TRANSCULTURAL NURSING

INTRODUCTION Nurses need to understand how culture affects behavior and what functions it serves, because nurses are accountable for observing and assessing clients response, which are influenced by culture. Theories of transcultural nursing with established approaches to patients from varying cultures are relatively new. According to Madeline Leininger(1987), the education of nursing students in the area of transcultural nursing, which began in the mid-1960s, is only now beginning to yield significant results. Today, nurses with different cultural insights and a deeper appreciation of human life and values are developing sensitivity for culturally appropriate, individualized clinical approaches as a result of the introduction of transcultural concepts into nursing curriculum.

Definition of major terms related to transcultural nursing 1. Transcultural nursing

Leininger defined transcultural nursing as a formal area of study and practice focused on comparative human care differences and similarities of the beliefs, values and patterned life ways of cultures to provide culturally congruent, meaningful and beneficial health care to people. Transcultural nursing is a comparative study of cultures to understand similarities (culture universal) and difference (culture-specific) across human groups. (Leininger, 1991)

2. Culture Culture refers to learned, shared, and transmitted values, beliefs, norms, and lifeways of a specific individual or group that guide their thinking, decisions, actions, and patterned ways of living.

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

4. Ethnicity It is a consciousness of belonging to a group. 5. Cultural Identify It is the sense of being part of an ethnic group or culture 6. Culture care The subjectively and objectively learned and transmitted values, beliefs and patterned life ways that assist, support, facilitate or enable another individual or group to maintain their wellbeing and health, to improve their human condition and lifeway, and to deal with illness, handicaps, or death. 7. Culture care universality Common, similar or dominant uniform care meanings, patterns, values, life ways or symbols that are manifested among many cultures and reflect assistive, supportive, facilitative or enabling ways to help people. 8. Culture care diversity The variabilities and/or differences in meanings, patterns, values, life ways or symbols of care within or between collectives that are related to assistive, supportive or enabling human care expressions. 9. Material culture It refers to objects such as dress, arts that are specific to a culture

10. Non-material culture It refers to beliefs customs, languages, and social institutions of a particular culture 11. Subculture Subculture is composed of people who have a distinct identity but are related to a larger cultural group. 12. Bicultural When a person who crosses two cultures, lifestyles, and sets of values. 13. Acculturation It is the process by which an individual or group from culture A learns how to take on many or the behaviors, values, and lifeways or culture B. That is people of a minority group tend to assume the attitudes, values, beliefs, find practices of the dominant society resulting in a blended cultural pattern. 14. Cultural shock It may result when an outsider attempts to comprehend or adapt effectively to a different cultural group. The outsider is likely to experience feelings of discomfort and helplessness and some degree of disorientation because of the differences in cultural values, beliefs, and practices. Culture shock may lead to anger and can be reduced by seeking knowledge of the culture before encountering that culture. 15. Cultural imposition Refers to efforts of the outsider, both subtle and not so subtle, to impose his or her own cultural values, beliefs, behaviors upon an individual, family, or group from another culture. 16. Cultural awareness It is an in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people.

17. Culturally congruent care Refers to those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are made to fit with individual, group, or institutions cultural values, beliefs and lifeways to provide meaningful health care service. 18. 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.

Nursing Decisions
Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. 1. Cultural preservation or maintenance:- refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people or a particular culture to retain and preserve relevant care values so that they can maintain their wellbeing, recover from illness, or face handicaps or death 2. Cultural care accommodation or negotiation:- refers to those assistive, supportive, facilitative or enabling creative professional actions and decisions that help people of a designated culture to adapt or to negotiate with others for a beneficial or satisfying health outcome with professional care providers 3. Cultural care repatterning or restructuring:- refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help clients reorder, change, or greatly modify their life ways for new, different and beneficial health care patterns while respecting the clients cultural values and beliefs.

MAJOR CONCEPTS
 Illness and wellness are shaped by a various factors including perception and coping skills, as well as the social level of the patient.  Cultural competence is an important component of nursing.  Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress.  Religious and Cultural knowledge is an important ingredient in health care.  Health care provider 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.  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.  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.  For a nurse to successfully provide care for a client of a different cultural or ethnic to background, effective intercultural communication must take place.

Need of cultural knowledge for nurses

 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 such as Ayurveda and pancha karma.

HEALTH PRACTICES IN DIFFERENT CULTURES

Use of Protective Objects Protective objects can be worn or carried or hung in the home- charms worn on a string or chain around the neck, wrist, or waist to protect the wearer from the evil eye or evil spirits.

Use of Substances . 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.

Religious Practices Practices such as from a divine source the burning of candles, rituals of redemption, and in many instances a heritage consistent person may prayer.

Traditional Remedies The use of folk or traditional medicine is seen among people from all walks of life and cultural ethnic back ground. Many plants are used by specific communities.

Healers Within a given community, specific people are known to have the power to heal. These approaches may originate in culture, ethnicity or religion.

Gender Roles In many cultures, the male is dominant figure and often they take decisions. The female usually is passive. In some other cultures females are dominant.

Beliefs about mental health In the traditional belief system, mental illnesses are caused by a lack of harmony of emotions or by evil spirits.Another belief that problems in this life are most likely related to transgressions committed in a past life.

Economic Factors Factors such as unemployment, underemployment, homelessness, lack of health insurance poverty prevent people from entering the health care system.

