• In the PR culture, many Catholic practices concerning death and mourning are followed. In some PR families, a “code of silence” is implemented. This means that the individual whose death is anticipated is not informed of their prognosis. It is also customary for the dying patient’s family to remain in the waiting room where they mourn the impending death by way of a vigil. It is expected that the religious leader be with the patient during the time of death. Furthermore, it is customary that the family spokesperson is the one who initially receives the report of death. The family of the deceased may desire to kiss and make physical contact with the body after the passing. After they are given intimate time with the deceased, a private space should be made available in order for the family to express their bereavement. Additionally, PR Americans usually are in support of organ donation, however, only certain family members (the spokesperson) should be the individual who makes and verbalizes this decision on behalf of the patient. In the PR community, autopsies are frowned upon as they are viewed as a violation of the body.

• Understanding death rituals is important in the nursing practice as nurses must be aware and remain sensitive to the patient’s wishes, the family and customs which are routinely followed during this time. 

•  Puerto Ricans face more danger of poor health outcomes than any other Hispanic subgroup, however, limited studies have been conducted on this topic. As the population and service consumption escalates, nurses should be able to adapt and develop unique programs to advocate for this vulnerable community. 

• It is essential for the nurse to realize how pivotal communication is in providing optimal culturally competent care. A nurse must understand that the Spanish spoken by Puerto Ricans might vary considerably from the Spanish spoken by persons from other Hispanic cultures. Additionally, tone of voice is important for the nurse to recognize because Puerto Ricans characteristically exhibit a melodic and peaceable tone, and could misconstrue the nurse’s use of high pitch and voice inflection as aggressive.

• As a sign of respect, many Puerto Ricans avoid eye contact when greeting elderly. Furthermore, there is a negative correlation with the lack of ability to speak English, and its connection to lack of adequate treatment of Puerto Ricans in the United States. Yet, the nurse should be aware that even with the assistance of a translator, vital messages may fail to be translated accurately and may result in poor outcomes. 

• The nurse must also be cognizant that Puerto Ricans have a great desire for family support and that many medical decisions are made collectively by the patient and their family. Finding a way to incorporate the entire family while respecting the desires of the patient can be challenging, therefore, nurses have to familiarize themselves with patient rights.

• Puerto Ricans primarily pursue alternate forms of care when disease is exhibited with only 9% of parents choosing a physician first. Religion plays a significant role in the treatment options for Puerto Ricans. According to Giger (2018), Many Puerto Rican Americans are Catholic and believe in Santeria, a belief that originated among the Yoruba people in Nigeria and was brought to PR via slaves.” This belief helped to birth other untraditional treatment options such as hot and cold treatment concepts, and amulets worn to provide healing. It of benefit to the nurse to grasp these concepts in order to provide the best care. 

• Nursing institutions and organizations should incorporate cultural education programs, and enforce continuing education classes that highlight culture.

•  Nurses should gain the knowledge of cultural differences by way of mandatory classes, in efforts to understand communication, treatment, and dietary prefernces of the Puerto Rican (PR) culture. 

• Health systems should actively facilitate culture change that elevates healthcare in education and practice.

•  It is valuable to offer health promotion and give explanation on how health prevention activities foster future health. 

• Essentially, nurses who plan to provide care and practice in Puerto Rico should undergo disaster training to efficiently deliver care to Puerto Rican Americans. 

• Nurses must be able to retain the knowledge learned from Puerto Rican culture and apply it into practice to deliver efficient treatment. 

         In the 1400s, this land was occupied by approximately 50,000 Taino Indians and they called their land Boriken or Borinquen which stands for “the great land of the valiant and noble Lord” or “land of the great lords.”  In 1493, Christopher Columbus arrived and claimed the land for Spain. During that time, the Taino Indians lived in small villages, grouped by clans and led by a single chief. The tribe lived off of tropical based crops; sweet potatoes, pineapples, cassava and seafood. The Taino welcomed the first group of colonizers with gold nuggets they picked by hand from the river. The seaside port that welcomed the colonizers was named San Juan and is still the capital today. San Juan was the most important seaside post for Spain’s military and they defended it massive fort on the harbor. Throughout the centuries, Spain fought off conquest attempts from the French, Dutch, and British.  Nonetheless, it was the Treaty of Paris, which was signed in 1898 after the Spanish-American War, that ceded Puerto Rico to the US. Puerto Rico gained its citizenship in 1917.  Presently, the people of Puerto Rico are undecided as to whether they want to become a state of U.S. or remain a commonwealth status. This is a major political conflict for the citizens of Puerto Rico that has been going on for decades.  

·  Religious Practice: Catholic and Protestant

·   Family structure: Family is the foundation of the Puerto Rico social structure. Honor is the most importance within family and not induvial achievement. The basic support of an individual is the first and second generation within family (aunt, uncle, cousins, grandparents, close friends and god parents.)

·  Location of living: Most individuals are living in the coastal regions of Puerto Rico

·  Education level:  It is common for individuals to graduate from High school with 70% of those who attend and less than 25% proceed to gain college education. Puerto Rico education system is closed related to the US system starting at age 6 and processing through primary, middle and high school. 

·   Types of jobs they occupy:  Major industries are pharmaceuticals, electronic manufactures, apparel and tourism. 

· Education (early childhood and development, language and literacy and high school graduation),

· Social and community (discrimination, incarceration and civic participation), 

· Health and health care (access to health care, access to insurance, and health literacy)

· Neighborhood and built environment (access to healthy foods, crime and violence, quality of housing)

This framework can help Healthcare providers develop tools and strategies that can improve health of all and close health gaps within the communities.