Chapter 16 Chinese Culture


  • Adam Anderton, SN - Utah Valley University - Orem, Utah
  • Sean N. Bennett, RN, MSN - Assistant Professor - Utah Valley University - Orem, Utah
  • Michelle Esplin, RN, BSN - Utah
  • McKell Palmer, SN - Utah Valley University - Orem, Utah
  • Madison Parker, SN - Utah Valley University - Orem, Utah
  • Linda Wiggins, SN - Utah Valley University - Orem, Utah
  • Melissa Yates, SN - Utah Valley University - Orem, Utah



  • .







China is the third largest nation according to land mass, but it has the largest population in the world. Of the almost 1.3 billion people, 92 percent are of the ethnic majority called Han. The remaining 8 percent come from a variety of ethnic backgrounds. China is made up of Inner and Outer China. Most of the ethnic minorities live in Outer China, and have their own languages, customs, and cultures. Mandarin Chinese is the official language of China, but there are a large number of regional accents and dialects that can make communication difficult (, 2015).


Chinese society values order above all else. The predominant religious and philosophical views promote maintaining stability, and balance. They believe that the universe has a natural design, and everything can be explained by that design. Order and hierarchy are the foundations of their society (Doctoroff, 2011).


About a quarter of the world’s population live in China.  It is officially called The People’s Republic of China with  Beijing (Peking) as the capital.  Ethnically, 92% of the people in China are Han Chinese, with the rest being national minorities (Flower, 2010).  Chinese religion is mostly Daoist, Confucian, and Buddhist.  China has several languages, all of which share the same script, with Mandarin as its official language (Flower, 2010).  China is proud of its ancient history which is more than 5,000 years old.  When Marco Polo visited china in the 13th Century, he described Chinese cities as larger and wealthier than European cities.  He also described a society that was well-ordered (Flower, 2010).  China’s rich cultural heritage has influenced western society in art, food, medicine, clothing, music, philosophy, and much more.   They invented print and moveable type (Flower, 2010).  They are commonly known for having introduced the world to noodles, gunpowder, and silk.  China is known globally for having one of the greatest wonders of the world, The Great Wall of China. The Chinese built the Great Wall around 200 BC along an east-to-west line across the historical northern borders of China to protect the Chinese states and empires against the raids and invasions from the Mongols. It can be seen from outer space and stands as one of the world’s greatest architectural and engineering marvels.  Today China has evolved into a combination of the ancient culture and the newer Western-influenced Chinese culture.  This is observed throughout the larger cities where traditional buildings sit beside skyscrapers and McDonald's and Kentucky Fried Chicken are found in a country where refrigeration is still somewhat uncommon.


The family unit is central to Chinese culture.  Single mothers and divorce are less common in China than in Western cultures (Flower, 2010).  Extended families, known as family clans, often contribute to a young person’s educational expenses including travel and tuition costs. Chinese culture has a great respect for their elders.  It is traditional to have family elders live with and be cared for by their families—not in nursing facilities (Flower, 2010).  It is believed that in healthcare settings, patients should be cared for with the same respect and importance as would be shown by any Chinese to their own family members (Meng, Xiuwei, & Anli, 2011).  Asking Chinese people how many children they have can be a sensitive issue because of the government’s One Child policy, which is still kept in much of China (Flower, 2010).


Values and Norms

Chinese values and norms are greatly built on the concept of what is called ‘face’. This is roughly translated as ‘honor’, ‘respect’ or ‘good reputation’. There are four different types of ‘face’; 对面 子(dui-mian-zi),  给 面 子(gei-mian-zi), 六面 子(liu-mian-zi) and 讲面子 (jiang-mian-zi).  Each type of ‘face’ is earned or given differently;  对面 子(dui-mian-zi) is the ‘face’ resulting from actions or deeds observed by others.  给  面子  (gei-mian-zi) is ‘face’ earned by how one treats others by showing respect.  六面子  (liu-mian-zi) is developed over time by avoiding mistakes and showing wisdom through action. 讲面子  (jiang-mian-zi) is when one's ‘face’ is increased though others by compliments and good reports. It is very important to maintain and work at improving ones ‘face’ at all times (, 2015) (, 2015).

