JoAnn Glittenberg, RN
Cultural values confronting OR nurses Until recently, nurses have sought to understand two dimensions of manthe biological and psychological-and have to a large part ignored the third dimension-culture. The need t o understand the cultural beliefs and practices of humans should apply not only to the culture of the patient but also to the beliefs within nursing, including the particular area of the operating room. In trying to understand the biological dimension of man, one might ask, Are humans determined only by the biological characteristics similar t o all animal life? Scholars such as B F Skinner, in his book Beyond Freedom and Dignity, have viewed human behavior as manageable and malleable in the same
JoAnn E Glittenberg, R N , PhD, is an associate professor at the University of Colorado Medical Center School of Nursing in Denver. A graduate of the Beth-El School of Nursing in Colorado Springs, Colo, she received a BS, MS, MA, and PhD from the University of Colorado in Boulder.
manner as the behavior of a rat in a mazeway. Much research today seems t o confirm t h a t humans share with other animal life many of the same biological and psychological reactions. Human biology follows the same chemical and genetic bases as other forms of life. The human diversity so apparent in our world is due largely to the process of natural selection. Biological variation such as skin color, hair texture, visual acuity, temperature adjustment, nose shape, and even stature and dimensions of the human body are examples of the complex interaction of biological adaptations to various ecological niches in our globe over long periods of time. However, man is more than an evolving biological creature. Blatant biological determinism serves only t o blunt our awareness of the complexities and diversities of human existence.l The major differences in behavior among h u m a n groups depend on culture. According to Alland, it is culture that frees man from strict biological controL2 Today, a s never before in Western medicine, the dimension of cultural beliefs is seen as one of the most powerful determinants of health behavior. In teaching institutions, new courses concerning transcultural health and medical anthropology are finding eager students in all the health professions. Research aimed a t discovering the associations between cultural practices and health is increasing.
AORN Journal, June 1978, V o l 2 7 , No 7
1291
What is meant by “culture” and how can we use knowledge of cultural traits to heal more effectively? First, we must understand what culture refers to: it is the learned values, beliefs, and life goals of a group of people who have interacted together for a period of time. These learned cultural beliefs are passed on from generation to generation through a process of socialization and are modified in a dynamic fashion over time. Each one of us, whether patient, nurse, surgeon, or chaplain, carries within us a blueprint for living, a mazeway of responding, that is a result of our cultural socialization. Humans are socialized to follow this pathway; it becomes a way of interpreting the world and providing a pattern of response to familiar or new situations. These mazeways are said to be adaptive. When we examine individual cases, it may not be apparent how or why this pattern of response is adaptive. In our ethnocentric way, we may cringe at those who refuse t o eat the sacred cow or refuse a lifesaving blood transfusion, while we stubbornly refuse to give up our gas-guzzling, air-polluting sacred car. On an individual basis, adaptation may be difficult to comprehend. However, when we view the cultural behavi o r - o r mazeway-within the cultural context of society in which the individual lives, there emerges a reason that accounts for the behavioral patterns. In spite of the adaptiveness within the cultural context, some of these behavioral patterns have severe consequences on the health status of the group. For example, among the Bedouin people in Niger, child-bearing women are often immobilized with pains in their legs and must resort to using canes to support themselves while walking. The reason for this is osteomalacia, a disease caused by a lack of sunshine or a vitamin D deficiency in the diet. A cul-
1292
tural practice is the cause of this condition: the married Bedouin women are not allowed to leave their black, goathair tents often, and when they do, they cover themselves from head to toe with a heavy black cloak with mere slits for the eyes.3 Consequently, these women lack sufficient sunshine for calcium metabolism. Another example of severe consequences of a cultural practice occurred during the early 1900s when there were devastating outbreaks of pneumonic plague in Manchuria. The cause of the epidemics could be traced to a change in fashion among European women. Fashion demanded the fur of the Manchurian marmot to such an extent that inexperienced hunters, eager to capitalize on the craze, trapped slow, sick animals, which t o experienced trappers were taboo. These sick animals were suffering from plague. Hunters, infected with the rodent disease, quickly spread the epidemic when they traded in the illventilated Manchurian inns. Thus, as a result of a fashion craze, millions perished. Today, we are also faced with disease processes that are culturally induced. Stress-related cardiovascular diseases as well as cancers of various types are conclusively related to our cultural patterns of a highly industrialized, urbanized ~ o c i e t yThose .~ of you involved in gross trauma surgeries are aware of the results of our cultural value of speed-from skateboards to automobiles-the idea is to get there as fast as possible, but not necessarily in one piece. Cultural values and practices can kill. As important as it is to be aware of the cultural values of a group or society, it is equally important to consider the particular belief system of the individual patient. We do not operate on a social group nor a society-rather, the scalpel touches one human a t a time, the
AORN Journal, June 1978,Vol27, No 7
he germ theory is not a universal explanation for disease causation.
