This essay dealt on the role of culture in influencing healthcare choices of three distinct nationalities: Italian, American Indian, and Chinese. These nationalities have their own distinct medicine practices influenced by traditional beliefs. Professional nurses and healthcare providers have combined some of these practices with modern medicine.
Practitioners and healthcare experts have recognised that there is a need to provide a study on traditional medicine and its role in modern medicine practices. Ann Hubbert (2008) of the University of Nevada argued that the healthcare profession must welcome and respect the existence of traditional practices, particularly the traditional Indian medicine (TIM), and recognize its role in healthcare and in the nursing practice.
Chinese traditional medicine and nursing practices are recognised in western countries and many parts of Asia. Acupuncture and herbal medicine have been indorsed by the World Health Organization to cure minor illnesses like asthma and nausea. In Italy, family closeness influences their belief in the care of patients who are in persistent vegetative state (PVS) and end-of-life situations.
Introduction
This essay is about three different cultures: Italian, American Indian, and Chinese. We examined how these cultures influenced healthcare choices of the three nationalities and found their roles in the success of the treatment.
The traditional Indian medicine (TIM) introduces healing as a way of living, as it relates with nature and the “forces” around us. The Chinese oriental and herbal medicine has been practiced for centuries. Italians have a few superstitions when it comes to treatment. But the three cultures have been woven through generations. The Italian culture, the TIM, and Chinese medicine are now influenced by modern medicine which, as they say, is an application of the scientific processes. There are some open-minded professionals who want to combine modern medicine with the traditional ways of healing. How this will be applied is up to the experts. For the main time, nurses should be open-minded about cultural sensitivities in the treatment processes of different cultures.
Effects of Italian culture on health care choices
Many Italians believe in superstitions, particularly about their concept of the “evil eye,” also known as “malocchio” In Italian. According to this belief, someone can inflict harm on somebody by having an evil eye on that person, and this eventually happens intentionally or unintentionally. The “evil eye” belief has some versions in other Latin countries, such Puerto Rico, and some Asian countries. If somebody in the family experiences a sudden illness (slight illness or discomfort), the belief is that someone has made an evil eye on that person. This usually occurs on children who cannot resist a bad spell. Some Italians consult faith healers before going to a physician. Another cultural practice is that before Italians seek professional help, they first ask the advice of a “therapeutic woman” who may perform some ritual to heal the illness.
When a nurse encounters this kind of patient, the technique should be to “educate” first the patient. The first attempt of changing the patient’s belief may not happen. Superstitions are like beliefs; they are woven through generations and passed down in social interactions. Beliefs and superstitions are found in old folks’ practices but not on educated and new-generation Italians.
An Italian tradition worth mentioning here is the way they provide care for family members who are in end-of-life situations. Family members are valued and they have to feel family love even during the last days of their life on earth. Catholic tradition and close family ties strengthen this kind of belief.
Culture is seen in Italians’ patient-centred care. For example, in a study involving Italian health care professionals, participants exhibited patient-centredness different from the practice of American healthcare professionals. The study drew on the opinion of Italian doctors in portraying their culture and how they dealt with Italian patients compared with American doctors’ relationship with American patients.
Patient-centredness refers to “adopting a bio-psychosocial perspective; considering the patient as a person; sharing power and responsibility; valuing the therapeutic alliance, and considering the effects of the doctor as a person, on the consultation” (Lamiani et al., 2008, p. 713). In this study, Italian doctors exhibited and explained the culture of Italian patients and their healthcare choices in the context of culture.
The researchers explored the inter-group reflections of Italian and American physicians on their respective cultures. Patient-centred care described the patients’ illness, respect for their autonomy, and the handling of their emotions. Italian culture and its effects on healthcare can be seen in the dialogue and results of the study. Illness experience was solicited from the participants, including information of the patient’s social network and other valuable information.
In the Italian culture, the issue of cancer can be talked about only if the patient speaks of it. For example, an Italian physician narrated about his experience with a patient, saying that “cancer is still a big elephant in Italy so it is not usual to talk about it,” and felt that if the doctor had been the first to mention cancer, “the patient’s anxiety may get bigger” (Lamiani et al., 2008, p. 716). It is unusual to talk openly about cancer especially if the physician is talking with the patient who has the illness. Physicians in the study said that in the American culture, people find it helpful to talk about cancer so the physician and the patient can have an open discussion about it. An Italian physician said that he would try to protect the patient by not saying anything about the “Big C” if the patient does not say anything about it.
