultural/ethnic group?
  • If a migrant, how long has the person lived in the host country?
  • How does the person present himself/herself? (Cultural identity)
  • Can communication be effective in the language of the interviewer? Does the person need an interpreter?

Communication

  • Voice quality and any accent that reflects geographical, educational and social status. Pitch and tone vary among people from different parts of the world.
  • Use of silence and non-verbal communication that reflects the person's cultural influences.
  • Silence may reflect use of language, meanings and values attached to health and illness issues.
  • Non-verbal communication may reflect cultural influences in terms of hand movement and signs, use of fingers, tapping. Across cultures hand movement and signs mean different things, and may offend.
  • Eye movements, gaze and body movement may indicate comfort zone. In some cultures people stand very close to each other when talking. This close proximity may be a sign of tactile cultures where touch is used as part of interpersonal communication. Eye contact is avoided as a sign of respect by people of different cultures in encounters in relation to the age, gender, social and organisational position of the other person(s). However, eye contact avoidance may be viewed erroneously by others from different cultures as indicating guilt, defiance and/or disrespect.
  • Gestures, expressions or body postures - observe for gender differences, signs of respect, or misinterpretation of body language as aggression/hostility. Observe for any clues in elements of verbal and non-verbal communication.
  • Touch - gender and cultural differences in accepting to be touched or to touch others are important issues for physical examination. Preferences for same gender nurse, doctor and carer have to be ascertained.
  • Communication in the presence of family members and significant others in terms of cultural preferences and traditions, particularly when sensitivity about privacy and confidentiality are required.

Communication

Communicating with others is an essential part of our everyday life. The need to communicate shows itself in many ways. Communication fulfils several functions that are important for our well-being and survival. It helps us establish relationships, share information and ideas, and give meanings to everything we do. In the health care professions, communication assumes major significance in demonstrating a caring and a therapeutic approach. Failure to give accurate and easily understood information, for example, can lead to anxiety and may have serious consequences where sensitive treatment are concerned. Communication is a dynamic and complex process (Potter & Perry, 1997).

When we consider a social encounter, we may become aware of the many visible and invisible aspects of communication. The spoken word, the written message and the non-verbal gesture or facial expressions play an important part in getting the message across. Similarly, these aspects are part of showing acknowledgement and understanding of the message. In effective communication, the shared meaning of the message is crucial to the outcome of the social encounter. Understanding of the meanings of what is being conveyed can be achieved through the congruent interpretation of language and associated non-verbal gestures and symbols.

In cross-cultural encounters, the need to demonstrate effective communication assumes an even greater significance because there may be more scope for misunderstanding and conflicts. Thus, making the wrong assumptions about the cultural background of individuals may lead to breakdown in communication, rendering it ineffective (Downes, 1999). Cross-cultural communication is not easy, particularly in care settings where patients/clients may present with varying degrees of pain and distress that may be compounded by a lack of language skills to get them understood in the health system. Communication that is culturally competent assumes that the skills and knowledge of the staff meets the standards of cross-cultural communication. One of the reasons why families from minority ethnic background have problems accessing services is due to two-way communication difficulties. The use of interpreters has been encouraged but there is no substitute for culturally competent staff.

Communication styles and processes vary across cultures (Robinson, 1998). It is assumed that there are certain universal features such as vocal or oral expressions, use of language and symbols, non-verbal communication such as touch and gestures across ethnic groups and cultures. However, across these universal characteristics there are specific aspects of communication that vary within and between cultural groups. Language and dialects, for instance, show variations in usage between different age groups in the same cultural group. Furthermore, as Giger and Davidhizar (1999) have described, space and proximity among people also influence communication. Robinson (1998) has given an in-depth expose of intercultural communication and emphasises the role of beliefs, values and language. For example, trust, racism, prejudice and power can all be communicated through verbal and non-verbal actions and gestures. Communication has to be flexible and adaptive, taking into account the cultural sensitivities as well as the health care context. Cultural variations may be observed with respect to:

  • Linguistic and Language skills
  • Worldview of the client and professional
  • Context perception
  • Relationship building, confidentiality and trust
  • Individualistic and collectivist cultural orientation

Henley and Schott (1999) provide useful practical hints on communication in multi-ethnic environments. Some of the areas that they consider are: getting names right, listening with respect, non-verbal communication such as gestures, eye-contact, facial expression, physical distance and proximity, language difficulties, use of interpreters and the presentation of written materials. The interpretation of concepts such as privacy, mutual trust, modesty, dignity in practice owe much to the impact of cultural influences on individuals and social groups.