T
sponge count is for one human a t a time. How do we consider the cultural beliefs of each human being who becomes our patient in the operating room? Ideally, it is through communicating with the individual before the anesthetic, before the scalpel, before the sponge count. However, my experience in the operating room and the recovery room has impressed upon me that this ideal is too often only a n ideal. We are making progress in preoperative counseling, but we need to continue striving toward this goal. We need to become aware of cultural diversity and its influence on health behaviors and specifically on the healing process following surgery. Recently, many efforts have been made by nurses toward understanding the cultural beliefs of people of color, but less attention has been given t o more subtle cultural variations. In our diverse, multicultural nation, the mixture of ethnic group, class, and religion results in a variety of beliefs concerning causality of disease, power of medicine, roles of healers, death and dying, and life after life. A learning experience in a course I teach on transcultural health has been enlightening but disturbing t o students. They are assigned to compare the health beliefs of two families from various cultural backgrounds, for example, between a hospitalized Japanese Buddhist and a hospitalized Christian Scientist. This investigation highlights the diversity
in beliefs and challenges the viewpoints held by the students. For instance, discovering that the germ theory is not a universal explanation for disease causation and that others perceive reality differently open the students’ minds to broader dimensions in the healing arts. Broader dimensions in the healing arts are concerns for nursing whether they be in the operating room or elsewhere. Knowledge regarding cultural beliefs and alternative health care delivery that has emerged within the past ten years compels us t o reexamine our positions as nurses and humanists. No longer can we ignore the cultural diversity within our hospital settings. Those who enter bring with them the roots of their cultural as well as their biological heritage. Besides the cultural heritage of the patient, the nurse must learn to recognize his or her own cultural beliefs and understand how these beliefs will affect his or her relation with the patient in nursing practice. We must ask what cultural beliefs professional nurses bring to the setting. OR nurses belong to one group of health care professionals in our dominant culture, but .there are other healers equally as important to segments of our population-the curanderos, the spiritualists, the medicine men, and the Christian Scientist readers are but a few within our society. Professional nurses share similar roles and statuses with healers
AORN Journal, June 1978, Vol27, No 7
1293
throughout the world. How really different in effect are we from the barefoot doctors in China or Guatemala? How different are we from the spiritualists of Puerto Rico or the curanderos of the Hispanic communities? First, our world views are likely t o be different; we view disease as caused in large part by microbes or patterns of 1iving:One thing we share in common with the healers of the world is that we deal with the symptoms of illness. When ill, individuals throughout the world do not grapple with the disease specifically, but they struggle with the effects of the illness, the losses, discomforts, and fears. In our healing houses, our temples of hope, we attempt to deal with these effects of disease by establishing a place of healing, caring, and comforting. Clearly, our positions as healers are complex. Statuses and roles assigned to us by the society within which we live are sometimes counter to what we may personally feel should be our role. Throughout the world, healers are often associated with the supernatural, for illness and dying are processes closely associated with beliefs about the supernatural. We, a s nurses, are characterized as “angels of mercy” and physicians as “ministers of health” or “little gods.” These are not derogatory labels but need to be understood as part of the particular belief system in which we play a major role in the healing process. Nurses working within the operating room setting have specific statuses and roles determined by the cultural values of this particular setting within the hospital. If we think of the operating room as a place in which individuals interact in a highly ritualized manner, one comprehends the importance of maintaining the strong cultural patterns, mazeways, and blueprints of behavior of t h e operating room. The names “operating room theater” and “the gallery” imply the action taking
1294
place is highly dramatic. Masks, gowns, and drapes disguise the humans behind them. No other location within the hospital setting is as highly charged with emotion. Besides maintaining a n antiseptic atmosphere, the scene is highly impersonal, perhaps to maintain an adaptive balance in the interactions. However, taken as separate actions of individuals, the behaviors may appear rigid and self-effacing. Efficient teamwork is more critical than personal expression. Deviance from the norm may result in disaster or a t least discomfort. Expressing emotion too freely a t critical periods may destroy or hinder a lifesaving procedure. Thus, reinforcement and maintenance of the cultural patterns within a n operating room setting are highly adaptive. In the recovery room, the behavior changes-masks are removed and a more relaxed atmosphere pervades. The interactions between surgeon and nurse seem to be directed toward relaxing the surgeon, with the specific goal of preparing the surgeon to reenter the outside world and to interact effectively. The patient, still semiconscious, soon will have a new status and role as a postoperative patient. Gowns a r e changed and new behaviors expected as he is transferred t o the unit nurses. The process of surgery reaches an end with change of geographical location. Consequently, each event in the surgical process has a powerful impact on the recovery of the patient. Understanding how cultural patterns of the operating room are maintained to meet the goal of effective health care is paramount in effective functioning as an OR nurse. In summary, man must be viewed as more than a mere animal although he shares with all animal life certain biological and psychological constraints. More than mere animals, humans possess the additional adaptive
AORN Journal, June 1978, Vol27, No 7
dimension of culture. The diversity in cultural patterns is strong evidence of human adaptation to a wide variety of life situations. As professional nurses, we maintain a value system powerful for our effective functioning a s carers a n d healers within our culture. However, as part of our value system, we must recognize a whole gamut of human potentialities and provide a n atmosphere less arbitrary and more flexible in order t o enable each diverse person to survive,
grow, achieve, and find comfort.
