ASNA Independent Study Activity

ASNA Independent Study Activity – Cultural Assessment of Koreans

Roberson, Charlene M

Objectives: At the conclusion of this activity the learner should be able to

1. Rephrase essential elements of a general cultural assessment.

2. Describe the cultural profile of a Korean.

3. Relate how nursing care must be modified to meet the cultural needs of Koreans.

Directions: Read the article carefully. Copy the answer sheet printed at the end of the article (Page 16) and fill out all sections completely. Mail to the address provided along with the appropriate fee. Certificates will be mailed upon successful completion of the post-test. Should you fail the test you will be notified and provided an opportunity to retake the test. All retakes will require an additional fee.

Contact Hours and Accreditation: This activity for one contact hour is provided by the Alabama State Nurses Association, which is an accredited provider of continuing education in nursing by the American Nurses Credentialing Center (ANCC) and the Alabama Board of Nursing.

Cultural Assessment of Koreans

Part I: General Cultural Assessments:

These concepts are applicable to any culture not just the Koreans. A comprehensive cultural assessment may take many hours to complete and nurses do not have that kind of time in today’s health care environment. Therefore, it is imperative for nurses to employ critical thinking skills to guide the assessment process. An example is the following brief overview of a cultural assessment. Not all questions should be asked; however, all concepts should be reviewed mentally and inquire only about those areas that are pertinent.

* Where was the person born and/or how long have they lived in the US?

* Do they live in an ethnic environment?

* Who are the support people & does the support network speak on behalf of the patient?

* What is the communication style both verbal & non-verbal?

* Does the patient and/or the spokesperson comprehend and communicate inEnglish?

* What are their health & illness practices and customs?

And how will this impact nursing care?

Most institutions use untrained interpreters. One drawback is that their interpretations may be culturally jaded. They often base the interpretations on their own perceptions and may withhold (or not ask) vital information because of potential embarrassment to self, patient, or family members. The following guidelines are suggested when using any interpreter and especially an untrained one such as a family member.

* Meet with the interpreter beforehand and explain the purpose of the translation.

* If the interpreter is a stranger to the patient allow time beforehand for both to develop rapport if at all possible.

* Be patient and allow extra time for the message and the response to be translated. Encourage the translator to use the patient’s own words and NOT paraphrase the patient’s thoughts.

* Use simple language, no professional jargon, and use short units of speech.

* Ask the same question in more than one way.

* When asking the question look and speak to the patient and not the interpreter.

* Observe non-verbal clues for both the patient and the translator.

Part II: Specifics to the Korean Culture

Family Dynamics: The family unit is very important in Korean culture. It is common for several generations to live in the same home. Elders are especially respected. In the past it was thought that many children were the future stability and security of the family. Today the family unit is breaking down and an increasing number of younger urban Koreans are living in single family units. Even in these single-family units, the family remains important. Koreans believe that their life goals are focused on fulfilling the family roles and obligations. Therefore, family dynamics are centered on nurturing self-esteem, family identification, maintaining honor, and approval , of others. To this end a family considers cohesion, interdependence, and harmony as extremely important. Nurses will notice this when a Korean enters into the health care system accompanied by their multigenerational family members.

Men view their responsibility to be the representative and protector of their family. Although decision-making is family focused with all members having input, the final decision is most often that of the husband, eldest son, or father. It is unthinkable for children to place themselves” in opposition to the wishes of their elders. Obedience is natural. This is evident when children visit someone in the health care setting; they will be well behaved.

It is common to see same sex Koreans walking hand in hand or arm in arm. This merely shows good friendship. The Gay and Lesbian lifestyle is not well tolerated. Most marriages are still arranged. Marital fidelity is extolled and practiced. Often when a woman’s husband dies, she will not remarry.

Many Korean women work and their contributions are valued and considered essential to the family. However, women are considered the primary caretakers of the home and children. It is common for women to feel that their greatest achievement is to see that their children do well in school.

Religious Practices: In the US most Koreans are Christian. Prior to Christianity Koreans were followers of the Shamanism, Buddhist, Taoism, or Confucianism traditions. The oldest is Shamanism or spirit worship. Webster defines Shamanism as, “A religion of Northern Asia characterized by a belief in an unseen world of gods, demons, and ancestral spirits responsive only to Shamans.” A Shaman is a priest who uses magic for the purpose of curing the sick and other activities. Today this indigenous religion is most often practiced in rural areas of Korea but may also be seen in urban areas. Chanting and praying are common practices. It is not unusual to have a mixture of religions in the same households.

Illness Beliefs: Some believe that illness is the result of bad luck, misfortune, or imbalance of the spirits. Many Koreans although Christian maintain a good relationship with the spirits and may have a spiritual healer known as a Moodang. They may be hired to discover the cause of illness and devise ways to rid the body of the illness.