The study also focused on Italians’ love and care for their aged population. Italians do not want to admit their aged parents or relatives in institutions or homes for the aged. As much as possible, they personally care for them even when an end-of-life situation occurs. This is commendable, if we talk or compare this with other cultures. Personal touch in end-of-life situations can provide “an extension,” or ease the suffering, than institutional care. But institutional health care combined with family healthcare is more effective.
Another study was conducted by Solarino et al. (2011) which focused on Italian physicians’ perception about patients who are in the persistent vegetative state (PVS). As much as possible, Italians care for their loved ones who are in the PVS and, because of their Catholic belief, they do not want to alter the purpose of God for their loved one’s predicament.
The study focused on the Italians’ concept and belief of euthanasia and physician-assisted suicide. The paper mentioned Eluana Englaro who was a relatively young Italian woman in persistent vegetative state (PVS). In Italy, euthanasia and physician-assisted suicide are not covered in their jurisprudence; therefore, the case became controversial when it was brought to the Supreme Court. It was Eluana’s father who brought the matter to the Supreme Court as he did not want to continue the nutrition and hydration and allow his daughter to suffer more who had been in that pitiful situation for seventeen years. The Supreme Court understood and ruled in favor of the father. This was a landmark case but it did not represent the general sentiments of the Italian public as it was against their culture and beliefs.
The purpose of Solarino et al.’s (2011) study was to get the opinion of Italian physicians regarding their belief about end-of-life practices. Survey questionnaires were used to get the opinion of the participants. It was found in the survey that 66% of the Italian physicians believed the Supreme Court was right in their decision as it followed the wishes of the patient. Fifty percent of the physician respondents did not believe in euthanasia but a significant number (42%) approved of it. The results of the survey were against the general belief about euthanasia and end-of-life situation.
If we try to analyse the case of Eluana Englaro, we find that she was in the PVS for a long time already, so that her father believed it was too much of his daughter to suffer that long. His case was denied three times by a lower court, so he had to appeal the case to the Supreme Court. Although it was against his culture and beliefs, he believed it was time for his daughter to go. The question of euthanasia and end-of-life situations is controversial because this depends on the belief of a people. However, beliefs can be altered depending on the situation. But, was culture “changed” when the father asked the court to terminate the treatment? This requires another field of discussion. As nurses, our duty is only to provide the best care for our patient, and not to alter their beliefs. Respect for their culture and beliefs means respect for their individuality.
Effects of American Indian culture on health care choice
The Traditional Indian Medicine (TIM) practiced by shamans or healers has been the subject of interest for research by Western healthcare providers. American Indians have practiced this kind of healthcare for centuries and they rarely divulge how they practice it when they come in contact with Western healthcare practitioners. Because of this, they are unable to share the perspectives of their healthcare, and also healthcare professionals are unable to discover the advantages of Indian medicine. Professor Ann Hubbert (2008) of the University of Nevada, who has been involved with TIM practitioners, said in her article that it is the responsibility of healthcare professionals to have an open mind and respect the practice of minority cultures so that they can share their philosophy with the rest of the world. Many American Indians still practice the TIM principles of healing, and if they practice it along with modern medicine, nurses should be supportive of this phenomenon.
TIM practices include the “spiritual,” which for the American Indians has a broad meaning since it is not only about religion, as the Western culture would have it. TIM concept of spirit refers to the “active flow of energy that connects all living things to ‘God, the Universal Energy/source, or Great Spirit’” (Hubbert, 2008, p. 66). Spiritual in TIM is “a way of living” (Hubbert, p. 66).
The Comanche medicine man practices the foundational keys as embodied in the “Seven Sacred Aspects of Life” and “the essence of a holistic individual” (Monetatchi, 1987 as cited in Hubbert, 2008, p. 67). TIM has a philosophy that can be shared with healthcare professionals to enhance the way of living. The TIM philosophy is “Health Equals Balance” (Monetatchi, 1998b, 1988c; Monetatchi, Ortega & Flores, 1987 as cited in Hubbert, p. 68). The Seven Sacred Aspects provide values that nurses and healthcare providers can share with patients. The Seven Sacred Aspects are: “respect, honesty, truth, humility, compassion, wisdom, and unconditional love” (Hubbert, 2008, p. 68).
