NCM 120:

Decent Work Employment & Transcultural

Nursing

Chapter 7

Transcultural Perspective in the

Nursing Care of Adults

Chapter 7
Transcultural Perspective in the Nursing Care of Adults
Introduction

This chapter discusses transcultural perspectives of health and nursing care associated with
developmental events in the adult years. The focus is primarily on young and middle adulthood.
The first section of this chapter presents an overview of cultural influences on adulthood, with an
emphasis on how health/illness situational crises or transitions might be influenced by cultural
variations. The second section provides the context for and gives an example of a health-related
situational crisis. The influences of culture on individual and family responses to health problems,
caregiving, and health/illness transitions and crises are discussed.

Specific Objectives

At the end of the lesson, the students should be able to:

1. Evaluate how culture influences adult development.

2. Explore how health-related situational crises or transitions might influence adult
development.
3. Explain how gender and specific religious beliefs and practices might influence an adult’s
health and/or illness during situational crises or transitions.

Duration

Chapter 7: Transcultural Perspective in the Nursing 5 hour lecture, 1 hour

Care of Adults assessment
Lesson Proper

Overview of Cultural Influences on Adulthood

Health/illness crises and/or transitions during adulthood are of interest to nursing because
they include responses to health and illness. In addition, health/illness transitions influence how
individuals respond to health promotion and wellness by shaping individual lifestyles including
eating habits, exercise, work, and leisure activities. Consider, for example, how pregnancy (a
transition into motherhood) influences many young adult women to improve their diet, begin
moderate exercises, abstain from alcohol, and, in general, take better care of themselves so their
baby will be healthy.
The adult years are a time when gradual physical and psychosocial changes occur. These
changes are usually gradual and reflect the normal processes of aging. These physical changes, or
physiologic development, are evident in the hormonal changes that take place in adulthood in both
men and women. Psychosocial development, or the development of the personality, may be more
subtle but is equally important. Both physiologic development and psychosocial development are
influenced by cultural values and norms, and they occur throughout a lifetime.
Physiologic Development during Adulthood
Women undergo menopause, one of the more profound physiologic changes that results in
a gradual decrease in ovarian function with subsequent depletion of progesterone and estrogen.
While these physiologic changes occur, self-image and self-concept (psychosocial terms) change
also. The influence of culture is relevant because women learn to respond to menopause within the
context of their families and culture. The perception of menopause and aspects of the experience
of menopausal symptoms appear to vary across cultures. It has sometimes been assumed that non-
Western women do not experience the menopausal problems seen in Western society because their
status increases as they age; however, this assumption has been challenged. In Western cultures,
such as Canada and the United States, youth and beauty are valued and aging is viewed with
trepidation. Western medicine has tended to treat the symptoms of menopause with hormone
replacement therapy, surgical interventions, and/or pharmaceutical products. Although there are
not many studies on the perimenopausal transition across cultural groups, there seem to be cultural
differences in the reporting of symptoms associated with treatments for menopausal symptoms.
One recent study has shown that such factors as length of time spent in the United States and
social–economic status were significant predictors of number and severity of menopausal
symptoms among immigrant women (Im, Lee, & Chee, 2010). This reinforces an earlier statement
that women (as well as others) learn to respond to menopause and aging within the context of their
families and culture.
Men also have physical and emotional changes from the decreased levels of hormones.
Loss of muscle mass and strength and a possible loss of sexual potency occur slowly. However,
developmental differences among both adult men and women have not been extensively examined
cross-culturally, and most existing theoretical and conceptual models of adult health do not provide
insight into cultural variations. The cultural belief that aging, however gradual, is a normal process
and not a cause for medical and/or surgical intervention may be more apparent in diverse cultural
groups.
Psychosocial Development during Adulthood
Adulthood was termed the “empty middle” by Bronfenbrenner (1977). A noted
developmental psychologist, his use of this term was an indication of Western culture’s lack of
interest in the adult years. Traditionally, these years were viewed as one long plateau that separates