0
Notes 1. Alexander Alland, Adaptation in Cultural Evolution: An Approach to Medical Anthropology (New York: Columbia University Press, 1970) 170. 2. Alexander Alland, The Human lmperative (New York: Columbia University Press, 1972) 151. 3. Margaret Read, Culture, Health, and Disease (London: Tavistock Publications, Ltd, 1966). 4. Richard W Lieban, "The field of medical anthropology," in Culture, Disease, and Healing, David Landy, ed. (New York: Macmillan Publishing Co, 1977) 11-31.
Correction In the article "Cerebral revascularization" by Christopher B Shields, MD, (April 1978), Figure 1 was printed twice and Figure 2 was omitted. Both
figures are printed here with their legends as they should have appeared.
Fig 1. Angiogram of lateral left common carotid discloses supraclinoid internal carotid stenosis (long white arrow) in a patient with a slowly progressing stroke. Superficial temporal artery is noted (double arrowheads).
Fig 2. Postoperative angiogram of patient shown in Fig 1 shows an enlarged superficial temporal artery (double arrowheads) filling the entire middle and anterior cerebral circulation. The internal carotid artery has progressed to complete occlusion in the interim between the two angiograms. The external carotid artery is filling well (black arrows).
AORN Journal, June 1978, V o l 2 7 , No 7
1295
Cultural values confronting OR nurses Until recently, nurses have sought to understand two dimensions of manthe biological and psychological-and have to a large part ignored the third dimension-culture. The need t o understand the cultural beliefs and practices of humans should apply not only to the culture of the patient but also to the beliefs within nursing, including the particular area of the operating room. In trying to understand the biological dimension of man, one might ask, Are humans determined only by the biological characteristics similar t o all animal life? Scholars such as B F Skinner, in his book Beyond Freedom and Dignity, have viewed human behavior as manageable and malleable in the same
JoAnn E Glittenberg, R N , PhD, is an associate professor at the University of Colorado Medical Center School of Nursing in Denver. A graduate of the Beth-El School of Nursing in Colorado Springs, Colo, she received a BS, MS, MA, and PhD from the University of Colorado in Boulder.
manner as the behavior of a rat in a mazeway. Much research today seems t o confirm t h a t humans share with other animal life many of the same biological and psychological reactions. Human biology follows the same chemical and genetic bases as other forms of life. The human diversity so apparent in our world is due largely to the process of natural selection. Biological variation such as skin color, hair texture, visual acuity, temperature adjustment, nose shape, and even stature and dimensions of the human body are examples of the complex interaction of biological adaptations to various ecological niches in our globe over long periods of time. However, man is more than an evolving biological creature. Blatant biological determinism serves only t o blunt our awareness of the complexities and diversities of human existence.l The major differences in behavior among h u m a n groups depend on culture. According to Alland, it is culture that frees man from strict biological controL2 Today, a s never before in Western medicine, the dimension of cultural beliefs is seen as one of the most powerful determinants of health behavior. In teaching institutions, new courses concerning transcultural health and medical anthropology are finding eager students in all the health professions. Research aimed a t discovering the associations between cultural practices and health is increasing.
