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TRANSCULTURAL HEALTH CARE

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TRANSCULTURAL HEALTH CARE

A Culturally Competent Approach

4th Edition

Larry D. Purnell Phd, RN, FAAN

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2013 by F. A. Davis Company

Copyright © 2013 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Robert G. Martone Director of Content Development: Darlene D. Pedersen Project Editor: Victoria White Electronic Project Manager: Tyler Baber Design and Illustrations Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new infor- mation regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Transcultural health care : a culturally competent approach / [edited by] Larry D. Purnell. — 4th ed. p. ; cm.

Includes bibliographical references and index. ISBN 978-0-8036-3705-4 I. Purnell, Larry D. [DNLM: 1. Cultural Competency—United States. 2. Delivery of Health Care—United States. 3. Cultural Diversity—United States.

4. Ethnic Groups—United States. W 84 AA1]

362.1089—dc23 2012016099

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v

Foreword

Knowing is not enough, we must apply. Willing is not enough, we must do.

Goethe

Goethe’s quote is considered a call to action by organ- izations as prestigious as the Institute of Medicine, and it remains one of my favorite quotes today. It has such incredible implications for health care, particu- larly as we struggle with the extended time it takes to translate research into practice. In fact, oftentimes, de- spite strong evidence, we are slow in enacting the changes we need to improve the health care and nurs- ing we deliver. In some cases we are waiting for the “indisputable” evidence, and in other cases we are sim- ply being resistant to change. But occasionally the need for change is thrust upon us, momentum builds, and the realization emerges that there isn’t a need to prove the obvious before acting but a need to act as the obvious is all around us. This has become the case with cultural competence in health care.

My knowing about the importance of cultural com- petence developed as I grew up in my bilingual, bicul- tural Puerto Rican family, where perspectives about health and health care were incredibly varied, and at times at odds with Western medicine. My knowing grew, as I trained to be a health-care professional in underserved and diverse settings such as Newark, New Jersey, and New York City, where we saw pa- tients from all cultures, classes, and racial/ethnic back- grounds. What became crystal clear to me was that while we were learning the best medications to treat hypertension or the most advanced algorithms for di- agnosing and treating disease, if we couldn’t commu- nicate effectively with our patients or get them to buy into, agree with, and cooperate with what we were try- ing to accomplish, then all that medical knowledge was worth nothing. Whether a doctor, a nurse, or other health professional, caring for patients required an understanding of the sociocultural factors that might impact their health beliefs and behaviors, rang- ing from how they presented their symptoms, to how they viewed disease and illness, to what informed their health care, diagnostic, and treatment choices. Cases where we couldn’t bring our knowledge to bear to ease suffering or cure disease because of “cultural differ- ences” with patients were the ones that kept us up at night and were the most frustrating and disappointing

of all. Along the way I also learned to appreciate that we all have culture and that the tools and skills I needed to learn to communicate clearly with patients wouldn’t just be helpful in the care of those who were culturally different from me, but to any patient with whom I interacted. For at the end of the day, there were always three cultures in the room—my culture; the patient’s culture; and the cultures of medicine, nursing, and other health professions—making every encounter cross-cultural in one way or another.

Despite these almost daily epiphanies during my training, there were few resources available that might provide me with guidance on how to become an effec- tive communicator and caregiver in this new world I was entering. Fortunately, this has changed. New models have been developed, leaders have emerged, and health-care professionals no longer need to go blindly into cross-cultural encounters without guid- ance, as there are real and practical approaches that facilitate improved understanding, communication, and care. Knowing is not enough, we must apply.

Transcultural Health Care: A Culturally Compe- tent Approach builds on a framework for cultural competence—which is essential in the care of the individual—by bringing together health-care providers of various backgrounds and disciplines to share their knowledge, expertise, and experiences in the field with particulars about different populations. This information is presented to provide details about the social and cultural fabric of different cultural groups, with the important caveat that it is not to be used to stereotype patients within these groups, as each pa- tient is an individual and diversity can be as extensive within groups as it is among groups. It is from this principle—that learning background information about cultural groups can help health-care providers both develop a “radar” for potential pitfalls when caring for them and serve as a springboard for in- quiry with the individual patient—that Transcultural Health Care emerges.