Husband and Hoffman (2003) refer to the work of Gerrish, Husband and Mackenzie (1996) and add further support to their suggestion that health care professionals should develop transcultural communicative competence. Gerrish, Husband and Mackenzie (1996, p. 26) suggest that 'transcultural communicative competence requires the individual to learn to understand cultural values, behavioural patterns and rules of interactions in specific cultures'. As well as describing the elements of the model of transcultural communicative competence, Husband and Hoffman (2000) outline the main features of a systems theoretical model of intercultural communication, the T.O.P.O.I, which stands for Tongue (language), Order, Persons, Organisation, and Intentions.

In health care settings the importance of effective communication cannot be emphasised enough. Many factors affect communication between people. Given the complexity of the situation, communication between care personnel and the patient/clients and their relatives are fraught with possibilities of the communication not being effective, and at worst, affect trust and confidence. Communication remains one area where complaints are all too common (Department of Health, 2000). Above all, communication has to be ethical, this means that it has to 'be timely and desired by the patient, it must be accurate, it must be provided in words that are understandable to the patient and family, and it must be conveyed in a gentle, respectful and compassionate manner' (Latimer, 1998, p.1743).

In summary, the cross-cultural aspects of communication are important features that need to be considered at both the individual and cultural levels. Verbal and non-verbal communication patterns vary, as do rules of interactions. In order to enhance the effective of communication in transcultural encounters these patterns and rules should be understood by both parties, otherwise the risk and likelihood of ineffective communication becomes greater. The use of the models briefly presented here may go some way to assist the facilitation of the expected level of knowledge and skills acquisition.

Spirituality, Religious Beliefs And Practices

Spirituality is an integral part of the person, the whole being (Weller, Feldman & Purdam, 2001). When providing care to the person, it important not to overlook the spiritual dimension because as Ellison (1983, p. 332) has suggested, "The spiritual dimension does not exist in isolation from our psyche and soma, but provides an integrative force". Or, to re-emphasise its importance, without spirituality, the person cannot be considered as whole with respect to what holistic care assumes. Spirituality is often construed as the connectedness with a higher force or power, and a feeling of wholeness.

Many minority ethnic groups identify strongly with their faith (Weller, Feldman & Purdam, 2001). Their religion provides them with the spiritual support and guidance throughout their life. In health as in illness, religious faith can be a source of inspiration and comfort.

Religious beliefs and practices vary within and across communities. (See for example www.bbc.co.uk/worldservice). It is therefore important not to assume that the information in the following pages apply to all persons from that particular ethnic group.

Religion and spirituality often get used interchangeably, but they are not one and the same thing. Spirituality is more than religion (Oldnall, 1998). Peterson and Potter (1997) have suggested that spirituality is a broad concept and relates to the wholeness of the person, whilst religion is an aspect of spirituality. Spiritual health is thought of as a dimension of the person. Hence spiritual needs have to be met to ensure holistic care of the individual.

In a review, Narayanasamy (1999, p. 274) has summarised some of the definitions of spirituality. His own is that spirituality is 'rooted in an awareness which is part of the biological make up of the human species. Spirituality is therefore present in all individuals and it may manifest as an inner space and strength derived from perceived relationship with a Transcendent God / an Ultimate Reality, or whatever an individual values as supreme'. He goes on to suggest that the spiritual dimension of the person evokes feelings of faith, hope, love, and gives meaning and reason for existence. Religion is an organised system of beliefs that provides a basis for service, worship of a God or supernatural power (Peterson & Potter, 1997). Religious practices and rituals are symbolic and represent what is seen as meaningful to the individual.

However, some people do not believe in God (atheists) or are unsure (agnostics) and/or do not follow any religion. One has to be aware of the needs of all these patients. They will include those who seek comfort in their faith only when they become ill.

The information below is not meant to be a 'recipe'. In order to understand the religious beliefs and practices of individuals and groups, it is essential to ask them appropriate questions about their religion and preferences in a sensitive manner.