Relationship to others determines how one behaves in Chinese culture. Five different types of relationships are observed; Ruler and subject, husband and wife, parents and children, brothers and sisters, and friends.  It is believed that society will be stable if the five relationships are properly maintained (, 2015) (, 2015).

Overall, the Chinese are a collective society and prefer groups rather than being alone. Chinese will sacrifice their own personal needs or feelings for the good of their group and will go to great lengths to avoid public embarrassment of others. It is normal to keep one’s personal opposing opinions quiet in public settings in order to avoid both parties losing ‘face’ (, 2015) (, 2015).

Non-verbal communication plays a large role in the Chinese’s group dependent culture. The Chinese rely on posture, facial expression and tone of voice to discern what someone is feeling. Facial expressions are interpreted as ones reaction to what someone is saying, so usually the Chinese have an emotionless expression when speaking. It is seen as disrespectful to stare into another’s eyes, this is observed in crowded situations as the Chinese tend to avoid eye contact in order to maintain their own privacy (, 2015) (, 2015).

Etiquette is greatly valued in Chinese culture and is reflected by much of their behavior and norms. Specific etiquette is expected in many daily practices including meetings, gift giving, dining and business practices (, 2015) (, 2015).

All greetings are considered formal where the eldest person of the group should be greeted first.  A handshake is common and is accepted when greeting foreigners. When greeting someone, it is customary to look towards the ground, address the person by an honorific title and their surname. It is polite for one to address the other by their first name only after being advised otherwise it would be disrespectful to address by their first name. (, 2015) (, 2015).

Gift giving in Chinese culture generally takes place at Chinese New Year, births and weddings. Recent marketing has influenced gift giving at birthdays as well. Eight is the luckiest number, giving a set of eight as a gift will bring luck to the recipient. Gifts should never be given in a set of four as the number four is an unlucky number. Also, gifts should not be anything symbolizing severing a relationship such as knives or scissors. Handkerchiefs, clocks, flowers and straw sandals are associated with funerals and death and should not be gifted. Gifts should not be wrapped in white, black or blue paper. Gifts should always be presented with two hands and should not be opened when received. It is customary to refuse a gift up to three times before they are accepted by the recipient (, 2015) (, 2015).

Proper dining etiquette is a sign of respect. It is considered a great honor to be invited into one's home for dinner as the Chinese prefer to entertain in public places. Dining etiquettes begins with accepting the honor of dining with them, if unable to attend, it is considered polite to explain the conflict causing the absence. A small gift is customary for the hostess. One should arrive on time and remove shoes before entering the house. One should wait to be told where to sit and the guest of honor typically is given the seat facing the door. Chopsticks will be used, so learning how to use them is important if attending a Chinese dinner. The host is the first to begin eating and should be the first to offer a toast. It is considered respectful to eat well and show enjoyment of the meal, this can be shown by slurping or belching sounds. It is respectful to try everything that is offered but to never eat the last piece of food from a serving tray. Bones should be placed on the table or in a bowl if provided. Rice bowls should be held close to the mouth while eating. It is not necessary to finish all food that is served. When eating at a restaurant tipping older workers is considered an insult whereas tipping younger workers is becoming more commonplace (, 2015) (, 2015).

All of the etiquette practiced in Chinese culture is primarily for showing and maintaining honor for oneself and one another.

Traditions, Beliefs, and Attitudes

Ancient Chinese culture is more than 5000 years old and is immensely diverse. China consists of more than 1 billion people. This large of a population constitutes a wide range of customs and traditions. The present day Chinese culture is a mix of old world traditions and a westernized lifestyle. The Penn State College of Science describes the balance as “the juxtaposition of towering skyscrapers with heritage buildings, the contrast of western fashion with the traditional Chinese Qipao dress, the people’s paradoxical affinity for both dim sums and McDonald’s” (“Chinese Culture, Tradition, and Customs,” 2015). The varying traditions include celebrating holidays, religious traditions, music, and much more. Celebrating correctly is a big part of Chinese culture and tradition. You are supposed to share your happiness with others, so it is common to have celebratory meals for special occasions. Another interesting and different tradition is that it is common for women to take a one month rest after pregnancy. It is common for the woman to go that whole month after childbirth without showering or washing her hair as well. Traditions also include the groom paying the bridesmaids for the right to take the bride (“Chinese Cultural Traditions”, 2014). Another tradition that is commonly practiced is wearing red underwear for Ben Ming Nian. Ben Ming Nian refers to the year of the zodiac animal in which one was born. “As there are 12 zodiac animals (Rat, Ox, Tiger, Rabbit, Dragon, Snake, Horse, Sheep, Monkey, Rooster, Dog, Pig), one undergoes a 12-year cycle to reach his or her Zodiac Year (or Ben Ming Nian)” (Ben Ming Nian, 2014).