Why is this book, and this edition, so timely? In the past, arguments about the importance of cultural competence were based primarily on making the case that our nation was becoming increasingly diverse and that as health-care professionals we need to be pre- pared to care for patients of different sociocultural backgrounds. This is an important argument, no

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doubt. Shortly thereafter, research began to emerge demonstrating that being inattentive to cultural issues in the clinical setting leads to lower quality of care for specific populations, such as racial and ethnic minorities—a term that became known as disparities in health care. Yet what has evolved more recently is a burgeoning literature documenting the impact of cul- tural factors on health-care quality, cost, and safety. New research demonstrates that when we are not skilled or prepared to care for patients from diverse backgrounds, they may, when compared to their Cau- casian counterparts, suffer more medical errors with greater clinical consequences; have longer hospital stays for the same common clinical conditions; and may have more unnecessary tests ordered—all due to language or cultural barriers between health-care providers and patients. With health-care reform and payment reform on the horizon, we literally can no longer afford to be ill prepared to meet the needs of an increasingly diverse nation.

As we look toward the future, we see signs of a breakthrough occurring. More and more is being writ- ten about the topic of cultural competence. Students who years ago had to be convinced of the importance of this issue are now arriving more sensitized about cultural competence than ever before and are demand- ing to build their skills in the field. More research is being conducted on cultural competence and its im- pact on quality, safety, and cost. Additional areas are

being cross-linked to cultural competence, such as patient-centeredness and health literacy. New quality measures and accreditation standards are being devel- oped, and in some states cultural competence training has become a condition of health professional licen- sure. There is little doubt that the field of cultural competence is moving from the margin to the main- stream and from a luxury to a necessity. As individual providers, we must all do our part to ensure that we are delivering high-quality care to any patient we see, regardless of her or his race, ethnicity, culture, socio - economic class, or language proficiency. Transcultural Health Care: A Culturally Competent Approach helps us build the radar to identify and understand key cross-cultural issues among diverse populations and, when applied with the tools and skills that are essen- tial for exploring the sociocultural perspectives of the individual patient, positions us for success. Now it is time for us to learn the lessons and skills so gracefully shared with us in this book to make a difference in pa- tients’ lives. Willing is not enough, we must do.

Joseph R. Betancourt, MD, MPH Director, The Disparities Solutions Center and

Director of Multicultural Education, Massachusetts General Hospital Associate Professor of Medicine,

Harvard Medical School Cofounder, Manhattan Cross-Cultural Group

vi Foreword

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vii

Preface

The Purnell Model for Cultural Competence and its accompanying organizing framework continue to be used in education, clinical practice, administration, and research. The Model and selected chapters have been translated into Arabic, Flemish, French, Korean, Portuguese, Spanish, Turkish, and Korean, attesting to its value on a worldwide basis. In addition, many health-care organizations have adapted the organizing framework as a cultural assessment tool, and numer- ous students in the United States and overseas have used the Model to guide research for theses and dissertations. The Model is increasingly being used as a guide to help ensure organizational cultural competence.

This fourth edition of Transcultural Health Care: A Culturally Competent Approach has been revised based upon responses from students, faculty, and practicing health-care professionals such as nurses, physicians, emergency medical technicians, nutrition- ists, and people in noetic sciences. In addition, this edi- tion is divided into two units. Unit 1, Foundations for Cultural Competence: Individual and Organizational, has the following features:

• An expanded chapter on the overview of transcul- tural diversity and health care

• A separate chapter on the Purnell Model for Cultural Competence, with specific questions in the organizing framework instead of objectives

• A separate chapter on individual competence and evidence-based practice

• A separate chapter on organizational cultural competence

• A separate chapter on global health

Unit 2 is entitled Aggregate Data for Cultural- Specific Groups. As in previous editions, we have made a concerted effort to use nonstereotypical language when describing cultural attributes of specific cultures, recognizing that there are exceptions to every descrip- tion provided and that the differences within a cultural group are determined by variant cultural characteris- tics. One important change on the Model is that the pri- mary and secondary characteristics of culture are now

called “variant cultural characteristics” at the sugges- tion of gay, lesbian, and transgendered communities.

The first time a cultural term is used in a chapter, it is in boldface type and is defined in the glossary. Because faculty and clinical practitioners have found the Appendix—Cultural, Ethnic, and Racial Diseases and Illnesses—valuable, it remains in the book. Abstracts are included in the main textbook for each culturally specific full chapter located on Davis Plus.

