to better schools, housing, health care, and lifestyle as
they increase their income (Ostrove, 1999). In many
other countries, however, social class is a powerful in-
fluence on social relationships and can determine how
people relate to one another even in a health care set-
ting. For example, the caste system still exists in
India, and people in the lowest caste may feel unwor-
thy or undeserving of the same level of health care as
people in higher castes. The nurse must determine if
social class is a factor in how clients relate to health
care providers and the health care system.
Cultural Patterns and Differences
Knowledge of expected cultural patterns provides a
starting point for the nurse to begin to relate to people
with ethnic backgrounds different than his or her own
(Andrews & Boyle, 2003). Being aware of the usual
differences can help the nurse know what to ask or
how to assess preferences and health practices. Nev-
ertheless, variations among people from any culture
are wide: not everyone fits the general pattern. Indi-
vidual assessment of each person and family is nec-
essary to provide culturally competent care that meets
the client’s needs. The following information about
various ethnic groups should be a starting place for
the nurse in terms of learning about greetings, ac-
ceptable communication patterns and tone of voice,
and beliefs about mental illness, healing, spirituality,
and medical treatment.
AFRICAN AMERICANS
Several terms are used to refer to African Americans
such as Afro-American, black, or person of color; there-
fore, it is best to ask what each client prefers.
During illness, families are often a support sys-
tem for the sick person, although the client maintains
his or her independence such as making his or her
own health care decisions. Families often feel com-
fortable demonstrating public affection such as hug-
ging and touching one another. Conversation among
family and friends may be animated and loud. Greet-
ing a stranger usually includes a handshake, and di-
rect eye contact indicates interest and respect. Silence
may indicate a lack of trust of the caregiver or the
situation (Fields, 2001).
The church is an important and valued support
system for many African Americans, who may receive
frequent hospital visits from ministers or congrega-
tion members. Prayer is an important part of healing.
Some in the black community may view the cause
of mental illness to be a spiritual imbalance (Fields,
2001) or a punishment for sin (Andrews & Boyle,
2003). African-American clients may use folk reme-
dies in conjunction with Western medicine.
AMERICAN INDIANS
OR NATIVE AMERICANS
Older adults usually prefer the term American Indian,
whereas younger adults prefer Native American.
Many Native Americans refer to themselves by a tribal
name such as Winnebago or Navajo. A light-touch
handshake is a respectful greeting with minimal
direct eye contact. Communication is slow and may
be punctuated by many long pauses. It is important
not to rush the speaker or interrupt with questions.
This culture is accustomed to communicating by
telling stories, so communicating can be a long, de-
tailed process. Family members are reluctant to pro-
vide information about the client if he or she can do so,
believing it violates the client’s privacy to talk about
him or her. Orientation to time is flexible and does not
coincide with rigidly scheduled appointments.
Mental illness is a culturally specific concept, and
beliefs about causation may include ghosts, breaking
taboos, or loss of harmony with the environment.
Clients are often quiet and stoic, making few if any
requests. Experiences that involve seeing visions or
hearing voices may have spiritual meaning;thus,
these clients may not view such phenomena as illness.
Native Americans with traditional religious beliefs
may be reluctant to discuss their beliefs and prac-
tices with strangers. If the client wears a medicine
bag, the nurse should not remove it if possible. Others
should not casually discuss or touch the medicine bag
or other ritual healing objects. Other Native Ameri-
cans belong to Christian denominations, but they
may incorporate healing practices or use a spiritual
healer along with Western medicine (Meisenhelder
& Chandler, 2000).ARAB AMERICANS
The preferred term of address may be by region, such
as Arab Americans or Middle Eastern Americans, or
by country of origin such as Egyptian or Palestinian.
Greetings include a smile, direct eye contact, and a
social comment about family or the client. Using a
loud voice indicates the importance of the topic, as
does repeating the message. To appear respectful,
those of Middle Eastern background commonly ex-
press agreement in front of a stranger, but it does not
necessarily reflect their true feelings. Families make
collective decisions with the father, eldest son, uncle,
or husband as the family spokesperson. Most appoint-
ments viewed as official will be kept, although human
concerns are more valued than is adhering to a sched-
ule (Meleis, 1996).
This culture believes mental illness to result
from sudden fears, attempts to manipulate family,
wrath of God, or God’s will, all of which focus on the146 Unit 2 BUILDING THENURSE–CLIENTRELATIONSHIP