The individual is the representation of the balance “among and between their physical being, mental being, spiritual being, their environment, and their relationship with God” (Hubbert, p. 68). If any one of the components becomes out of balance, the result is disease. The healing process involves “harmony and balance” among the different forces mentioned above. The shaman performs healing by aligning the forces and seeing to it that the individual has balance with the forces of nature. Hubbert (2008) indicated that the healthcare system must understand the TIM philosophy and not undermine its existence. Moreover, the healthcare system, particularly the nurses must:
- Accept that TIM philosophy and spiritual teachings are parts of the healing process;
- Know how TIM spiritual healing can be incorporated in the nursing assessments;
- Provide physical space for TIM shaman to perform spiritual practices;
- Welcome TIM shaman or healer in the healthcare institution;
- Blend the cultural practices of TIM with the nursing culture.
Hubbert (2008) said that these challenges have been explored and made part of a program conducted between 1984 and 1990. An Apache nurse commented that that sort of program was needed as American Indians often would enter an “unknown world” once they come in contact with the healthcare system, particularly the Catholic faith-based healthcare system in the locality of the Southwestern American Indian nations (Hubbert, 2008, p. 66). This particular nurse, a model in the nursing profession, requested for an educational workshop among nurses to increase their cultural knowledge and sensitivity of American Indians and the TIM.
The culture care theory was applied to the partnership of TIM and professional healthcare. Madeleine Leininger invoked the theory of Culture Care Diversity and Universality which has been used as a framework for examining the linkages present between different cultures, and to know which features of spirituality and healing can be used among and between cultures. “Generic care” is the term used by Leininger (1991 as cited in Hubbert, 2008) to refer to “the cultures’ folk or Indigenous practices, beliefs and values” (Hubbert, p. 68).
Nurses who are used to service patients of diverse cultures have applied “ethnonursing research process” to find new ways of healthcare to be applied to patients of diverse cultures, or to apply it to patients who believe the practice.
Effects of Chinese culture on health care choice
Culture plays a key role in the Chinese health care choice. Chinese immigrants bring this practice along with them wherever they go and in pursuit of their profession. Religion as a part of culture also influences their daily lives and their philosophy about health and the practice of nursing. Chinese nurses provide the best healthcare they can because of their values and philosophical beliefs.
Confucian teachings, valued by most Chinese, are ingrained in Chinese nurses’ psyche. Confucius taught harmony with people and nature, the negative effects of egoistic attitude, respect for the elderly and the parents, and love of family. Respect for parents is one of the most fundamental teachings of Confucianism. But parents must have good behavior, know how to take care of themselves, respect and love their children, and accomplish some household chores for the family. (Chen, 2001)
The Chinese have high regard for education and their beliefs and values always emphasise family strength and solidarity, wherein group or collectivity is made to strengthen the family. The Chinese believe that natural phenomena are divided in a way they are related, for example, day and night, man and woman, good and bad, and so on. Interactions between opposites have to be balanced, and when there is an imbalance in the vital energy called “Qi,” the result is illness.
When a woman has just given birth, she is required to be in bed for a certain period of time, say 48-72 hours, and has to wear heavy clothing even if the atmosphere is very warm. Nurses sometimes meet heavy resistance when they warn Chinese women not to wear heavy clothing as they might acquire sickness in their situation (Chamberlain et al., 1999 at cited in Chen, 2001, p. 271). The way to deal with this situation is to remind them but not to the extent of changing their belief as it may take a while, and the effective way to influence a long-time belief (that is physically harmful) is through education.
Acupuncture is a long-time part of Chinese medicine. The Chinese believe that acupuncture can relieve stress as the needles penetrate through the different points of the body. Chinese nurses support this tradition. One type of practice is auricular acupuncture which reduces anxiety. However, there have been reported adverse effects of acupuncture and Chinese herbal medicines, such as fainting and vomiting. The duty of the nurse is to remind patients but not to warn them as to cause fear.