The Chinese belief system is mainly built on top of the religions. Different religions have a different set of beliefs that follow with those religions. The main religions are Buddhism, Islam, Christianity, and Taoism. 85% of Chinese people have religious beliefs, while only 15% are considered atheists (“Religions & Beliefs in China”, 2015).

The Pew Research Center conducted a research as part of its “Global Attitudes Project”. Pew collected over 3,000 samples in China, and the results are actually quite surprising, given that China is ruled by a Communist government. Much higher than other countries, more than 80% of the Chinese respondents verbalized that they were satisfied with their nation’s development. Chinese are also the most optimistic about their country’s economic situation. Despite their strong belief and confidence in their country, Chinese respondents also verbalized that they did not believe that hard work brings success (Bildner, 2013).


China is as diverse in its religious identity as it is in its cultural identity. With an immense geography, variety of ethnicities, and ancient history, native and foreign religions blend to create a diverse religious tradition (He, 2012).


Religions native to China include Taoism, Confucianism, as well as numerous ethnic folk religions. The fundamental belief of Taoism is Dao, (The Way). The Chinese believe Dao is the guiding principle that brings order and harmony to everything in the Universe. T’ai chi is an expression of this belief system. It conveys an understanding of the connection between movement, nature, and health.  Taoists believe that there is duality in all things, a yin (negative) and a yang (positive).  To them, trying to eliminate evil is pointless, because good will always naturally replace evil.  Because of this belief, Taoists do not subscribe to the idea of heaven and hell.  For them, joy comes from living in harmony with the natural ebb and flow of life (, 2015). Confucianism is considered more of a philosophy than a practicing religion. There are no specific religious rituals associated with Confucianism, it is rather a set of ethical principles based on the teachings of the philosopher Confucius who lived in China in the 6th-5th century BC (, 2015). The wide variety of folk religions found in China are closely tied to the ancient patriarchal clan system, and are found predominantly in the northern and southern regions of China. The rituals of these religions are often based on the worship of nature, as well as the worship of ancestors (He, 2015).


The three primary religions of foreign origin that are practiced in China are: Buddhism, Islam, and Christianity. In China, Buddhism is separated into three sects: Han Buddhism, Tibetan Buddhism, and Theravada Buddhism. Each group practices in a different geographical region, and while similar, each applies varying elements to its individual form of worship. Islam was introduced in China in the 7th century AD. Chinese Muslims follow the practices of Muslims around the world. They follow the same dietary restrictions, worship five times a day, fast, and complete a hajj pilgrimage to Mecca. Christianity is the newest religion in China. Catholicism was introduced by missionaries in the thirteenth century AD while Protestantism didn’t come to China until the beginning of the nineteenth century (He, 2012).


Sense of Self and Space

Within the Chinese culture, individuals highly value the opinions of their friends and family.  This is referred to as maintaining “face.”  "Fundamentally “face,” represents a person’s reputation and feelings of prestige (both real and imagined) within their workplace, society, their family unit and among their friends" (, 2013). Without the approval and praise of a person’s community, Chinese individuals ‘lose face’ and often view themselves as unsuccessful and have a poor sense of self.

As a result of placing so much value in maintaining ‘face,’ the Chinese work hard to cultivate positive relationships and interactions within their community.  They avoid insulting, embarrassing, shaming, yelling at, or otherwise demeaning a person (, 2014).  Avoiding these actions is especially important when in public.  The Chinese try not to make demands or create conflict; if they encounter a potential problem, they calmly explain the situation without jumping to any conclusions.  This non-confrontational approach maintains respect towards the individuals involved.  Breaching emotional boundaries is a major social error amongst the Chinese.