AORN Journal, June 1978, V o l 2 7 , No 7
1291
What is meant by “culture” and how can we use knowledge of cultural traits to heal more effectively? First, we must understand what culture refers to: it is the learned values, beliefs, and life goals of a group of people who have interacted together for a period of time. These learned cultural beliefs are passed on from generation to generation through a process of socialization and are modified in a dynamic fashion over time. Each one of us, whether patient, nurse, surgeon, or chaplain, carries within us a blueprint for living, a mazeway of responding, that is a result of our cultural socialization. Humans are socialized to follow this pathway; it becomes a way of interpreting the world and providing a pattern of response to familiar or new situations. These mazeways are said to be adaptive. When we examine individual cases, it may not be apparent how or why this pattern of response is adaptive. In our ethnocentric way, we may cringe at those who refuse t o eat the sacred cow or refuse a lifesaving blood transfusion, while we stubbornly refuse to give up our gas-guzzling, air-polluting sacred car. On an individual basis, adaptation may be difficult to comprehend. However, when we view the cultural behavi o r - o r mazeway-within the cultural context of society in which the individual lives, there emerges a reason that accounts for the behavioral patterns. In spite of the adaptiveness within the cultural context, some of these behavioral patterns have severe consequences on the health status of the group. For example, among the Bedouin people in Niger, child-bearing women are often immobilized with pains in their legs and must resort to using canes to support themselves while walking. The reason for this is osteomalacia, a disease caused by a lack of sunshine or a vitamin D deficiency in the diet. A cul-
1292
tural practice is the cause of this condition: the married Bedouin women are not allowed to leave their black, goathair tents often, and when they do, they cover themselves from head to toe with a heavy black cloak with mere slits for the eyes.3 Consequently, these women lack sufficient sunshine for calcium metabolism. Another example of severe consequences of a cultural practice occurred during the early 1900s when there were devastating outbreaks of pneumonic plague in Manchuria. The cause of the epidemics could be traced to a change in fashion among European women. Fashion demanded the fur of the Manchurian marmot to such an extent that inexperienced hunters, eager to capitalize on the craze, trapped slow, sick animals, which t o experienced trappers were taboo. These sick animals were suffering from plague. Hunters, infected with the rodent disease, quickly spread the epidemic when they traded in the illventilated Manchurian inns. Thus, as a result of a fashion craze, millions perished. Today, we are also faced with disease processes that are culturally induced. Stress-related cardiovascular diseases as well as cancers of various types are conclusively related to our cultural patterns of a highly industrialized, urbanized ~ o c i e t yThose .~ of you involved in gross trauma surgeries are aware of the results of our cultural value of speed-from skateboards to automobiles-the idea is to get there as fast as possible, but not necessarily in one piece. Cultural values and practices can kill. As important as it is to be aware of the cultural values of a group or society, it is equally important to consider the particular belief system of the individual patient. We do not operate on a social group nor a society-rather, the scalpel touches one human a t a time, the
AORN Journal, June 1978,Vol27, No 7
he germ theory is not a universal explanation for disease causation.
T
sponge count is for one human a t a time. How do we consider the cultural beliefs of each human being who becomes our patient in the operating room? Ideally, it is through communicating with the individual before the anesthetic, before the scalpel, before the sponge count. However, my experience in the operating room and the recovery room has impressed upon me that this ideal is too often only a n ideal. We are making progress in preoperative counseling, but we need to continue striving toward this goal. We need to become aware of cultural diversity and its influence on health behaviors and specifically on the healing process following surgery. Recently, many efforts have been made by nurses toward understanding the cultural beliefs of people of color, but less attention has been given t o more subtle cultural variations. In our diverse, multicultural nation, the mixture of ethnic group, class, and religion results in a variety of beliefs concerning causality of disease, power of medicine, roles of healers, death and dying, and life after life. A learning experience in a course I teach on transcultural health has been enlightening but disturbing t o students. They are assigned to compare the health beliefs of two families from various cultural backgrounds, for example, between a hospitalized Japanese Buddhist and a hospitalized Christian Scientist. This investigation highlights the diversity
in beliefs and challenges the viewpoints held by the students. For instance, discovering that the germ theory is not a universal explanation for disease causation and that others perceive reality differently open the students’ minds to broader dimensions in the healing arts. Broader dimensions in the healing arts are concerns for nursing whether they be in the operating room or elsewhere. Knowledge regarding cultural beliefs and alternative health care delivery that has emerged within the past ten years compels us t o reexamine our positions as nurses and humanists. No longer can we ignore the cultural diversity within our hospital settings. Those who enter bring with them the roots of their cultural as well as their biological heritage. Besides the cultural heritage of the patient, the nurse must learn to recognize his or her own cultural beliefs and understand how these beliefs will affect his or her relation with the patient in nursing practice. We must ask what cultural beliefs professional nurses bring to the setting. OR nurses belong to one group of health care professionals in our dominant culture, but .there are other healers equally as important to segments of our population-the curanderos, the spiritualists, the medicine men, and the Christian Scientist readers are but a few within our society. Professional nurses share similar roles and statuses with healers