Beliefs about everyday life issues vary among people from different religious backgrounds. Practices about all activities of living may be influenced through these beliefs. The following are examples of issues you should develop an awareness of and sensitivity to in the context of care to people from different religious persuasions:

  • Modesty and privacy
  • Clothing, jewellery and make-up
  • Washing and hygiene
  • Hair care
  • Prayer
  • Holy days, festivals
  • Food preferences
  • Physical examination
  • Birth
  • Contraception
  • Abortion
  • Specific ceremonies and practices such as communion
  • Attitudes to death, dying and mourning
  • Medication
  • Healing practices
  • Transfusions, organ donation and transplant
  • Last offices
  • Post mortem
  • Funeral services

It should be appreciated that religious worship and observance can play a significant role in giving meaning to events and experiences to people who believe in their respective faiths.

Personal Hygiene Needs

Personal hygiene refers to the self-care measures people use to maintain health (Potter & Perry, 1997, p. 1017). Personal hygiene needs cover a range of needs for the maintenance of the integrity of the skin, skin care, hair care, and oral hygiene, care of the ears and eyes, nostrils, perennial care. Personal hygiene needs are influenced by physical condition, disability, age, gender, social practices, knowledge, body image, socio-economic status, cultural variables and personal preferences (Potter & Perry, 1997).

Personal hygiene needs are also subject to adaptation through transitions during the lifespan as observed in the new-born, during infancy, childhood, puberty, pregnancy, adulthood, menopause and ageing. Hygiene needs and the rituals associated with them may have a basis in religious and cultural beliefs and practices, in particular with respect to the ideas of 'purity' 'impurity' or pollution and 'purification'.

The ideas about purity and pollution are common in most religions and are found in the explicit beliefs and practices about hygiene in Judaism, Islam, Hinduism and to some extent in Buddhism (Henley and Schott, 1999). Bodily secretions and fluids are considered polluting. These include sweat, urine, faeces, semen, menstrual fluid, vomit, blood and any other discharges, for example exudates from wounds. Across religious beliefs and practices, hygiene rituals are of significant importance and associated with everyday life events. Washing is essential requirement for both cultural and religious reasons. People may not feel spiritually and physically clean unless the traditional practices are carried out. Preference for running water may be expressed, as it is believed to be the most effective cleaning agent. Hence, a shower is preferred to a bath.

For example, in Islam, washing of the face, hands, feet and mouth before prayer constitutes one of the main principles. A wash and cleaning the mouth are essential before prayers to Hindus and Sikhs. Examples among Orthodox Jews include washing of hands before getting out of bed in the morning and before breaking bread. They also do not clean their teeth during fasts to prevent possibility of swallowing water.

In the South Asian and Islamic cultures, the perineal area is washed following use of the lavatory and the left hand is used. The right hand is used only to touch clean things and eating food.

Thus, the personal hygiene needs of different ethnic and religious groups vary according to the beliefs that they hold about the body and different bodily functions. In social and cultural practices influence hair care as do religious beliefs, and perceptions about bodily functions, health, and illness attributions. When caring for the client/patient we need to be sensitive to their privacy, modesty and dignity.

Individual's personal hygiene needs vary in health and illness, throughout lifespan and in death. When attending to the personal hygiene needs of individuals, it is essential to be sensitive to their cultural needs. A cultural assessment should be carried out to identify culture-specific needs as well as preferences. For example, the preference of a same gender nurse or doctor, as in the case of women, particularly those from an Islamic background.

Baxter (1992) describes the care of patients' hair and discusses the preferences of African/Caribbean and Asian people. Similarly, Baxter (1993) discusses how to observe the skin of people with dark skin in order to make accurate and reliable nursing diagnosis.

Skin And Hair Care

Biological Variations

For the delivery of holistic care to individuals and their families, it is important to have a thorough understanding of the socio-cultural as well as the biological factors that influence health and recovery form illness. Recognising changes from the expected normal range in biological functioning within and between ethnic groups can assist in achieving the outcomes of good quality care. In critical instances, making the right observation and interpreting signs can save lives.

Biological variations refer to differences in the biological, inherited, and cultural features of persons or ethnic groups. They suggest comparison with other people. Biological variations can range from the observable or visible (external macroscopic) or the not visible (internal) features of human functioning. The internally occurring variations can only be detected through tests and pathological examination. An understanding of these variations can enable the nurse to assess, plan, and implement care that is culturally competent.

Much of what is known about biological phenomena has been drawn from studies conducted predominantly with 'white' subjects. Therefore, the biological standardised baselines are not reflective of the non-white ethnic groups. However, in recent years the awareness of variations among and within ethnic groups has emerged as a source of further understanding of biological and socio-cultural phenomena.

