Transcultura l Nursing

INTRODUCTION

Transcultural nursing with established clinical approached to clients with varying cultures are
relatively new.

According to Madeleine Leininger (1987) founder of the filed of transcultural nursing in the mid
1960s. The education of nursing students in this field is only now beginning to yield significant
results.

Today nurses with a deeper appreciation of human life and values are developing cultural
sensitivity for appropriate individualized clinical approaches.

Religious and Cultural knowledge is an important ingredient in health care. If the client do not
respond as nurse expects the nurse may interpret it as unconcern or resistance the nurse then can
be anxious and frustrated in order to incorporate cultural knowledge in care cultural knowledge in
care.

It is important to understand some definition and cultural components that are important in health
care.

For a nurse to successfully provide care for a client of a different cultural or ethnic to background,
effective intercultural communication must take place. Intercultural communication occurs when
each person attempts to understand the others point of view from his or her own cultural frame
of reference. Effective intercultural communication is facilitated by the nurse identification of
areas of commonalities. After reaching a cultural. understanding, the nurse must consider cultural
factor throughout the nursing process.

Major Nursing organizations have emphasized in the last decade the importance of considering
culture factors when delivering nursing care.

According to the American Nurses s Association (1976) Consideration of individual value

systems and lifestyles should be included in the planning and health care for each client Nursing
curriculum recognize the contribution nursing to the health care needs of a diverse and multi
cultural society life-style may ret1ect cultural heritage.

DEFINITIONS
Culture

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 ones 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

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.

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.

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).

Recognize that the more disparate the differences are between the biomedical model and the
lay/popular explanatory models, the greater the potential for, on to encounter resistance to
Western HPDP programs.

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

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 selfcare 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 clients 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.
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 clients 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 magicalpowers,
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 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 traditionalapproach 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 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;
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 belief that effect 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

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 clients 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 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.
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).