Transcultural Nursing

A humanistic and scientific area of formal study and practice in nursing

which is focused upon differences and similarities among cultures with
respect to human care, health, and illness based upon the people's cultural
values, beliefs, and practices, and to use this knowledge to provide cultural
specific or culturally congruent nursing care to people ... Leininger

KEYPOINTS

• According to Madeleine Leininger communication must take place.

(1987) founder of the field of Intercultural communication occurs
transcultural nursing in the mid when each person attempts to
1960s. The education of nursing understand the other’s point of
students in this field is only now view from his or her own cultural
beginning to yield significant frame of reference. Effective
results. intercultural communication is
• Today, nurses with a deeper facilitated by the nurse
appreciation of human life and identification of areas of
values are developing cultural commonalities. After reaching a
sensitivity for appropriate cultural. understanding, the nurse
individualized clinical approaches. must consider cultural factor
• Religious and Cultural knowledge is throughout the nursing
an important ingredient in health process.
care. If the client do not respond as • Major Nursing organizations have
nurse expects the nurse may emphasized in the last decade the
interpret it as unconcern or importance of considering culture
resistance the nurse then can be factors when delivering nursing
anxious and frustrated in order to care.
incorporate cultural knowledge in • According to the American Nurses’
care cultural knowledge in care. s Association (1976) ”Consideration
• It is important to understand some of individual value systems and
definition and cultural components lifestyles should be included in the
that are important in health care. planning and health care for each
• For a nurse to successfully provide client Nursing curriculum recognize
care for a client of a different the contribution nursing to the
cultural or ethnic to background, health care needs of a diverse and
effective intercultural multi cultural society life-style may
ret1ect cultural heritage.

DEFINITIONS

Culture

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 • Broadly defines set of values, beliefs and traditions, that are held by a specific group
of people and handed down from generation to generation. Culture is also beliefs,
habits, likes, dislikes, customs and rituals learn from one’s family. (Specter 1991).
• Culture is the learned, shared and transmitted values, beliefs, norms and life way
practices of a particular group that guide thinking, decisions, and actions in patterned
ways.

Religion:

• Is a set of belief in a divine or super human power (or powers) to be obeyed and
worshipped as the creator and ruler of the universe? Ethical values and religion
system of beliefs and practices, difference within the culture and across culture are
found

Ethnic

• refers to a group of people who share a common and distinctive culture and who are
members of a specific group.

Ethnicity

• a consciousness of belonging to a group.

Cultural Identify

• the sense of being part of an ethnic group or culture

Culture-universals

• commonalities of values, norms of behavior, and life patterns that are similar among
different cultures.

Culture-specifies

• values, beliefs, and patterns of behavior that tend to be unique to a designate

culture.

Material culture

• refers to objects (dress, art, religious arti1acts)

Non-material culture

• refers to beliefs customs, languages, social institutions. Subculture: -composed of

people who have a distinct identity but are related to a larger cultural group.

Bicultural

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 • a person who crosses two cultures, lifestyles, and sets of values.

Diversity

• refers to the fact or state of being different. Diversity can occur between cultures and
within a cultural group.

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Acculturation

• individuals who have taken on, usually observable, features of another culture.
People of a minority group tend to assume the attitudes, values, beliefs, find
practices of the dominant society resulting in a blended cultural pattern.

Cultural shock

• the state of being disoriented or unable to respond to a different cultural

environment because of its sudden strangeness, unfamiliarity, and incompatibility to
the stranger's perceptions and expectations at is differentiated from others by
symbolic markers (cultures, biology, territory, religion).

Ethnic groups

• share a common social and cultural heritage that is passed on to successive

generations.,

Ethnic identity

• refers to a subjective perspective of the person's heritage and to a sense of

belonging to a group that is distinguishable from other groups.

Race

• the classification of people according to shared biologic characteristics, genetic

markers, or features. Not all people of the same race have the same culture.

TRADITIONAL CONCEPTS OF HEALTH AND DISEASE

When viewed across a variety of multicultural groups, explanations for health and disease
that characterized, many traditional beliefs about disease causation, treatment, and general
health practices can be seen as highly complex, dynamic, and interactive. These
explanations often involve family, community, and/or supernatural agents in cause and
effect, placation, and treatment rituals to prevent, control, or cure illness. A failure to
understand and appreciate these "differences" can have serious implications for the success
of any Health Promotion and Disease Prevention (HPDP) effort.