AORN Journal, June 1978, Vol27, No 7
1293
throughout the world. How really different in effect are we from the barefoot doctors in China or Guatemala? How different are we from the spiritualists of Puerto Rico or the curanderos of the Hispanic communities? First, our world views are likely t o be different; we view disease as caused in large part by microbes or patterns of 1iving:One thing we share in common with the healers of the world is that we deal with the symptoms of illness. When ill, individuals throughout the world do not grapple with the disease specifically, but they struggle with the effects of the illness, the losses, discomforts, and fears. In our healing houses, our temples of hope, we attempt to deal with these effects of disease by establishing a place of healing, caring, and comforting. Clearly, our positions as healers are complex. Statuses and roles assigned to us by the society within which we live are sometimes counter to what we may personally feel should be our role. Throughout the world, healers are often associated with the supernatural, for illness and dying are processes closely associated with beliefs about the supernatural. We, a s nurses, are characterized as “angels of mercy” and physicians as “ministers of health” or “little gods.” These are not derogatory labels but need to be understood as part of the particular belief system in which we play a major role in the healing process. Nurses working within the operating room setting have specific statuses and roles determined by the cultural values of this particular setting within the hospital. If we think of the operating room as a place in which individuals interact in a highly ritualized manner, one comprehends the importance of maintaining the strong cultural patterns, mazeways, and blueprints of behavior of t h e operating room. The names “operating room theater” and “the gallery” imply the action taking
1294
place is highly dramatic. Masks, gowns, and drapes disguise the humans behind them. No other location within the hospital setting is as highly charged with emotion. Besides maintaining a n antiseptic atmosphere, the scene is highly impersonal, perhaps to maintain an adaptive balance in the interactions. However, taken as separate actions of individuals, the behaviors may appear rigid and self-effacing. Efficient teamwork is more critical than personal expression. Deviance from the norm may result in disaster or a t least discomfort. Expressing emotion too freely a t critical periods may destroy or hinder a lifesaving procedure. Thus, reinforcement and maintenance of the cultural patterns within a n operating room setting are highly adaptive. In the recovery room, the behavior changes-masks are removed and a more relaxed atmosphere pervades. The interactions between surgeon and nurse seem to be directed toward relaxing the surgeon, with the specific goal of preparing the surgeon to reenter the outside world and to interact effectively. The patient, still semiconscious, soon will have a new status and role as a postoperative patient. Gowns a r e changed and new behaviors expected as he is transferred t o the unit nurses. The process of surgery reaches an end with change of geographical location. Consequently, each event in the surgical process has a powerful impact on the recovery of the patient. Understanding how cultural patterns of the operating room are maintained to meet the goal of effective health care is paramount in effective functioning as an OR nurse. In summary, man must be viewed as more than a mere animal although he shares with all animal life certain biological and psychological constraints. More than mere animals, humans possess the additional adaptive
AORN Journal, June 1978, Vol27, No 7
dimension of culture. The diversity in cultural patterns is strong evidence of human adaptation to a wide variety of life situations. As professional nurses, we maintain a value system powerful for our effective functioning a s carers a n d healers within our culture. However, as part of our value system, we must recognize a whole gamut of human potentialities and provide a n atmosphere less arbitrary and more flexible in order t o enable each diverse person to survive,
grow, achieve, and find comfort.
0
Notes 1. Alexander Alland, Adaptation in Cultural Evolution: An Approach to Medical Anthropology (New York: Columbia University Press, 1970) 170. 2. Alexander Alland, The Human lmperative (New York: Columbia University Press, 1972) 151. 3. Margaret Read, Culture, Health, and Disease (London: Tavistock Publications, Ltd, 1966). 4. Richard W Lieban, "The field of medical anthropology," in Culture, Disease, and Healing, David Landy, ed. (New York: Macmillan Publishing Co, 1977) 11-31.
Correction In the article "Cerebral revascularization" by Christopher B Shields, MD, (April 1978), Figure 1 was printed twice and Figure 2 was omitted. Both
figures are printed here with their legends as they should have appeared.
Fig 1. Angiogram of lateral left common carotid discloses supraclinoid internal carotid stenosis (long white arrow) in a patient with a slowly progressing stroke. Superficial temporal artery is noted (double arrowheads).
Fig 2. Postoperative angiogram of patient shown in Fig 1 shows an enlarged superficial temporal artery (double arrowheads) filling the entire middle and anterior cerebral circulation. The internal carotid artery has progressed to complete occlusion in the interim between the two angiograms. The external carotid artery is filling well (black arrows).
AORN Journal, June 1978, V o l 2 7 , No 7
1295