There is always, however, the need to exercise caution when making assessment of biological functions across different ethnic groups. It is too easy to make assumptions and draw conclusions on limited information or interpretation that is not correct. Assessment of the individual may reveal biological variations that do not necessarily correspond to variations observed when groups are studied.

Giger and Davidhizar (1999) describe biological variations in detail in Chapter 7.

Under the dimensions of biological variations: Giger & Davidhizar (1999)

Body structure
Body weight
Blood group, Rh factor
Drug interaction and metabolism

Susceptibility to disease
Skin colour
Enzymatic and genetic variations
Electro cardio-graphic patterns

It is questionable whether some of the categories for discussion under biological variations by Giger & Davidhizar (1999), for example AIDS, and Nutritional Preferences and Deficiencies are strictly appropriate since these can also be attributed to the combined interactive influences of environmental and biological factors, and not just solely to one set of factors.

Some Issues For Consideration

Body Structure

Body structure variations can be observed across ethnocultural groups in terms of body size, shape, and colour of skin. Gender differences between men and women, and transitions during the lifespan are also observed, such as with image-related variations.

  • Birth weight of new-born, body proportions, and the mother's body, size and structure are related.
  • Bone density - prevalence of rickets and osteoporosis among some ethnic and environmental groups, and differences across men and women.
  • Skeletal bone mass; in childhood, puberty, adolescence, adult and older adult.

The facial features provide a means of categorising people. The complex features of the face are very useful sources of information during the lifespan in both men and women.

Observing Skin Colour

Patients, relatives and carers may be asked to comment about the skin colour of a patient as means of corroborating the significance of any observation that you have made. The skin of the individual can reveal many underlying causes of discoloration, bruising, disease processes and infections. When you are not familiar with the effects of biological disturbances on skin colour, texture and tone different to your own, it may be useful, if it is acceptable, to involve the patient and relatives. The purpose should be to engage them in the interpretation of the observation by asking about the 'normal' appearance and tone of the skin. They may point out what the skin looks and feels like, and what they notice to be different as a result of illness. This may be particularly useful during the initial assessment when a baseline needs to be established for future comparisons. Engaging the patient and relatives also assists in developing rapport and a sense of partnership in care.

Skin colour is perhaps the most noticeable biological difference among people of different ethnic backgrounds. Differences in skin colour are due to pigmentation and adaptability to the environment.

Giger and Davidhizar (1999) have suggested that the darker the patient's skin colour, the more difficult it is to assess changes to colour. However, it should be added that overcoming any difficulty in making accurate observations requires a level of knowledge and practice in real life experiences of engaging with patients. Asking patients the appropriate questions with sensitivity may assist in deriving the specific knowledge and skills about observing skin colour.

EXERCISE 2.1
Learning Activity

Exercise 1
· Observe the skin colour, texture and tone in different parts of the visible body surfaces. Note these.
For example, the nail beds, the tips of the fingers, the palm of the hands, the mucous membrane of the lips, facial skin, sole of the feet.
· Observe these in different conditions such as cold temperature, warm environment, before and after exercise.

Exercise 2
· Observe the colour of the eyes, the sclera (white of the eye as opposed to the pupil), and the conjunctiva.

Exercise 3
With mutual consent, these exercises can be repeated with another person, who has a different skin colour, the aim being to assess similarities and differences in visible signs in people of different skin colour.

· Repeat these observations in Exercise 1 and 2
· Discuss your observations and the underlying explanations for these.

Principles Of Observing Skin Colour

By adopting a set of principles that can guide the accurate observation of skin colour of our patients/clients, errors and misinterpretation of signs can be avoided. Misunderstanding about the significance of signs can be, in the least, embarrassing and insensitive and in the extreme, fatal.

Giger and Davidhizar (1999) suggest the following principles:

It is necessary to establish a baseline for skin colour. Observations should be preferably in daylight as this is more reliable. When taking observations in an artificially lit environment, use at least a 60-watt bulb. Often, the standard torches and lights over patient's bed are not sufficient to provide the illumination required to make subtle distinction in skin colour and texture.

It is advisable to begin with skin surface with the least pigmentation such as the sole of the feet, palm of hands, inner aspect of arm, abdomen, buttocks, mouth, conjunctiva, and nail bed. Generally, an underlying red tone is typical of all skin, regardless of the degree of pigmentation. However, one has to be aware of possible problems with the skin surfaces as a result of illness itself, which may make them less reliable sites of observation.