• Be aware that the health concepts held by many cultural, groups may result in
people choosing not to seek Western medical treatment procedures because they do
not view the illness or disease as coming from within themselves
• Be aware that in many Eastern cultures and other cultures in the developing world,
the locus of control for disease causality often is centered outside the individual,
whereas in Western cultures, the locus of control tends to be more internally oriented
(Dim-out, 1995).
• Recognize that individuals from other cultures might not follow through with health-
promoting or treatment recommendations because they perceive the medical or
other health- promoting encounter as a negative or perhaps even hostile experience.

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 • Acknowledge that many individual patients and health care practitioners have
specific notions about health and disease causality and treatment called explanatory
models. These models are generally a conglomeration of the respective cultural and
social training, beliefs, and values; the personal beliefs, values, and behaviors-, and
the understanding of biomedical concepts that each group holds (Klein man, 1980).
• Be aware of the need to be flexible in the design of programs, policies, and services
to meet the needs and concerns of the culturally diverse population, groups that are
likely to be encountered.

Traditional Concepts of Illness Causality

• Be aware that folk illnesses are generally learned syndromes that individuals from
particular cultural groups claim to have and from which their culture defines the
etiology, behaviors, diagnostic procedures, prevention methods, and traditional
healing or curing practices.
• Remember that most cases of lay illness have multiple causalities and may require
several different approaches to diagnosis, treatment, and cure including folk and
Western medical interventions
• Recognize that folk illnesses, which are perceived to arise from a variety of causes,
often require the services of a folk healer who may be a local corianders, shaman,
native healer, spiritualist, root doctor, or other specialized healer.
• Recognize that the use of traditional or alternate models of health care delivery is
widely varied and may come into conflict with Western models of health care
practice.

Understanding these differences may help us to be more sensitive to the special beliefs and
practices of multicultural target groups when planning a program. Culture guides behavior
into acceptable ways for the people in a specific group as such culture originates and
develops within the social structure through inter personal interactions.

CONCEPT OF CULTURE

Culture is learned by each

generation through both formal
and informal life experiences.
Language is primary through
means of transmitting culture. The
practices of particular culture often
arise because of the group's social
and physical environment. Culture
practice and beliefs are adapted
over time but they mainly remain
constant as long as they satisfy
needs.

Cultural awareness

It is an in-depth self-examination
of one's own background,
recognizing biases and prejudices
and assumptions about other
people
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PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR HEALTH CARE PERSONNEL

Cultural background affect a person's health in all dimensions, so the nurse should consider
the client's cultural background when planning care. Although basic human needs are the
same for all people, the way a person seeks to meet those needs is influenced by culture.

• To heighten awareness of ways in which their own faith system. Provides resources
for encounters with illness, suffering and death.
• To foster understanding, respect and appreciation for the individuality and diversity
of patients beliefs, values, spirituality and culture regarding illness, its meaning,
cause, treatment, and outcome.
• To strengthen in their commitment to relationship-centered medicine that
emphasizes care of the suffering person rather than attention simply more to the
pathophysiology of disease, and recognizes the physician as a dynamic component of
that relationship.
• To facilitate in recognizing the role of the hospital chaplain and the patient's clergy as
partners in the health care team in providing care for the patient.
• To encourage in developing and maintaining a program of physical, emotional and
spiritual self-care introduce therapies from the East, such as ayurveda and pancha
karma

Leininger (1991,2002a) has defined transcultural nursing as a comparative study of cultures

to understand similarities (culture universal) and difference (culture-specific) across human
groups

Culturally congruent care

Care that fits the people's valued life patterns and set of meanings -which is generated from
the people themselves, rather than based on predetermined criteria. Discovering client's
culture care values, meanings, beliefs and practices as they relate to nursing and health
care requires nurses to assumes the roles of learners of client’s culture and copartners with
client's and families in defining the characteristics of meaningful and beneficial care.
(Leininger,2002

Culturally competent care is the ability of the practitioner to bridge cultural gaps in
caring, work with cultural differences and enable clients and families to achieve meaningful
and supportive caring. Culturally competent care requires specific knowledge, skills, and
attitudes in the delivery of culturally congruent care and awareness.

Pacquiato (2003) identifies three distinct levels of cultural competence at the practitioner,
organizational and social levels.