Traditional Chinese treatment includes herbal medicine, application of a diet regiment, eating animal secretions and internal organs, traditional massage, scraping the surface of the skin by an edged instrument in treating “mumps or seizures” (Ludman & Newman, 1984, Louie, 1985 as cited in Chen, 2001, p. 272).
Chinese medicine has a classification that can be called systematic. For example, the Chinese classify body parts, diseases, and phases in life as Yin or Yang. Materials used in medicine application are also classified as either Yin or Yang. One example is when a woman who has menstrual imbalance; she may be checked as having a Yin condition and the treatment consists of taking in Yang foods or herbs to correct the imbalance (Ludman & Newman, 1984 as cited in Chen, 2001). Chinese use animal organs to treat illnesses of human organs. For instance, if someone has illness related to blood, he/she has to eat pig’s liver to treat the sickness of the blood.
Chinese culture is characterised by psycho-sociological factors. Internal conflicts in the family should not be known by the public. Conflicts add to a distortion of the relationship between nature or environment and person; therefore, it must be avoided. To challenge the knowledge of a person considered an expert in a particular field is an insult. A Chinese patient should not challenge the doctor or nurse who may have prescribed a drug regimen because that doctor or nurse is considered an expert. But tradition states that the Chinese patient should simply not follow the drug regimen and keep silent about it (Chae, 1987 as cited in Chen, 2001).
The situation may be harmful to the patient, or, the illness that is being addressed by the prescribed regimen might get worse. Nurses can correct this by reminding the patient that he/she has the right to ask the doctor or nurse about the prescribed regimen. Simply not talking about it and not following the prescribed regimen may worsen the illness. When it is a regimen, it has to be taken regularly and at the prescribed time of day. The nurse or healthcare professional has to explain and make sure that the patient takes the medicine. If the nurse notices that the patient is not following the prescribed regimen, for reasons of belief, then the nurse has to alert the physician and the nearest kin of the patient so that matters would not get worse. The nurse should provide a thorough explanation of the prescribed regimen. It is important that the patient understands the value of taking the medicine.
In Taiwan, people have high regard for Chinese traditional medicine and folk beliefs, but they also respect western medicine. In the rural areas, traditional medicine and beliefs are very much observed or followed. But there is something remarkable in the modern way of applying Chinese medicine. They try to combine the traditional and modern medicine which is encouraged by their government. An agency in Taiwan known as “The National Health Insurance of Taiwan” pays for both traditional and modern ways of Chinese treatment. (Hubbert, 2008)
In western countries, traditional Chinese medicine has become popular. Health professionals and nurses are providing more attention in its application. The United States has also paid attention by establishing the National Institute of Health Center for Complementary Medicine, which provides a databank on traditional medicine based on scientific principles. The World Health Organization has recognised the importance of traditional medicine like acupuncture in treating nausea, pain and asthma. Chinese nurses can contribute to the improvement of healthcare by sharing their knowledge in traditional medicine and incorporating this to modern medicine.
European medicine is no stranger to Chinese medicine; in fact, the Chinese had influenced the introduction of science in Europe. There were great physicians in China before Hippocrates introduced medicine in Europe. Western science improved during the 20th century. But Chinese medicine and science have been here and is instrumental to the improvement of nursing in the global healthcare system. This development, a combination of China’s philosophical and medicinal beliefs and practices, along with Western science, has a significant promise to the advancement of nursing research which will benefit China, the western countries and the rest of the world (Yin et al., 2000, as cited in Chen, 2001, p. 272).
References
Chen, Y. (2001). Chinese values, health and nursing. Journal of Advanced Nursing, 36(2), 270-273.
Hubbert, A. (2008). A partnership of a Catholic faith-based health system, nursing and traditional American Indian medicine practitioners. Contemporary Nurse, 28(1-2), 64-72.
Lamiani, G., Meyer, E., Rider, E., Browning, D., Vegni, E., Mauri, E.,…Truog, R. (2008). Assumptions and blind spots in patient-centredness: Action research between American and Italian health care professionals. Medical Education, 42(1), 712-720. Web.
Solarino, B., Bruno, F., Frati, G., Dell’Erba, A., & Frati, P. (2011). A national survey of Italian physicians’ attitudes towards end-of-life decisions following the death of Eluana Englaro. Intensive Care Medicine, 37(1), 542-549. Web.