childhood from old age. It was assumed that decisions affecting marriage and career were made in
the late teens and that drastic changes in developmental processes seldom occurred afterward. For
many years, most developmental theorists saw adulthood as a period to adapt to and come to terms
with aging and one’s own mortality. Western thinking has changed considerably since
Bronfenbrenner’s observations. Psychosocial development in middle age is now viewed as a
vigorous and changing stage of life involving many challenges and transformations.
Sociocultural factors in Western society have precipitated tremendous changes, producing
crises, change, and other unanticipated events in adult lives. Divorce, remarriage, career changes,
and increased mobility, as well as other societal changes (the sexual revolution, the women’s
movement), have had a profound impact on the adult years. Many middle-aged adults may be
caught in the sandwich generation—still concerned with older children (and sometimes
grandchildren) while also increasingly concerned with the care of aging parents. Middle life can
be a time of reassessment, turmoil, and change. Society acknowledges this with common terms
such as midlife crisis or even empty nest syndrome, along with other terms that imply stress,
dissatisfaction, and unrest. However, adulthood is not always a tumultuous, crisis-oriented state;
many middle-aged persons welcome the space, time, and independence that middle age often
brings. Midlife can be a time of challenge, enjoyment, and satisfaction for many persons. We now
tend to view a “midlife crisis” as a time of transition that can be a positive experience, including
the mastery of new skills and behaviors that help an individual to change and grow in response to
a new environment (Meleis et al., 2000).
Chronological Standards for Appropriate Adult Behavior
Much of the work on adult development was done in the 1960s and 1970s by
developmental psychologists such as Bronfenbrenner (1977); Havighurst (1974); and Neugarten
(1968), all of whom proposed different theories about adult development. We still rely on some of
this early work as we attempt to understand the complexities of adult development. Neugarten
(1968) observed that each culture has specific chronologic standards for appropriate adult behavior
and that these cultural standards prescribe the ideal ages at which to leave the protection of one’s
parents, choose a vocation, marry, have children, and, in general, get on with life. The events
associated with these standards do not necessarily precipitate crises, but they do bring about
change. What is more important is the timing of these events. As a result of each culture’s sense
of social time, individuals tend to measure their accomplishments and adjust their behavior
according to a kind of social clock. Awareness of the social timetable is frequently reinforced by
the judgments and urging of friends and family, who say, “It’s time for you to …” or “You are
getting too old to …” or “Act your age.
 Problems often arise when social timetables change for unpredictable reasons. An example
is the recent trend of adult children, frequently divorced, unemployed, or both, returning to live
with their parents, often bringing along their own children. Grandparents caring for grandchildren
is now a common phenomenon in Western society. Being widowed in young adulthood or losing
one’s job at age 50 due to an economic downturn are examples of events in adulthood that are
likely to cause stress and conflict because they occur outside of the acceptable social timetable.
Culture exerts important influences on human development in that it provides a means for
recognizing stages in the continuum of individual development throughout the lifespan. It is
culture that defines social age, or what is considered an appropriate behavior in each stage of the
life cycle. In nearly all societies, adult role expectations are placed on young people when they
reach a certain age. Several cultures have defined rites of passage that mark the line between youth
and adulthood; in the United States, markers of beginning adulthood include reaching the legal age
to obtain a driver’s license, to drink alcohol, or to join the military forces.
Menarche is a milestone in a young girl’s physiologic development and a psychologically
significant event that provides a rather dramatic demarcation between girlhood and womanhood.
However, this is not an event that is celebrated openly in Western culture; most girls are too
embarrassed to talk openly about it with anyone but their mothers or close friends. There are no
definitive boundaries that mark adulthood for either young girls or young boys, although legal
sanctions confer some rights and responsibilities at the ages of 18 and 21 years. There is no single
criterion for the determination of when young adulthood begins, given that different individuals
experience and cope with growth and development differently and at different chronologic ages.
A young boy who joins the military forces at age 18 and serves in Iraq or Afghanistan may “grow