Space and cost concerns limit the number of chapters that are included in the book; therefore, additional cul- tural groups are on Davis Plus. Also on Davis Plus are student resources such as review questions, Web sites of interest, case studies, and reflective exercises. Additional faculty resources on Davis Plus include PowerPoint slides with clicker check questions for each chapter and a question bank.

Specific criteria were used for identifying the groups represented in the book and those included in elec- tronic format. Groups included in the book were selected based on any of the following six criteria:

• The group has a large population in North America, such as people of Appalachian, Mexican, German, and African American heritage.

• The group is relatively new in its migration status, such as people of Haitian, Somali, and Arab heritage.

• The group is widely dispersed throughout North America, such as people of Iranian, Korean, Hindu, and Filipino heritage.

• The group is of particular interest to readers, such as people from Amish heritage.

• The group is of particular interest to students and staff from other countries, such as European Americans.

A particular strength of each chapter is that it has been written by individuals who are intimately famil- iar with the specific culture. Again, we have strived to portray each culture comprehensively, positively, and without stereotyping. We hope you enjoy the book.

Larry D. Purnell

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ix

Contributors

Richard Adair, MD Adjunct Professor of Medicine University of Minnesota Minneapolis, Minnesota

Karen Aroian, PhD, RN, FAAN Director of Research and Chatlos Endowed Professor University of Florida College of Nursing Orlando, Florida

Linda Ciofu Baumann, PhD, RN, FAAN University of Wisconsin-Madison Madison, Wisconsin

Joseph R. Betancourt, MD, MPH Director of Disparities Solutions Center Massachusetts General Hospital Boston, Massachusetts

Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN

Transcultural Healthcare Consultant Transcultural C.A.R.E. Associates Blue Ash, Ohio

Marga Simon Coler, EdD, Dr. Causa Honoris, FAAN, APRN-BC

Professor Emeritus University of Connecticut South Hadley, Massachusetts

Jessie M. Colin, PhD, RN, FAAN Professor and Director of Nursing PhD, Nursing

Administration and Nursing Education Programs Barry University Miami Shores, Florida

Tina A. Ellis, RN, MSN, CTN Nursing Instructor Florida Gulf Coast University Fort Myers, Florida

Myriam Gauthier, MSN Graduate Student in Nursing Faculté des sciences infirmières, Université Laval Pavillon Ferdinand-Vandry, Québec

Rauda Gelazis, RN, PhD Retired, Associate Professor Ursuline College Pepper Pike, Ohio

Homeyra Hafizi, MSN, RN, COHN/S, LHRM Coordinator, Employee Health and Workers’

Compensation Wuesthoff Health System/HMA Rockledge, Florida

Laurie B. Hartjes, PhD, RN, PNP-BC Educational Design Consultant Lodestone Safety International Beverly, Massachusetts

Keiko Hattori, RN, PhD Assistant Professor Kawasaki University of Medical Welfare Kurashiki, Okayama, Japan

Sandra M. Hillman, PhD, MS, BS, RN Associate Professor College of Mount Saint Vincent Bronx, New York

David Hodgins, MSN, RN, CEN Indian Health Service Shiprock, New Mexico

Olivia Hodgins, RN, PhD, MSA, BSN Map Instructor and Nurse Executive Indian Health Service San Fidel, New Mexico

Kathleen Huttlinger, PhD, RN Associate Director for Graduate Programs New Mexico State University Las Cruces, New Mexico

Eun-Ok Im, PhD, MPH, RN, CNS, FAAN Professor and Marjorie O. Rendell Endowed

Professor University of Pennsylvania Philadelphia, Pennsylvania

Misae Ito, RN, MW, MSN, PhD Professor Kawasaki University of Medical Welfare Kurashiki, Okayama, Japan

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Jayalakshmi Jambunathan, PhD, MSN, BSN, MA BSc

Professor, CON UW Oshkosh Director, Research and Evaluation and Assistant

Dean UW Oshkosh Oshkosh, Wisconsin

Galina Khatutsky, MS Research Analyst RTI International Waltham, Massachusetts

Sema Kuguoglu, PhD, BSN, RN Professor Emeritus, University of Mamara Funded Professor, University of Gazikent Istanbul and Gaziantep, Turkey