Besides the tone, the texture of skin should be observed. Touch and palpation of the skin may be useful in detecting rashes and areas of inflammation. When feeling for increased warmth, the dorsal surface of the fingers may be used for greater accuracy since they are more sensitive than the palm of the hand.

The conjunctiva of the eyes is a reliable site to observe for 'pallor' and cyanosis. In the health as well as in illness, the conjunctiva can reveal useful signs. In conditions where bleeding is a feature, it is easier to detect signs of bleeding into the skin or beneath the mucous membrane without causing too much distress. Small round flat dark red spots (or petechiae) are indicative of such type of bleeding.

Besides the conjunctiva, the sclera (the white of the eye) can be observed for signs of jaundice. Again, a baseline should be established, because the sclera of dark-skinned people often has a yellow discoloration due to fatty deposits. This is normal.

The hand can reveal useful information. The palms of the hands and soles of the feet are often lighter in colour and are used for comparison, and detection of changes in temperature, blood pressure and lack of oxygen to the extremities. The nail bed is a useful site to observe for pallor or cyanosis. However, caution should be exercised in practice as the nail bed may be highly pigmented, thick, or have melanin deposit, and therefore may not be a reliable source of observations. In 'white' people, the nail-beds are pink, with translucent white tips. In persons with dark skin, brown or black pigmentation is present in longitudinal streaks (Potter & Perry, 1997).

The skin surface should be observed for signs of eczema, psoriasis, rash, keloid scars and wound healing.

Scars And Keloids

Keloids are overgrowths of fibrous tissue at the site of a scar following skin healing. Up to 16% of Black African people in a random sample reported having keloids (Berman and Kapoor, 2000). The same authors state that keloids form more frequently in Polynesians and Chinese than in Indian and Malaysian populations. Keloids develop following cuts and piercing of the skin. Disfigurement occurs when scarring is excessive (Baxter, 1992).

Keloids can also occur when tightly curled hair is cut during shaving. The hair tends to curl back and puncture the skin, causing inflammation. Spots are common signs. Multiple small keloids can form, giving the face and back of the neck a rough and uneven appearance (Baxter, 1992).

Measures that assist to reduce keloids or permanent scarring include the avoidance of secondary infections following surgical and accidental cuts to the skin, and body piercing. Health care professionals should be mindful of resultant disfigurement and site surgical incisions or immunisation and vaccinations appropriately.

Skin Care

As an essential part of personal hygiene, skin care provides both for physiological safety and socially aesthetic functions. The privacy and dignity of the person should be maintained at all times during nursing activities. As part of the care of the person's skin, we should find out the person's choices and preferences. In assessing their needs, we must find out if the person has any allergies, skin sensitivities or preferences. This will enable us to use the appropriate cleansing lotion for the face, and the use of any bath oil, lotions or moisturiser.

Patients with dry skin should be observed for cracks and lesions. Elderly people are particularly vulnerable. Moisturising the skin should assist in maintaining some degree of suppleness. Early signs of need for moisturising the skin are superficial flakes, ashen appearance, itchiness, and discomfort. Particular care should be taken with patients with known conditions such as diabetes. Patients confined to bed should be turned frequently, and observations of the skin for early detection of pressure sores are critical.

Lawton (2000) has described and summarised the changes that can be observed on the skin as a result of underlying disease processes and their effects on skin colour and texture. When observing the skin of patients it is worth bearing in mind that some diseases cause an excess of pigmentation, whilst others cause a decrease in pigmentation. With excess pigmentation, there is a tendency for the skin to become 'darker' in comparison to what is normal for the individual. Conversely, with loss of pigmentation, there is a tendency for the skin to become 'lighter'. When comparing skin colour in the same individual, it is useful to look at different parts of the body to ascertain how much the skin under observation has changed. Some examples of causes are given below.

Hypopigmentation (loss of pigmentation) or hyperpigmentation (excessive production of the pigment melanin) is more noticeable in people with dark skin.