Mental Illness is considered to be a disruption of the spiritual self. It is often feared and considered shameful. Sometimes this fear or shame may cause the patient and/or the family spokesman to deny or minimize the full extent of emotional problems. If a patient needs to be screened for depression use a tool that does not include the word depression. There are many depression screening tools available both with and without the term depression.

Some Koreans practice coin rubbing which is based on the belief that illness needs to be drawn out of the body. A coin is heated or smeared with oil and then vigorously rubbed over the body. The result is red welts. If assessed on the body of a child or elderly person, it does not necessarily mean abuse. Evaluate the situation if the red welts are noted.

Communication Styles: The elders (1st generation) may not speak English; however, they usually have a high level of English comprehension. Their understanding will be improved if the nurse speaks slowly, uses short phrases, and looks directly at them. If the patient feels intimidated or fearful (as when ill) they may be uncomfortable speaking English even if they have a good command of the language. When possible, it is best to use family members as interpreters. If the family is not present you may employ a stranger as long as they are respectable in demeanor and appearance. Gender is unimportant.

Koreans are given three names. Their last name is the family name and is written first. The second is the generational name and the given name written last. The given name is what Korean family or friends call each other. Always greet the person using a title and last name (family name) unless instructed otherwise. Never, ever greet the person with the first name (given name) unless given specific permission. If the person is elderly the nurse will never be given this permission.

A sign of respect to the nurse is a quick quarter bow upon an introduction. In a US health care setting it unnecessary to return the bow.

Koreans will not demand their rights as individuals and will unquestionable rely upon, and accept the right of the hierarchy to make the best decisions for them. Most Koreans believe in the teaching of Confucius, which states that they must accept their assigned roles in the fixed society of authority. This becomes important when signing consents. The patient may not sign anything until the family decision-maker reviews the documents.

During the process of delivering nursing care, be prepared for them to ask you personal questions. Examples would include, “How old are you?” or “Are you married?” These are not impolite questions to a Korean. Especially the age question, because if you are an older nurse you will be afforded more respect, much as an elder in their community. Their tone of voice implies many qualities with wide varieties of pitches and tones. A nurse may interpret a normal conversation as arguing because the speaker will talk louder on an aspect deemed important. They will also speak louder and more authoritarian toward younger individuals or younger nurses. Elders and gray haired nurses are always spoken to in quieter, more respectable tones. Nurses and doctors are viewed as authority figures and will be treated with great respect. When you respect someone you do not disagree with them; therefore, sometimes they will answer “yes” even when the word “no” is more appropriate. Koreans rarely use the word “no.” Instead they will provide non-verbal clues implying a negative response. A common clue is hesitation before responding. Be alert to this as many Westerners often miss this clue.

Assessments: Although Koreans will hug, touch, and even push each other when they are comfortable, it is not acceptable for you, the nurse, to touch them or enter their close personal space except for an examination. The initial nursing assessment will be difficult, as Koreans will not be forthcoming with personal data even regarding their health. Always bear in mind, that they are taught from childhood not to share inner feelings with a stranger. Remember that data the nurse might consider essential and not private might be very personal to someone brought up in the Korean culture. An example would be questions about breast self exams, sleep patterns, elimination, etc. Therefore, your assessment will probably remain incomplete until a trusting relationship has been established. If you perceive an increasing discomfort level, delay asking questions not directly related to presenting symptoms. Be alert to the patient’s and their significant other’s body language and facial expressions. Nurses will notice little direct eye contact until the patient (and significant others) are comfortable with you. They may frequently glance or look at you if they suspect you are not looking at them. It is proper for the nurse to look at the patient even thought they may avoid your gaze during this initial assessment. Some nurses incorrectly interpret their facial expressions as flat or dull. However, as rapport is established, more facial expressions will be directed toward you and other members of the health care team. Once you sense the establishment of rapport or a comfort level, finish the assessments. Determine if the patient wants a family member present when completing the assessment. As they do not openly share feelings with strangers, they probably will not say “thank you”, “I’m sorry”, or “excuse me” as you are providing nursing care.

Activities of Daily Living: They are very modest and women are more so than men. Provide for their privacy. In addition they are often cold natured and like the room warm by US standards. Koreans are veiy clean. They may need extra towels and cloths. At times they rub their skin to help exfoliate the dead cells. Older women tend to wash their hair once or twice a week. They frequently trim their nails and prefer to do their own care. If an elder needs care the younger family member will provide care without being asked. Again let them do this. Let them perform this care even if the patient is able to care for self.