Anahid Kulwicki, PhD, RN, FAAN Professor and Associate Dean for Research Director of the PhD in Nursing Program Florida International University Miami, Florida

Ginette Lazure, PhD Professeure titulaire Université Laval Pavillon Ferdinand-Vandry Médecine, Québec

Stephen R. Marrone, EdD, RN-BC, CTN-A Deputy Nursing Director State University of New York SUNY Downstate Medical Center Brooklyn, New York

Susan Mattson, RNC-OB, CTN-OB, PhD, FAAN Professor Emerita Arizona State University College of Nursing and

Health Innovation Scottsdale, Arizona

Afaf Ibrahim Meleis, PhD, DrPS (hon), FAAN Margaret Bond Simon Dean of Nursing University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Mahmoud Hanafi Meleis, PhD, PE Retired Nuclear Engineer Philadelphia, Pennsylvania

Cora Munoz, PhD, RN Professor Emerita/Adjunct Professor Capital University Columbus, Ohio

Irena Papadopoulos, PhD, MA (Ed), BA, RN, RM, NDN, FHEA

Professor Middlesex University Highgate Hill, London, UK

Ghislaine Paperwalla, BSN, RN Research Nurse in Immunology Veterans Administration Medical Center Miami, Florida

Jeffrey R. Ross, MAT, MA, BFA ESL Teacher and Tutor Springfield School System and the University

of Akron Akron, Ohio

Ratchneewan Ross, PhD, MSc (Public Health), RN Associate Professor and Director of International

Activities Kent State University Kent, Ohio

Susan W. Salmond, EdD, RN, CNE, CTN Dean and Professor University of Medicine and Dentistry of New Jersey Newark, New Jersey

Stephanie Myers Schim, PhD, RN, PHCNS-BC Associate Professor Wayne State University College of Nursing Detroit, Michigan

Janice Selekman, DNSc, RN Professor Nursing University of Delaware Newark, DE

Jessica A. Steckler, MS, RN-BC CEO The Firm of Jessica A. Steckler Erie, Pennsylvania

Marshelle Thobaben, RN, PHN, MS, FNP, PMHNP Department Chair, Professor Humboldt State University Arcata, California

Hsiu-Min Tsai, RN, PhD Dean of Academic Affairs and Associate Professor Chang Gung University of Science and Technology Tao-Yuan, Taiwan

x Contributors

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Anna Frances Z. Wenger, PhD, RN, FAAN Professor and Director Emeritus of Nursing Goshen College Goshen, Indiana

Marion R. Wenger, PhD Professor of Linguistics and Foreign Languages Goshen College Goshen, Indiana

Cecilia A. Zamarripa, RN, CWON University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Rick Zoucha, APRN, BC, DNSc, CTN Associate Professor Duquesne University School of Nursing Pittsburgh, Pennsylvania

Contributors xi

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xiii

Reviewers

Kristie Berkstresser, MSN, RN, CNE, BC Assistant Professor of Nursing HAAC—Central Pennsylvania’s Community College Lancaster, Pennsylvania

Judy Shockey Carter, MSN Ed, RN Assistant Professor Anderson University Anderson, Indiana

Sabrina L. Dickey, RN, BSN, MSN Assistant Faculty in Nursing Florida State University Tallahassee, Florida

David N. Ekstrom, PhD, RN Associate Professor Pace University, College of Health Professions Lienhard School of Nursing New York, New York

Mary L. Padden, RNC,APN-C, FN-CSA Assistant Professor, Nursing Cumberland County College Vineland, New Jersey

Priscilla L. Sagar, EdD, RN, ACNS-BC, CTN Professor of Nursing Mount Saint Mary College Newburgh, New York

Lisabeth M. Searing, PhD, MSN, RN Assistant Professor Illinois Wesleyan University, School of Nursing Bloomington, Illinois

Gale Sewell, RN, MSN, CNE Assistant Professor Indiana Wesleyan University Marion, Indiana

Jeanine Tweedie, MSN, RN, CNE Nursing Faculty Hawaii Pacific University Kaneohe, Hawaii

Mai-Neng Lee Xiong, BSN Director of Nursing People Incorporated Mental Health Services St. Paul, Minnesota