up” more quickly than the 18-year-old who lives with his parents, has a part-time job, and attends
a local community college.
Adulthood is usually divided into young adulthood (late teens, 20s, and 30s) and middle
adulthood (40s and 50s), but the age lines can be fuzzy. Generally, a young adult in his or her late
teens and early 20s struggles with independence and issues related to intimacy and relationships
outside the family. Role changes occur when the young adult is pursuing an education,
experiencing marriage, starting a family, and establishing a career. A middle adult most often
concentrates on career and family matters. However, as previously mentioned, adulthood is not
necessarily an orderly or predictable plateau. Experiences at work have a direct bearing on the
middle-aged adult’s development through exposure to job-related stress, levels of physical and
intellectual activity, and social relations formed with coworkers. “Recareering” or changing
careers during middle adulthood is also becoming more common. At home, family life can be
chaotic, with role changes and other developmental transitions occurring with dizzying frequency.
Often, adults are faced with the realization that they are getting older and feel like they have made
the wrong choices or left many things undone.
Some life changes can lead to developmental crises. According to Erikson (1963), a
developmental crisis occurs when an individual experiences normal and expected age-appropriate
challenges. For example, a young adult may have difficulties separating from his or her parents
and establishing independence. This is usually resolved as “homesickness” and dissipates as the
young adult can adjust to a new lifestyle such as college, the military, or employment away from
home. A health/illness situational crisis is often focused and specific and can occur anytime.
Sometimes, a situational crisis can be precipitated by an illness, such as a diagnosis of type 2
diabetes or the death of an infant. A situational health/illness crisis is usually time-limited,
although additional transitions may occur. How well individuals cope with and manage the
challenges of health/illness crises and transitions in adulthood is influenced by cultural values,
traditions, and backgrounds.
Developmental Transitions: Achieving Career Success
Many persons in traditional Western culture define career success in financial terms, while
others may see it as providing service or making a contribution to the lives of their fellow citizens.
Achieving success in one’s career—including adequate financial remuneration and satisfaction
and enjoyment—is considered an important developmental task or goal in adulthood. However,
there are many groups who struggle to attain this goal. Immigrants to the United States, Canada,
or Europe may find it very difficult to find employment that pays an adequate salary or offers
opportunities for advancement or job satisfaction. North America and Europe and other parts of
the world have experienced a tremendous influx of immigrants and refugees from Southeast Asia,
Latin America, Eastern Europe, the Middle East, Africa, and other geographical areas. Although
immigrants and refugees may aspire to career success or earn a higher salary, those may be difficult
goals to attain. They may have difficulty with the language, with the skills and educational level
required, as well as other factors necessary for holding a good job in their new country.
Other factors, such as gender, also influence the attainment of satisfaction in career choices.
More women are working outside of the home, and there may be a different division of time and
energy for both spouses that pose challenges. Women’s presence in the work force has increased
dramatically, from 30.3 million in 1970 to 72.7 million during 2006 to 2010, and this has had a
significant impact on childcare and family finances. Although women have made significant gains
in certain occupations, many women continue to be employed in low-paying jobs with little chance
for advancement. Many are employed in occupations that have been traditionally oriented toward
women (Huffington Post, April 12, 2014), and the salaries are less than men earn in similar
positions. Working in a low-paying job that does not offer opportunities for advancement or
intellectual challenges does not lead to career success or recognition from one’s peers.
Many immigrant and refugee families experience role conflict and stress as gender roles
begin to change during contact with Western culture. For example, sometimes, the male head of
household who has immigrated is unable to find employment; if he was a professional in his former
country, he may be reluctant to accept the menial jobs that are traditionally filled by immigrants
or refugees when they first migrate to another country. Frequently, low-status jobs are more
available to immigrant women, yet their traditional roles are closely tied to the home and family.
When an immigrant or refugee woman begins to work outside of the home, her role changes, and