In contrast, physical boundaries and personal space don’t seem to be as high of a concern between Chinese individuals and their families/communities.  With the increasing number of people living in China, it’s no surprise that personal space is not a priority.  On crowded subways, riders have witnessed individuals putting both hands on either shoulder of an individual and moving them to the side to get past.  In addition, Chinese tend to be more more comfortable with physical contact especially with members of the same sex. Women in China are commonly seen walking hand-in-hand with other women and men are seen casually wrapping their arms around male friend’s shoulders while walking down the street (Archer, 2014).  While these actions aren’t practiced by most Westerners, this is a completely normal act for Chinese individuals.  These actions demonstrate deep care and respect for one another.

Communication Style and Language

In the Chinese culture, “Linked, rightfully, with the Confucian concepts of li 礼 (“rituals,” “propriety”) and he 和 (“harmony”) and with Chinese popular notions of guanxi 关系 (“relationship,” “networking”) and mianzi 面子 (“face”), keqi is viewed by scholars as a major Chinese interpersonal and discourse behavior, and the consensus they share seems to suggest that keqi permeates all Chinese communication processes and that Chinese individuals follow this behavioral paradigm regardless of the circumstances in which the communicative events take place” (Yanfang, 2014, p. 69). Simply stating please, thank you, how do you do, etc. are examples of standards of limao (civil politeness) which is expected to be expressed by all individuals. Keqi, on the other hand, is a set of social and interpersonal behaviors specific to Chinese culture to cultivate harmony that is more limiting than limao due to the restrictions based upon situation and the person one is communicating with.

Many examples of keqi can be observed with the scenario of hosting a meal. The host will insist on inviting the guest as many times as being refused, show hospitality at the table by placing the guest in the most honorable seat and urging the guest to  take more food (even when the guest is full), and will see the guest off until they are driving away in their car). To show respect, or keqi, by the guest, he or she will ensure that their presence is not a burden or inconvenience, will find an opportunity during the meal to invite the host for a meal at their residence in the future to reciprocate the host’s kindness, and the guest will usually bring a small gift to thank the host for the meal; to which the host will usually apologize for not having enough dishes even if there was plenty of food provided. “In short, …keqi … expresses itself in so many different forms and is such an integral part of the socialization process that when individuals gather for a meal it seems as if their purpose is not to eat but to engage in such a polite give-and-take show of kindness” (Yanfang, 2014, p. 71).


Food and Feeding Habits

Eating habits for Chinese culture is one thing that makes such a large contrast with the West. In the West, it’s traditional to all have a plate dished for each person. Chinese culture has the offered food placed in the middle of the table and everyone shares.  The typical meal starts with a few cold dishes like mashed cucumber with garlic or boiled peanuts. This is followed by some sort of noodle or rice which are considered the “staples” of Chinese food (, 2015).

Guests should be prepared to be offered a lot of food as Chinese are very proud of their culture of food and will offer many different types of cuisine. Traditionally, Chinese culture has many taboos when it comes to dining etiquette. Modern Chinese eating still have some key rules keep in mind in order to be an appropriate guest at the dinner table, especially when eating at a private home (, 2015).

One important consideration when using using chopsticks, remember to lay them on a dish when they aren’t being used. Don't stick chopsticks upright in the rice bowl. This is because somebody dies, the traditional shrine to them contains a bowl of sand or rice with two sticks of incense stuck upright in it.   Therefore, leaving chopsticks upright in a bowl is equivalent to wishing death upon person at the table (, 2015).

The spout of the teapot should not face anyone on the tablet. It is impolite. The spout should always be directed to where nobody is sitting, usually just outward from the table (, 2015).

Beggars tap on their bowls, and in a restaurant, if the food is coming too slow people will tap their bowls. Overall tapping on bowls is impolite and should be avoided as to not insult the host or the cook (, 2015).

Chinese people are very proud of their cuisines and eating traditions. Etiquette in dining has transitioned much to accommodate modern needs and trends but the basic foundation and traditions of Chinese dining remain (, 2015).