Cause

Hypopigmentation

Hyperpigmentation

Genetic

Albinism
Phenylketonuria

Freckles
Neurofibromatosis

Endocrine

Hypopituitarism

Addison's disease
Cushing's Syndrome

Inflammation

Eczema
Psoriasis

EczemaAcne

Chemicals

Chronic arsenic exposure

Silver poisoning

Drugs

Steroids

Oestrogen
Phenothiazines
Infection Leprosy
Yaws		 Pityriasis versicolor
Other Vitiligo
Halonaevus		 Malignant melanoma

(Adapted from Lawton, 2000)

Hair Care

'Hair reflects the well-being of an individual, and its care and grooming play a vital role in morale and self-esteem' (Baxter, 1992, p2). Biological variations are observed in the distribution of body hair across different ethnic groups, age and gender. Hair types vary.

Cultural and religious beliefs have an influence on the care of hair and hairstyles. Shaven heads, plaits and punk styles, all reflect individuality and aesthetic values. For example, religious beliefs and practices among orthodox Jews, Rastafarians and Sikhs prohibit men from cutting or shaving their hair.

Preferences and choice of hairstyles vary in time. Cultural influences play an important role in setting trends. Hairstyle is a significant aspect of self-identity and self-expression.

Ethnic Group

Hair Type

Hair Care

African/
Caribbean

Ranges from short, spiralled, kinky to long and straight.

Scalp and hair need moisturising following swimming and shampooing.
Spiralled texture and quality gives flexibility for styling. Suitable products should be used to moisturise.
Can be dry, brittle, fragile, easily tangled, matted, and difficult to comb. Weekly or fortnightly shampooing. Shampooing more often may make hair unduly dry. Moisturising will help prevent dryness.
Dreadlocks worn by Rastafarians are popular. Does not require combing or brushing. Not cut. Non-perfumed oil or moisturiser to be used.
Braided hair worn along the scalp in rows. Hair may be shampooed with braids left intact.
Relaxed (straightened) hair. Rollers may be used to add bounce.
Relaxed hair using hot comb method. When exposed to moisture can revert back to original texture. Care taken when washing and bathing the patient. Combing relaxed hair is not necessarily recommended.
Preparations for kinky, spiralled hair Need a good hairbrush with natural bristle. A wide toothcomb. Hair preparation to seal moisture in hair - oil or lanolin based preparation or oil free moisturisers.
Asian Tends to be straight, worn long.

Same as Europeans. Lightly oiled hair, with coconut based oil or olive oil.
Plaited hair may be a preference. Ends of plaits may be secured with braids; ribbons made of thick, black, threadlike material.

Orthodox Sikh males do not cut or shave their hair.

Sikh boys' topknots are covered with a handkerchief. Turban is worn when outdoors.
Preparation for straight hair Hairbrush, hair oils and braids (if required).

(Adapted from Baxter, 1992)

Conclusion

Skin and hair care are essential to the physical as well as psychosocial well-being of the individual. Adherence to the patient's/ client's cultural expectations and religious practices, as well as preferences are crucial factors in the delivery of culturally congruent care. The participation of the patient/client in the decision-making and choice in hair and skin care should be the developing partnership in care. The essential aspects of care presented here may be further expanded on to include physical and psychosocial aspects of care for different client groups.

Further Reading

Mad About Black Hair
Black Womens Health

Death, Dying And Bereavement

Death

Dying with dignity is a personal and human value in all cultures. In the event of caring for someone who is dying, the values and wishes of the person and the family should be respected. In a transcultural care setting, this requires culture-specific knowledge of beliefs and practices.

Death is a very complex human phenomena, as are beliefs, attitudes and rituals associated with it. Rees (1997, p.1) states that 'Death is one of the great mysteries of life and it is not surprising if people's attitudes towards it is diverse and ambiguous'. Death conjures up all sorts of images and a whole range of emotions, all very personal and complex. Across cultures, there are many examples of representations of death in symbols, arts and literature.

Religious beliefs play a significant role in determining the perceptions and responses of individuals and social groups towards loss, death and dying (Cowles, 1996). Such beliefs are influenced by the kind of explanations that are held about death and dying. For instance, a fatalistic view of death may well lead to the acceptance of the inevitable, whereas a less deterministic view may assist in posing several questions in an attempt to seek rational explanations and not accept death as inevitable (Laungani, 1995; Laungani, 1999).

On the death of a patient, the appropriate persons who are traditionally assigned such roles and offices should perform the cultural and religious rituals. In providing culturally acceptable nursing care, you need to be aware of both what is and what is not permissible to carry out from a religious and cultural perspective. It is important that you avoid stereotyping and use individual assessment to determine what is appropriate and culturally congruent. The legal and professional obligations of health care personnel to provide facilities for dealing with the dead person's body and subsequent disposal to the family should guide any actions taken.