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xv

Table of Contents

UNIT 1: FOUNDATIONS FOR CULTURAL COMPETENCE: INDIVIDUAL AND ORGANIZATIONAL 1

Chapter 1 Transcultural Diversity and Health Care 3 Chapter 2 The Purnell Model for Cultural Competence 15 Chapter 3 Individual Competence and Evidence-Based Practice

(with inclusion of the International Standards) 45 Chapter 4 Organizational Cultural Competence 60 Chapter 5 Perspectives on Nursing in a Global Context 74

UNIT 2: AGGREGATE DATA FOR CULTURAL-SPECIFIC GROUPS 89

Chapter 6 People of African American Heritage 91 Chapter 7 The Amish 115 Chapter 8 People of Appalachian Heritage 137 Chapter 9 People of Arab Heritage 159 Chapter 10 People of Chinese Heritage 178 Chapter 11 People of Cuban Heritage 197 Chapter 12 People of European American Heritage 214 Chapter 13 People of Filipino Heritage 228 Chapter 14 People of German Heritage 250 Chapter 15 People of Haitian Heritage 269 Chapter 16 People of Hindu Heritage 288 Chapter 17 People of Hmong Heritage 310 Chapter 18 People of Japanese Heritage 319 Chapter 19 People of Jewish Heritage 339 Chapter 20 People of Korean Heritage 357 Chapter 21 People of Mexican Heritage 374 Chapter 22 People of Polish Heritage 391 Chapter 23 People of Puerto Rican Heritage 407 Chapter 24 People of Russian Heritage 426

Appendix Cultural, Ethnic, and Racial Diseases and Illnesses 441

ABSTRACTS American Indians and Alaska Natives 449 People of Baltic Heritage: Estonians, Latvians, and Lithuanians 452 People of Brazilian Heritage 454

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People of Egyptian Heritage 456 People of French Canadian Heritage 459 People of Greek Ancestry 462 People of Guatemalan Heritage 464 People of Iranian Heritage 466 People of Irish Heritage 469 People of Italian Heritage 471 People of Somali Heritage 473 People of Thai Heritage 475 People of Turkish Heritage 477 People of Vietnamese Heritage 479

GLOSSARY 481 INDEX 489

xvi Table of Contents

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xvii

Contents – DavisPlus

American Indians and Alaska Natives People of Baltic Heritage: Estonians, Latvians, and Lithuanians People of Brazilian Heritage People of Egyptian Heritage People of French Canadian Heritage People of Greek Ancestry People of Guatemalan Heritage People of Iranian Heritage People of Irish Heritage People of Italian Heritage People of Somali Heritage People of Thai Heritage People of Turkish Heritage People of Vietnamese Heritage

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xix

Introduction

The Purnell Model for Cultural Competence and its organizing framework continue to be used in educa- tion, clinical practice, administration, and research by nurses, physicians, and other health-care providers. The Model has been translated into Arabic, Flemish, French, German, Korean, Portuguese, Spanish, and Turkish. Health-care organizations have adapted the organizing framework as a cultural assessment tool and to guide research for theses and dissertations in the United States and overseas. The Model’s useful- ness has been established in the global arena, recog- nizing and including the client’s culture in assessments, health-care planning, interventions, and evaluations. The Model has proven useful with organizational cultural competence as well.

Transcultural Health Care: A Culturally Competent Approach continues to be revised based upon feedback from students and clinical health-care providers, as well as educators from associate degree, baccalaureate, master’s, and doctoral programs. Their reviews and suggestions are appreciated.

This edition has been divided into two units. Unit 1 contains five chapters. Chapter 1, Transcultural Diver- sity and Health Care, gives an overview of transcultural health and nursing care along with essential terminology related to culture. Chapter 2 is an extensive description the Purnell Model for Cultural Competence, along with recommended questions to ask and observations to make when doing a cultural assessment or formulating questions for qualitative research. Chapter 3, Individual Competence and Evidence-Based Practice, includes in- ternational standards on culturally competent care and an extensive section on searching literature for evidence- based cultural research. Chapter 4, Organizational Cul- tural Competence, provides a crosswalk with the Purnell Model and CLAS Standards. Chapter 5, Perspectives on Nursing in a Global Context, addresses health-care organizations that have a global context, the forces that shape global health and nursing, and international migration.