Time Consciousness

Many cultures view the concept of time differently. Most western cultures have a linear understanding of time. Time moves swiftly in one direction and one must capitalize on it, or it will be gone. Time is therefore seen as important commodity, hence the well-known maxim, “time is money”. Eastern cultures generally consider time as being cyclical. The past, present, and future, circle in a continuum. One season follows another and generations come and go. To the Chinese, time is not a limited product, they would say “when God made time, He made plenty of it” (Lewis, 2014).


To the Chinese, time is intricately associated with personal relationships. Personal connections are the priority. Hence, the time one spends with another is seen as strengthening a relationship and is of more value than the content of the meeting. The Chinese are also very adept at multi-tasking.  Someone from another culture might take offense if the person with whom they were meeting continued to do other things during the conversation.  Rather than taking offense, it would be more productive to understand that a stronger relationship is being created through the time spent together (Owen, 2013).


In China, it is also essential to be seen as being considerate of another person’s time. Punctuality is very important in the Chinese culture. It is customary to show up fifteen to thirty minutes before the scheduled time for an appointment. It is then customary to announce, within ten to fifteen minutes of the start of the meeting, that one needs to be leaving soon. Of course they will not leave until the business has been concluded, but respect for another person’s time has been shown. While it is necessary to show this respect, it must also be understood that the Chinese expect a generous amount of time to be spent enhancing a personal relationship rather than merely discussing business. In Chinese culture, a personal relationship of trust and common interest is the foundation of all future interactions (Lewis, 2014).


Relationships and Social Organizations

The Chinese culture does not place constraints on relationships. Rather, they place an emphasis on observing and identifying the proper relationship. There is a strong belief in the Chinese culture that identifying the proper relationship is the "key to social harmony". There are five specific relationships which include "ruler to subject", "father to son", "husband to wife", "elder brother to younger brother", and "friend to friend". It is common that many businesses in China are made up of friends and extended family, which is not surprising because four out of five of these relationships are related to family and friends. According to Upton in his article about Chinese relationships, "most Chinese business people are not accustomed to "business only" relationships. Rather, they prefer to create a friendly and personal relationship first, and then conduct business afterwards" (Upton, 2013).

Similar to most other parts of the world, ancient China practiced a social hierarchy. Within the society, people were divided into 4 major classes or categories. These four categories included shi, long, gong, and shang. More responsibilities and value in society accompanied higher rankings. The first category, shi, came with the most responsibility and value. The shi were also known as "scholars" or "officials", and had positions such as advisors, clerks, overseers, and scribes. The shi could be identified by the silk robes that they wore. They also had rights to ride in chariots, carry weapons, and command battles. The factor that kept the shi at such a high standard was that they were well educated. The next category, the nong, included society members that assisted in producing food or helped sustain the society. Because of this, they were considered valuable members of the society. Farmers were included in the nong category as well. The third category included artisans and craftsmen. This category was known as the gong class. Some of their contributions to society included producing textiles, potteries, and working in various architectural works. They had a significant role and were valued because of their specific skill set. The last class was considered lowest because they did not produce anything or contribute anything to the society, but they did gain profit from organizations. Shopkeepers, bankers, sellers, and traders are all within the last class, which was known as the shang. The last category, the shang, were not allowed to have government jobs or carry weapons ("Chinese Social Hierarchy"). This interesting class system was thusly arranged because the members of the Chinese hierarchy believed that the government officials should not be concerned with money.


Education and Learning

It is known that the quality of childhood development, participation in education, and the outcomes of learning are the foundations for an individual to lead a successful life. Education is highly valued in the Chinese culture; furthermore, education is seen as a stepping stone to success and students in China are under a great deal of pressure to excel. This success is not so much for personal wealth, as it is to benefit the society. For example, a child would have the motivation to excel in a way that would most benefit his or her family and could be of service to their community as well.  In order for some Chinese families to facilitate quality education for their children, they must relocate in order to improve life chances for their children.  One study has found that "over 260 million Chinese people are migrants living in an area that is different from their household, or hukou registration" (p. 59). Interestingly, this study showed that similar to findings globally, girls have higher performance with literature whereas boys have higher performance in mathematics.