those changes alter the traditional power structure and the roles within the family. The lack of
adequate social supports, such as affordable daycare for children and adequate compensation for
work, and the additional physical and emotional stress result in an unacknowledged toll on
immigrant and refugee families.
Developmental Transition: Marriage and Raising Children to Adulthood
Marriage and raising children usually take place in early to middle adulthood. The age at
which young people marry and become independent varies by custom or cultural norm, as well as
by socioeconomic status. In Western culture, young adults of lower socioeconomic status leave
school, begin work, marry, and become parents and grandparents at earlier ages than middle-class
or upper-class young adults. Indeed, many North American families encourage early independence
by urging their children to attend college or to find employment away from home. Other cultural
groups, such as those from the Middle East and Latin America, place more emphasis on
maintaining the extended family. Even after marriage, a son and his new wife may choose to live
very close to both families and to visit relatives several times each day. Families from some
cultural groups, such as Hispanics, or traditional religious groups, such as the Amish, may be
reluctant to allow their young daughters to leave home until they marry. In many Muslim families,
girls do not leave home until they are married.
Increased mobility in American and Canadian societies has impacted family life as many
young families now live far away from grandparents, and the traditional influences of grandparents
on young grandchildren are decreasing. Sometimes because of geographical distance, grandparents
barely know their grandchildren, although digital photos via home computers, cell phones, Skype,
and other technological devices are helping to keep grandparents up to date with the growth and
activities of their grandchildren.
Health-Related Situational Crises and Transitions
Situational transitions often occur when a serious illness is diagnosed, or other traumatic
events occur to individuals and their families. Some developmental theorists refer to the initial
period as a “situational crisis” when a serious illness is diagnosed or traumatic event occurs. Such
a diagnosis or event often leads to fear and anxiety in the client and family members. As clients
and family members learn more about the precipitating condition, they realize that many of their
fears are unfounded as they gain more confidence in managing the illness condition. The “crisis”
dissipates but still the illness remains and must be managed appropriately. The client and family
must “transition” to living with a chronic illness. The leading causes of death in the United States
are heart disease, cancer, cerebrovascular disease, respiratory disease, accidents, and diabetes, and
they are usually diagnosed in adults. These conditions affect individuals, but they also occur within
a family system and affect children, spouses, aging parents, and other close relatives. Because
middle-aged adults may be caring for aging parents, adult children, and even grandchildren, the
illness of any one individual must be evaluated carefully for the myriad of ways in which it affects
all members of the family.
Caregiving
Caregiving occurs when an unpaid person, usually a family member, helps another family
member who has a chronic illness or disease. Many caregivers are women who are caring for their
aged and ill parents or husbands. Assuming the role of caregiver often predisposes women to
interrupted employment and limited access to health care insurance and pension and retirement
plans.
 Culture fundamentally shapes how individuals make meaning out of illness, suffering, and
dying. Cultural beliefs about illness and aging influence the interpretation and management of
caring for the ill and aged, as well as the management of the trajectory of caregiving. Family
members provide care for the vast majority of those in need of assistance. The demands of
caregiving can result in negative emotional and physical consequences for caregivers. How they
cope with stress, social isolation, anxiety, feelings of burden, and the challenges of caregiving will
all be influenced by cultural values and traditions.
References

Andrews, M. M., ( 2019). Transcultural Concepts in Nursing Care. Seventh Edition

Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American

Psychologist, 32, 513–531.

Huffington Post. (April 9, 2014). Women in the workforce: What changes have we made?
Retrieved from http://www. huffingtonpost.com/mehroz-bair/women-in-the-workforce-
wh_b_4462455.html

Im, E. O., Lee, S. H., & Chee, W. (2010). Subethnic differences in the menopausal symptom
experiences, acculturation and menopause among midlife minority women. Journal of
Transcultural Nursing, 21(2), 123–133.

Meleis, A. I., Sawyer, L. M., Im, E. O., Hilfinger Messias, D. K., & Schumacher, K. (2000).
Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23(1),
12–28.