At an individual level, most losses are acknowledged, although some may go unrecognised. Parkes (1998a) suggests that losses can be hidden, they are not admitted to anyone, and they give rise to feelings of shame and inadequacy. When loss is gradual, the person may ignore or minimise the impact of the loss (Parkes, 1998a). We adapt to personal loss through the grieving process.

Grieving

The feeling of grief is universal (Cowles, 1996). Grief reactions are normal and natural. Rees (1997, p.109) has described the grief process as 'the inner turmoil that follows bereavement and the individual's subsequent adaptation to the new situation'. However, individuals vary in the way in which they grieve and in the expressions of their grief. When a patient dies, you will also experience grief at losing him/her.

The experience of grief is very personal. In a study of participants from six diverse cultural groups, Cowles (1996) showed that people acknowledge that grief is something we all feel but may express in different ways. Thus the experience of grief is common to all of us.

Rees (1997) summarises Lindemann's five characteristics of normal grief: physical distress, preoccupation with the image of the deceased, guilt, hostility and loss of established pattern of conduct. Grief may be suppressed and unresolved grief may lead to denial and 'distorted grief reactions'.

Cultural and spiritual beliefs may figure largely in the expressions of grief in people who are believers in particular faiths. 'An individual may find support, comfort, and meaning in losses through the spiritual beliefs. Frequently a grieving person turns to formal religion for strength and support' (Featherstone, 1997, p.464). Across cultures, people of the same religious persuasion may express their grief in socially patterned ways that may reflect similarities as well as differences due to environmental and ecological factors (Laungani, 1999).

Dying

When a person comes to realise that he/she is dying, as many people who are terminally ill do, then they experience emotions and go through phases that Kubler-Ross' (1969) has described. There is the initial disbelief, denial and numbness, followed by anger. This give way to bargaining, followed by depression, and eventually acceptance. Rees (1997, p79-96) describes these stages with case studies.

This framework can be adapted and used to enquire about the culture-specific norms. Variations within and between cultures are expected to influence real life scenarios. However, grief reactions may not follow cultural norms, and individual assessment will avoid misunderstanding about the cultural beliefs and practices of patients and families. As Neuberger (1987) points out, whilst respecting the cultural and religious heritage of patients, we should not forget that we are dealing with individuals. Also, individuals may not always fit into what may be considered the 'norm' for their cultural and religious group.

Attitudes To Death: Cross-Cultural Issues

Attitudes to death vary across religious and cultural beliefs systems. Death may be seen as inevitable, the end or beginning of life. The following is an adaptation of Green (1991) Green (1993), Neuberger (1987), Neuberger (1999) and Rees (1997).

Religion

Beliefs and Attitudes to Death
Buddhism Belief in rebirth. Rebirth is continuous change in spiritual consciousness (not physical consciousness). Belief in after-death, reading of Buddhist text, the Tibetan Book of the Dead, for guidance to achieve better rebirth or reach liberation into a state of nirvana.
Christianity Belief in the afterlife, spiritual mode of existence. Belief in the resurrection, reunion of body and soul.
Hinduism Belief in reincarnation or rebirth. Goal is to attain Moksha, release form the cycle of birth and rebirth. Belief in life being governed by karma, that deeds of past lives have a continuous influence on events and course of present life.
Religion   Beliefs and Attitudes to Death
Islam Belief that souls are judged soon after death. Belief on the physical resurrection of the dead.
Jainism Belief in karma, salvation can be achieved through hardship, and the soul can be freed through ridding themselves of the karma they have acquired. Some believe in fasting to death.
Judaism Discourages any speculation about the nature of life after death. Belief in the resurrection of the dead. Controversial issue. Orthodox Jews believe in a general resurrection, when bodies and souls of the dead will be reunited, something that Liberal or secular Jews do not believe in.
Secularism Concerned only with life in this world, have no beliefs in gods, soul or spirits. No conscious experience is outside the body.
Sikhism A belief in karma and reincarnation. There is a positive attitude to life in this world. A belief that men and women return enriched in this world.

African Religions
(Great variability)

 Affirmation of the spiritual dimension of life. Complex issues, dynamism between the belief in the spirits of the dead and psychic forces. Belief in reincarnation but different to the Indian religions. Beliefs that death is a reality, and life ends at death, but some of the characteristics of the dead person may be reincarnated in a child born in the family.