Food Practices: Koreans eat 2-3 meals a day. In addition they eat many snacks and especially like fruit. They will eat until full and may not eat lunch if a big breakfast is consumed. The evening meal is always the largest and the entire family eats together. Meals are eaten with a large spoon or chop sticks. They do not like cold fluids as this is equated with causing imbalance or illness. The diet is usually high in fiber and spicy. Special favorites are Kim-chee (spicy cabbage), soups, and noodles. Rice is usually eaten with every meal. The diet consists of many vegetables and little meat. Barley water is a particular favorite beverage. It is non-alcoholic and consumed much like Americans drink sodas or Lemonade. Elders often fear tap water (practice dating back to when Korean water was not purified) and therefore will boil the water and keep in the refrigerator. Many Koreans are Lactose intolerant and thus dairy products are not popular. They use food as a prescription, i.e. Ginseng for colds, black tea with honey and slices of lemon, etc. In addition they believe that a sick person may be helped with eating spicy soups with onions and garlic. In the health care setting food or drink may be refused when first offered out of politeness – even if desired. Korean culture dictates an immediate refusal. Nurses should repeat the offer at least two (2) more times to make sure the patient does not want the food or beverage.

Symptom Management: Men are especially stoic in regard to pain. A typical comment might be, “I could die.” There is need for frequent, careful assessments of non-verbal clues for pain. If family members are present the patient may thrash around and be dramatic. Koreans fear pain medication – they fear addiction. The preference is for oral or intravenous administration in lieu of intramuscular medications. The intramuscular medication route is considered invasive.

If the person vomits they will tell you after the fact. They wish to vomit in private and probably will refuse an anti-emetic medication. Facts about diarrhea or constipation will not be Shared due to modesty. A Korean may take a laxative in private. Enemas will not be permitted.

Maternal Child Issues: A Korean woman will seek prenatal care and carefully follow recommendations of the health care provider. She will prefer a female doctor. Expect women to take a few home remedies such as Seaweed soup . to cleanse the blood and help with milk production. In addition some women may avoid eating chicken, crab, eggs, duck, and rabbit as it may harm the infant’s character or appearance. Rest is encouraged for pregnant women.

Labor practices are not remarkable. They may or may not have natural childbirth. Women, especially younger women, may be vocal during labor. Breast feeding may or may not be used. A breast feeding Mother will wean her infant before returning to work. Korean women usually do not pump their breast or store milk. Post Partum rest is considered important and encouraged. If something is wrong with the baby tell the father first and let him tell the mother. She will probably view this as something that she did wrong. The mother will need much support.

Serious or Terminal Illness: Tell the family spokesman first and they will tell both the patient and family. It must be emphasized that nurses and doctors do not share news of a serious or terminal illness with the patient initially. In all probability the patient will not ask about details. In the case of a bad prognosis the family unit will gather together as a whole and support the patient. The family and the ill individual will accept their fate, as everything happens for a reason. The rationale for this is the past life is viewed as learning lessons, the present is about living and carrying on with life, and the future is perceived but not focused on. The nurses’ role at this time is to be supportive, anticipate patient and family needs, and simply be available when or if needed.

Death Rituals: When death is imminent tell the family spokesman so that they can prepare the family. Again, nurses and doctors do not tell the patient directly. Family members usually prefer for the patient to remain in the hospital. And at the time of death, family members may moan, chant, burn incense, or pray. Provide for their privacy. To an outsider these actions may even seem over-dramatized. They will not leave the room quickly, choosing instead to remain with the body. It is common for the family members to cleanse the body after death. At death and under certain circumstances state and national laws mandate autopsies and a request for organ donations. Neither of these practices is looked on with favor as it tampers with the spirit. This presents an ethical dilemma for the nursing staff. It is advisable to have administrative (and pastoral care if available) support available when the family spokesman is consulted about organ donations or an autopsy. The family will probably not agree. You can share that the body is treated with dignity and respect and all organs are replaced in the original spot after the autopsy is over. However, even with this explanation this will be a difficult call. This is not a time for nurses to act alone. It is imperative to consult with administration.

Selected American Behaviors That Koreans Find Especially Offensive. Behaviors include:

* Not standing up when an elder or important person comes into the room.

* Showing the sole of your shoe.

* Crossing legs in front of an important person.

* Receiving or giving an item with one hand.

* Pointing the index finger.

* Smoking in front of an elder or important person.

* Shaking hands too firmly.

* Loud music.

* Wearing shoes in the home. (Home Health nurses should leave shoes at the door.)

* Licking your fingers.

* Drinking from a bottle – even water.

* Placing a pencil or pen in your mouth.

* Using a toothpick in public.

* Sitting on a table when communicating.

* Using red ink (red ink is used only in death books).

* Touching the head of another person.

* Not offering an item (juice) three (3) times.