In China, teachers are seen as experts in their fields, and it is their responsibility to pass on their knowledge and skill to their students. Rather than exploring, questioning, and assuming some autonomy in their learning, students are expected to memorize and repeat the information and skill of their teachers (Yang, Zheng, & Li, 2006). A popular and growing trend in China is for young men and women to participate in what is called “International School,” more formally known as International Baccalaureate Diploma Program (IBDP) schools (Wright, 2014).  These schools emphasize education and skills that are specifically useful in the 21st Century.  Their core requirements are labeled, “Creativity, Action, Service, Extended Essay, and Theory of Knowledge” (Wright, 2014).  Thousands of these schools exist around the world.  China is the biggest consumer of this approach to education because they recognize the need to modernize their educational approach by placing heavier emphasis on information technology and also on global, social, and economic considerations (Wright, 2014).


Work Habits and Practices

In the Chinese culture, work habits are deeply rooted in the idea that success comes from diligence and hard work and not by chance nor from which class you are born into (Pope, 2013).  The following qualities are valued by the Chinese in regards to work habits and practices: Saving and giving ‘face’, respect for elders and rankings, patience, politeness, and modesty (Business Etiquette in China, 2014).


When it comes to employment in China, a distinct class system exists.  People are divided into high-class, middle-class and low/working-class.  In China, high-class individuals make more than 1 million US dollars per year and mainly includes wealthy owners and CEOs of large companies.  The high-class group accounts for more than 1 million millionaires in China.  According to CNNMoney, it is expected to see the number of millionaires in China increase 74% to 2.3 million by 2020 (Yan, 2015).  According to research, China's middle class is now the biggest in the world, and is said to be rising much quicker than America's (Yan, 2015).  The middle class in China includes 109 million people with wealth of between $35,000 and $500,000US. Since 2000, twice as many Chinese as Americans have joined the middle class (Yan, 2015).  According to locals, “There is a huge gap in pay between middle and low-class. A person with an education and who can speak English can easily land a job that pays him $35,000US a year plus housing expenses. That’s almost 30 times more than the average low-class factory worker” (Chow, 2006).  People in the low-class group are among the most numerous.  There are a lot of Chinese factories that depend on human labor instead of machines to assemble products.  Rather than having tasks performed by sophisticated machines being monitored by highly-skilled workers, tasks can be performed more cheaply in China by low-paid workers (Hays, 2011).



The Chinese constitute the largest group of Asians living in the United States.  Asians are also one of the fastest-growing minority groups in this country (Yuwen, 2013).  By the year 2020, it is estimated that nearly one in ten Americans will be Asian (Park, 2011).  Registered Nurses need to be culturally competent in treating Chinese American patients in order to prevent misdiagnoses, misunderstandings, medical errors, and low-quality care (Park, 2011).


Chinese Americans face some unique challenges in healthcare. Language is one of the most significant barriers that get in the way of favorable treatment outcomes (Wyse, 2014).  The language barrier might be one of the reasons many Chinese Americans are hesitant to seek care.  (Juckett, 2014).  The fact that they have different beliefs about the causes of illness is another reason they may be hesitant to embrace Western medicine (Juckett, 2014).  Many may feel that American medicine is too strong.  They may prefer herbal remedies like the ones used in China over some of the medications offered to them in the United States (Duke, 2015).


Nurses also face special challenges when performing health assessments on this population.  Many Chinese American patients try very hard to be “good patients.”  To accomplish this, they may try extra hard not to inconvenience or be a burden on nurses and other healthcare staff.  For example, instead of expressing their pain or requesting pain medications, they may hide their pain symptoms and deny any pain when asked about it (Duke, 2015).  It is also a common part of Chinese culture to trust the authority and expertise of the nurse or the doctor and to want to leave the difficult decision making up to these authority figures (Duke, 2015).


Nurses need to be able to recognize the challenges that these differences in culture can present while working with Chinese American patients.  Nurses need to be clear with their expectations and extra perceptive in their assessments.  Nurses are responsible to make sure that a professional interpreter who is an expert with the Chinese language and culture is used.  They need to ask open-ended questions in order to learn what the patient's’ preferences are (Park, 2011), and then be willing to accommodate any reasonable requests.







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