Nursing Decisions

Leininger (1991) identified three nursing decision and action modes to achieve culturally
congruent care. All three modes of professional decisions and actions are aimed to assist,
support, facilitate, or enable people of particular cultures. The three modes for congruent
care, decisions, and actions proposed in the theory are predicted to lead to health and well
being, or to face illness and death.

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1. Cultural preservation or maintenance: Retain and or preserve relevant care values
so that clients can maintain their well-being, recover from illness, or face handicaps and/or
death .

2.Cultural care accommodation or negotiation- Adapt or negotiate with the others for a
beneficial or satisfying health outcome

3. Cultural care repatterning or restructuring : Records, change, or greatly modify

client’s life ways for a new, different and beneficial health care pattern

PURPOSE AND GOAL OF THE THEORY

• The central purpose of the theory is to discover and explain diverse and universal
culturally based care factors influencing the health, well-being, illness, or death of
individuals or groups.
• The purpose and goal of the theory is to use research findings to provide culturally
congruent, safe, and meaningful care to clients of diverse or similar cultures.

Status of Traditional Practices

Many traditional practices are used to prevent and a redemptive practice used to prevent
illness and harm treat illness, including objects and substances and religious practices.
(Morgenstern, 1966)

USE OF PROTECTIVE OBJECTS

Protective objects can be worn or carried or hung in the home. Amulets are objects with
magical powers, for all walks of life and cultural and ethnic backgrounds is example, charms
worn on a string or chain around the neck, wrist, or waist to protect the wearer from the evil
eye or evil spirits. Amulets exist in societies all over the world and are associated with
protection from trouble (Budge, 1978)

USE OF SUBSTANCES

Substances are ingested in certain ways or amounts regimen, an effort must be made to
determine if they are worn or hung in the home. This practice uses diet and consists of many
different observances. It is believed that the body is kept in balance or harmony by the type
of food eaten so many food taboos and combinations exist in traditional belief systems. For
example, it is believed that some food substances can be ingested to prevent illness. People
from many ethnic backgrounds eat raw garlic or onion In an effort to prevent illness or wear
them on' the body or hang them in the home.

Jews also believe that milk and meat must never be mixed or eaten at the same meal
(Steinberg, 1947) mind, and spirit, or the restoration of holistic health

RELIGIOUS PRACTICES

Another traditional approach to illness prevention female centers around religion and
includes practices such as from a divine source the burning of candles, rituals of redemption,
and In many instances a heritage consistent person may prayer. Religion strongly affects the

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way people attempt to prevent illness, and it plays a strong role in rituals associated with
health protection. Religion dictates social, moral, and dietary practices designed to keep a
traditional healer (Kaptchuk and Croucherl987)

Traditional Remedies

The admitted use of folk or traditional medicine increasing, and the practice is seen among
people from all walks of life and cultural ethnic back ground Use of folk medicine is not a
new practice among heritage consistent people, so many of the remedies have been used
and passed on for generations. The pharmaceutical, must be made to determine properties
of vegetation-plants, roots, tested stems, flowers, seeds, and herbs-have been studied
tested, cataloged, and used for countless centuries. Many of these plants are used by
specific communities. Others cross ethnic and community lines and are used in certain
Geographic areas in the person's country of origin.

When patients -do not adhere to a pharmacological regimen an effort must be made to
determine the remedy if they are taking traditional remedies. Frequently, the active
ingredients of traditional remedies are unknown. If a client is believed to be, taking them an
effort must be made to determine the remedy as well as its active in gradients Often, these
ingredients can be antagonistic or synergistic to prescribed medications. Over dose may
occur.

Healer's

In the traditional context, healing is the restoration of the person to a state of harmony
between the body, Within a given community, specific people are known to have the power
to heal. The healer may be male or and is thought to have received the gift of healing In
many instances a heritage consistent person may consult a traditional healer before, instead
of, or in conjunction with a modern health care provider. Many differences exist between
the Western physician and the Eastern A broad range of health and illness beliefs exist many
of these beliefs have roots in the culture, ethnic, religious, or social back ground .of a person
family, or community. 'When people anticipate fear or experience an illness or crisis, they
may use a modern or traditional approach toward prevention and healing.

These approach may originate in culture, ethnicity or religion. These beliefs and practices
may be internal or personal and person may be able to define or describe them. However,
they may be due to external social forces not within the person's control Examples of
external social forces include communication barriers, such as language differences, or
economic barriers causing limited access or lack of access to modem, health care facilities.