African-Caribbean
(No single religion)

 Spread of religious beliefs, depending on cultural traditions. Beliefs vary as in Christianity and other religions. Belief in the world of spirits. Rastafarianism – belief in the resurrection of the soul but not of the flesh.
Jehovah’sWitness Belief in resurrection but not the Trinity.
Seventh Day Adventist Belief in the integration of body, mind and spirit. Life on earth is preparation for life beyond. Belief in the resurrection. With the Second Coming of Christ, the dead will be resurrected and rewarded accordingly.

Care Of The Dying

Respect of the dying and dead is a universal concept across cultural and religious practices. When caring for the dying person, one has to be aware of the cultural and religious aspects of what is expected and preferred with respect to the wishes of the individual, family and relatives and the ethnic/cultural/religious community.

In certain situations and according to the expectations of family members, the dying person may wish to be cared for by a family member, or wish to die at home.

The religious rites associated with the care of the dying are influenced not only by religious beliefs but also by cultural practices. In most religions, some forms of prayers are offered. In some instances, reading from the relevant Holy Book, chanting or incantations may be carried out. For example, with a Sikh patient, reciting from the Guru Granth Sahab is deeply significant.

In Christianity, sacraments confer spiritual gifts, and baptism holds great significance, and symbolises entry into the family of Christ. When the person is very ill and near death, generally prayers and sacrament may be offered. For the dying patient who follows the Roman Catholic faith the last rites may be offered. The priest anoints the person 'on the forehead and hands in a ceremony which symbolises forgiveness, healing and reconciliation' (Green, 1993, p. 4). Great significance is attached to the last rites as a transition from this life. In the Free Churches, there are no sacraments other than what is considered to be in the form of personal inner experience.

In Islam, the person sits or lies down, with the head facing towards Mecca. A call to prayer is whispered in the ear. The Hindu person may wish to lie on the floor as a symbol of closeness to Mother Earth. A thread may be tied to the wrist or neck, blessed water sprinkled, and a tulsi leaf placed in the mouth. The Jewish patient may "wish to hear or recite special psalms, particularly psalm 23 (The Lord is my Shepherd) and the special prayer (The Shema)" (Green, 1991, p. 8).

At death, some religious customs forbid the touching of the body by a person who is not of the same religion, for example, Judaism and Islam. In certain customs, the family or relatives may prefer to prepare the body for burial or cremation. For instance, in Hinduism it is believed that the responsibility and duty (dharma) of family members to the dead persons can only be complete through observance of such practice (Laungani, 1996).

Mourning

In the cross-cultural context, the overt, observable behavioural responses to death and grief vary. This is the social and public expression of grief (Cowles, 1997). The expressions of grief vary from silence, crying, loud shrieks, lamentations and bodily movements. Parkes (1996) calls these the cultural and social displays of grief. For example, weeping and wailing that is socially patterned may be observed among Greek Cypriots (Helman, 2000, p.162). In some cultures, there may be a defined period of mourning, for example, among orthodox Jews, "the 'shib'ah' has a precise structure of mourning, lasting 7 days after the funeral, during which time the bereaved remain at home and are visited by consolers. Mourning dress is worn till the thirtieth day, and recreation and amusement is forbidden" (Helman, 1993, p.162). Individuals and groups vary in patterns of expression of grief and mourning and in the demonstration of shared communal mourning. Among Hindus a more communal approach and public show of emotions are observed (Laungani, 1999). Mourning may continue well after the physical act of burial or cremation. In Islam, the grave is visited for 40 days on Fridays, and alms are given to the poor.

Ceremonies are performed to mark particular time-oriented stages in mourning. For example, in the Jewish faith, rituals to mark the first anniversary, 'yahrzeit' is performed (O'Gorman, 1998).

Conclusion

Grief and loss are perceived as universal human responses. At a personal level the experience of grief may follow a specific pattern. This experience may remain hidden or given expression. Some expressions of grief become social and public displays as shaped by the cultural and social influences. The communal expressions of grief are given symbolic meanings. With respect to death, dying and bereavement, there are differences within and across communities. There may also be intergenerational differences in expectations and practices as a result of social and cultural changes, and migration. The religious and cultural practices of communities, and individuals in particular, have to be respected with regard to such a sensitive lifespan stage. Assessment, planning and delivery of care should take into particular consideration the spiritual needs of the individual and family.