Selected Korean Behaviors That Americans Find Puzzling: Behaviors include

* Not holding door open for you.

* Limp handshake.

* Always giving or receiving any item with two hands.

* Giving you better gifts than you gave them.

* Ordering food for a guest at a restaurant without asking what the guest wants.

* Men wearing white socks with suits.

* Stare and talk about Americans (or any non-Korean) in front of them.

* Women laughing with hands in front of mouth.

* Children being untrained until kindergarten.

* Sucking air with teeth.

* Little eye contact.

* Slap people when talking to you.

* Bump you in public and do not say, “I’m sorry”.

* Drinking from a cup and handing you the cup for you to drink from the same cup.

* A wife walking three (3.) paces behind the husband

* Men going out with men and women going out with women. (Families rarely go out together.)

* Prefer that you touch only the edges of a form or a piece of paper.

* A wife holding the family money.

* Offering you the item that you have complimented.

* Refusing an item – even though wanted three times for courtesy.

* Husband who never praises wife’s accomplishments – will only downplay her achievements.

* Eating rice with every meal.

* Motion for someone to come by placing palm down and sweeping fingers toward body.

* Having difficulty in saying no.

Post Test Questions – Select the one (1) best answer

1. Cultural Assessments should include which of the following variables:

A. Communication style & vital signs.

B. Length of time in the US & length of time for presenting symptoms.

C. Use of folk remedies & English comprehension.

D. All of the above.

2. During the admission process a patient demonstrates poor eye contact as evidenced by looking to the side and not at you. Your initial assessment is that the patient is

A. Clinically depressed.

B. Irritated at the admission process.

C. Fearful of the admission process.

D. Following expected Korean norms.

3. During routine care a family member asks you, “How old are you?” Your best response is to

A. Tell them the truth.

B. Create a humorous, obviously false age.

C. Respond, “Old enough to know better.”

D. All of the above.

4. You walk into the patient’s room and notice two adult males sitting very close with shoulders touching. You should

A. Alert the nursing staff to possible misbehavior on the unit.

B. Offer to bring an additional chair into the room.

C. Keep a close watch of the two.

D. Accept this behavior.

5. You offer a supper tray to a new admission that has been in the Emergency Room since early in the day. The emergency Room staff has indicated that the patient has not eaten. The patient refuses the tray. Your next action should be to

A. Start the admission process.

B. Indicate that you will be glad to bring a snack later if wanted.

C. Offer the tray at least two (2) more times.

D. Ask the family to talk to the patient about the need to eat.

6. During evaluation of the room environment you notice only one used towel and wash cloth. You should

A. Do nothing.

B. Offer to replace the used linen.

C. Ask, “Do you need additional towels and wash cloths?”

D. Provide several additional towels and wash cloths without asking.

7. A nurse knows to provide which of the following to a Korean patient?

A. Extra blanket.

B. Fresh water and ice.

C. Mouth wash.

D. Reading material.

8. A Korean man is having pain and all of the following options are ordered, which would be the patient’s preferred route?

A. PO or IV.

B. PO or IM.

C. IV or IM.

D. Any of the above.

9. Which of the following bed time snacks would be most appropriate?

A. Velveeta cheese & Crackers.

B. Ice Cream.

C. Milk & Cookies.

D. Banana.

10. Korean women prefer which of the following?

A. A female gynecologist.

B. A male gynecologist.

C. Either male or female examiner.

D. A Nurse Practitioner.

11. During an examination in a pediatrician’s office the nurse observes red welts. The nurse should

A. Get a second opinion from another nurse.

B. Evaluate the family’s illness practices and customs.

C. Notify DHR for a child abuse follow-up evaluation.

D. Mention to the pediatrician that the child has an allergic reaction.

12. When death is imminent the nurse should

A. Consult the doctor about contacting hospice.

B. Give broad opening statements to the patient to encourage them to talk about their impending death.

C. Call the minister.

D. Tell the family spokesman.

13. Koreans are accepting of organ donations under the following circumstances:

A. After careful explanation.

B. Only with extreme staff prodding.

C. If the family spokesman makes the decision to donate the organs.

D. Never under any circumstance.

14. At the time of death family members will probably do which of the following?

A. Leave the bedside and remain in the waiting area.

B. Burn incense and show little emotion.

C. Cleanse the body and meditate.

D. Burn incense and cleanse the body.

15. Many Koreans practice spirit worship in conjunction with other religious practices. They believe that the ancestral spirits are responsive only to

A. The family spokesman.

B. The Shaman.

C. Both A & B.

D. Neither A nor B.

Authored by: Charlene M. Roberson, MEd, RN, BC, Director of Leadership Services, Alabama State Nurses Association, (no vested interest).

Copyright Alabama State Nurses’ Association Sep-Nov 2003

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