IMMIGRATION

Every immigrant group has its own cultural attitudes ranging beliefs and practices regarding
these areas Health and illness can be interpreted in terms of personal experience and
expectations. There are countless ways to explain health and illness, and people base their
responses on cultural, religious, and ethnic back ground. The responses are culture specific,
based on a client's experience and perception.

Gender Roles

In many cultures, the male is dominant figure. In cultures where this is time, males make
decisions for other family members well as for themselves. For example, no matter which
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family member is involved cultures where the male dominate. The female usually is passive.
In African -American families, however as well as in many Caucasian families, the female
often is dominant Knowledge of the dominant member of the family is important
consideration in planning Nursing care folk illnesses, which are perceived to arise from a
variety of causes, often require the services of a folk healer who may be a local curandero,
shaman, native healer, spiritualist, root doctor, or other specialized healer. Recognize that
the use of traditional or alternate models of health care deliveries widely varied and may
come into conflict with Western models of health care practice. Understanding these
differences may help you to be more sensitive to the special beliefs and practices of
multicultural target groups when planning a program.

ILLNESS CAUSE AND PREVENTION RELATED TO FOOD

Several factors cause illness. A hot-cold imbalance, for example, is primarily caused by
improper diet. Food substances are classified as hot or cold with and without regard to their
actual temperature. This classification can vary from person to person, but essentially,
certain foods are known to be hot, and others are known to be cold. Examples of cold food
are, honey, avocados, bananas, and lima beans. Examples of hot foods-are chocolate,
coffee, com meal, garlic, kidney beans, onions, and peas. Illness can occur if these foods are
eaten in improper combinations or amounts. .

Traditional beliefs about mental health

In the traditional belief system, mental illnesses are caused by a lack of harmony of
emotions or, sometimes, by evil spirits. Mental wellness occurs when psychological and
physiologic functions are integrated. Some elderly Asian Americans share the Buddhist belief
that problems in this life are most likely related to transgressions committed in a past life. In
addition our previous life and our future life are as much a part of the life cycle.

ECONOMIC BARRIERS

Several economic barriers, such as unemployment, underemployment, homelessness, lack

of health insurance poverty prevent people from entering the health care system. Poverty is
by far the most critical factor. Poverty a relative term and changes from time and place. In
the United States, poverty is pervasive and found extensively among people in certain
norms geographical areas, such as rural populations, the elderly migrant workers, and illegal
aliens. Poor health, crippling diseases, drug and alcohol abuse, poor education; and inferior
are contributing social causes of poverty.

Several programs, both governmental and private, aid people with short- and long-tem
problems. It is important for the nurse to be aware clients needs and financial resources
available in the local community.

Time orientation

It is varies for different cultures groups. A client may be late for an appointment not because
of reluctance or lack of respect for the nurse but because he is less concerned about
planning ahead to be on time than with the activity in which he is currently engaged.

PERSONAL SPACE AND TERRITORIALITY;

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Personal space involves a person's set of behaviors and attitudes toward the space around
himself. Staff members and other clients frequently encroach on a client's territory in the
hospital, which includes his room, bed, closet, and belongings. The nurse should try, to
respect the client's territory as much as possible, especially when performing nursing
procedures. The nurse should also welcome visiting members of the family and extended
family. This can remind the client of home, lessening the effects of isolation and shock from
hospitalization.

SOCIOCULTURAL FACTORS AND THE NURSING PROCESS

Religious beliefs that affect the care Nursing;

• Belief about birth &death.

• Belief about diet and food practices.
• Belief regarding medical care

ROLE OF NURSE

The nurse should begin the assessment by attempting to determine the client's cultural
heritage and language skills. The client should be asked if any of his health beliefs relate to
the cause of the illness or to the problem. The nurse should then determine what, if any,
home remedies the person is taking to treat the symptoms

Nurses should evaluate their attitudes toward ethnic nursing care. Some nurses may believe
they should treat all clients the same and simply act naturally, but this attitude fails to
acknowledge that cultural differences do exist and that there is no one "natural" human
behavior The nurse cannot act the same with all clients and still hope to deliver effective,
individualized ,holistic care.

Sometimes, inexperienced nurses are so self-conscious about cultural differences and so

afraid of making a mistake that they impede the nursing process by not asking questions
about areas of difference or by asking so many questions that they seem to try into the
client' personal life.

The process of self-evaluation can help the nurse become more comfortable when providing
care to clients from diverse backgrounds

Culture is the sum total of mores traditions & beliefs about how people function
encompasses others products of human works & thoughts. Specific to member of an
intergenerational group, community or population.

• Nurses have a responsibility to understand the influence of culture, race &ethnicity

on the development of social emotional relationship child rearing practices &attitude
toward health.
• A child's self concepts evolves from ideas about his or her social roles
• Primary groups are characterized by intimate contact mutual support and pressure
for conformity.
• Important sub culture influences on children include ethnicity social class, occupation
school peers and mass culture
• Socioeconomic influences play major role in ability to seek opportunity for health
promotion for wellness
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 • Religious practices greatly influences health promotion belief in families.
• Many ethnic and cultural groups in country retain the cultural heritage of their
original culture.

• How culture influences behaviors, attitudes, and values depends on many factors and
thus is not the same for different members of a cultural group.
• Ethnocentrism can impede the delivery of care to ethnic minority clients and, when
pervasive, can become cultural racism.
• Stereotyping ethnic group members can lead to mistaken assumptions about a client.
• The nurse should have an understanding of the general characteristics of the major
ethnic groups, but should always individualize care rather than generalize about all
clients in these groups.
• Before assessing the cultural background of a client, nurses should assess how they
are influenced by their own culture.
• The nursing diagnosis for clients should include potential problems in their interaction
with the health care system and problems involving the effects of culture.
• The planning and implementation of nursing interventions should be adapted as
much as possible to the client's cultural background.
• Evaluation should include the nurse's self-evaluation of attitudes and emotions
toward providing nursing care to clients from diverse sociocultural backgrounds.

When nurses provide care to clients from a background other than their own, they must be
aware of and sensitive to the clients' sociocultural background, assess and listen carefully to
health and illness beliefs and practices, and respect and not challenge cultural, ethnic, or
religious values and health care beliefs. The nursing process enables the nurse to provide
individualized care

The nurse should begin the assessment by attempting to determine the client's cultural
heritage and language skills. The client should be asked if any of his health beliefs relate to
the cause of the illness or to the problem. The nurse should then determine what, if any,
home remedies the person is taking to treat the symptoms

Assessment enables the nurse to cluster relevant data and develop actual or potential
nursing diagnoses related to the cultural or ethnic need of the client. In addition the nursing
diagnosis should state the probable cause .The identification of the cause of the problem
further individualizes the nursing care plan and encourages selection of appropriate
interventions-cultural variables as they relate to the client. The extended family should be
involved in the care the Client's strongest support group. Cultural beliefs and practices can
be in-corporate into therapy.

• The client’s the nursing process; educational level and language skills should be
considered when planning teaching activities.
• Explanations of and practices into nursing therapies; aspects of care usually not
questioned by acculturated clients may be required for non-English speaking or non-
acculturated clients to avoid confusion, misunderstanding, or cultural conflict.
• The nurse may have to alter her usual ways of interacting with clients to avoid offend
ignore alienating a client with different attitudes toward social interaction and
etiquette. A client who is modest and self-conscious about the body may need
psychological preparation before some procedures and tests.
• The nurse can find out what care the client considers appropriate by involving him
and his family in planning care and asking about their expectations. This should be
done in every case, even if the nursing care cannot be modified. Because both the
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 nurse and the client are likely to take many aspects of their cultures for granted,
questions should be clear and explanations should be explicit.
• Discussing cultural questions related to care with the client and family during the
planning stage helps the nurse understand how cultural variables are related to the
client's health beliefs and practices, so that interventions can be individualized for
the client.
• The nurse evaluates the results of nursing care for ethnic clients as for all clients,
determining the extent to which the goals of care have been met.

Evaluation continues throughout the nursing process and should include feedback from the
client and family. With an ethnic minority client, however, self-evaluation by the nurse is
crucial as he or she increases skills for interaction. The nurse should consider questions such
as the following: .

CONCLUSION

Nurses need to be aware of and sensitive to the cultural needs of clients. The body of
knowledge relevant to this sensitive area is growing, and it is imperative that nurses from all
cultural backgrounds be aware of nursing implications in this area. The practice of nursing
today demands that the nurse identify and meet the cultural needs of diverse groups,
understand the social and cultural reality of the client, family, and community, develop
expertise to implement culturally acceptable strategies to provide nursing care, and identify
and use resources acceptable to the client (Boyle, 1987).

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