Time orientation It is varies for different cultures groups.People from different cultures have their own time management plans. Personal Space The nurse should try, to respect the client's personal space as much as possible, especially when performing nursing procedures. The nurse should also welcome visiting members of the family and extended family.

LENINGERS SUNRISE MODEL

A better way of understanding the factors that influence a person s perception of well-being is the sunrise enabler of Madeleine Leininger. Leininger s model of cultural care can be viewed as a rising sun. When using this model, the nurse can begin anywhere depending on the focus of nursing assessment. The model reflects influences of one s worldview on cultural and structure dimensions. The cultural and social structure dimensions include technological, religious, philosophic, kinship, social, value and lifeway, political, legal, economic, and educational factors. Each of these identified systems affects health. These cultural and social structure dimensions in turn influences environment and language, wherein emphasis should be placed since this is where the patient/client find themselves such as home conditions, access to particular types of food and family access to transport. Environment and language influence the involved health systems the folk, professional and nursing systems. The folk health system includes the traditional beliefs and practices on health care while the professional

health systems are those practices we learned cognitively through formal professional schools of learning. The combination of the folk health system and the professional health system meets the biological, psychosocial, and cultural health needs of the patient/client. These factors influence the patterns and expressions of caring in relation to the health of individuals, families, groups, and communities. To be able to make sound nursing care decisions and actions, these factors should be assessed properly and always be taken into consideration. To achieve culture congruent care, nursing actions are to be planned in one of three modes: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring.

Application of sunrise model First contact with the client

Phase I Record observations of what you see, hear, or experience with clients( includes dress and appearance, body condition features, language, mannerisms and general behavior, attitudes, and cultural features).

Phase II Listen to and learn from the client about cultural values, beliefs, and daily (nightly) practices related to care and health in the clients environmental context. Give attention to generic (home or folk) practices and professional nursing practices PhaseIII

Identify and document recurrent client patterns and narratives (stories) with client meanings of what has been seen, heard or experienced.

Phase IV Synthesize themes and patterns of care derived from the information obtained in phases I, II, III.

Phase V Develop a culturally based client- nurse care plan as a coparticipant for decisions and actions for cultural congruent care.

TRANSCULTURAL ASSESSMENT MODEL In a society nurse practitioners need to be prepared to work with all patients regardless of cultural background and to provide culturally appropriate nursing care for each patient. To provide culturally appropriate nursing care, nurse must understand specific factors that influence individual health and illness behaviors culturally diverse nursing care must take into account six cultural phenomena that vary with application and use, yet are evidenced among all cultural groups:1. 2. 3. 4. 5. Communication. Space. Social organization. Time. Environmental control.

6.

Biological variations

I.

COMMUNICATION

The word communication comes from the latin verb communicare which means : to make common, share, participate, or impart . Communication, however goes further than this definition implies and embraces the entire realm of human interaction and behavior. All behavior, whether verbal or nonverbal, in the presence of another individual in communication (Potter & Perry). VERBAL AND NONVERBAL COMMUNICATION Another way to conceptualize communication is in terms of verbal and nonverbal behavior:LANGUAGE OR VERRBAL COMMUNICATION 1. 2. 3. 4. 5. 6. 7. 8. Vocabulary Grammatical structure Voice qualities Intonations Rhythm Speed Pronunciation Silence

NONVERBAL COMMUNICATION

1. 2. 3. 4.

Touch Facial expressions Eye movement Body posture

COMMUNICATION THAT COMBINE VERBAL AND NONVERBAL ELEMENTS 1. 2. Warmth Humor

VOCABULARY Even though people may speak the same language, establishing communication is often difficult, since word meanings for both the sender and the receiver vary based on past experiences and learning. Words have both denotative and conative meanings. A denotative meaning is one that is in general use by most persons who share a common language. A connotative meaning usually arises from a person s personal experience. For example, while all Americans are likely to share the same general denotative meaning for the word pig, depending on the occupation and cultural perception of the person, the connotation may be entirely different and may precipitate completely different reactions. The word pig will invoke negative or positive reactions from certain people based on occupation and culture. For example, an orthodox Jew s reactions will differ from those of a pig farmer. For an orthodox Jew the word pig is synonymous with the word unclean or un holy and thus should be avoided. On the other hand, for a pig farmer the word pig implies a clean, wholesome means of making a living.

GRAMMATICAL STRUCTURE

Cultural differences are reflected in grammatical structure and the use and meaning of phrases. Length of sentence and speech forms may vary not only with cultures, but also with social class. For example, persons from the lower class commonly use short, simple sentences and are more direct than are persons with more education. Words choice, grammatical structure, speech fluency and articulation provide cues to social status and class. Jargon is also a speech variation that may prove to be a barrier to communication. Nurses frequently have difficulty expressing things in simple jargon free language (without medical terms) that patients can understand.

VOICE QUALITIES Paralinguistic, or paralanguage, refers to something beyond the words themselves. Voice quality, which includes pitch and range, can add an important element to communication.

INTONATIONS Intonation is an important aspect of the communication message. When people say they feel fine , this may mean they genuinely do, or they do not feel fine but do not wish to discuss it. If said sarcastically, it may also feel just opposite of fine. There is often a latent or sudden meaning in what a person is saying, and intonation frequently provides the clue that is needed to interpret the true message.

RHYTHM

Rhythm also varies from culture to culture. Some people have a melodic rhythm to their verbal communication, whereas others appear to lack rhythm. Rhythm may also vary among persons within a culture.

SPEED Rate and volume of speech frequently provide a clue to an individual s mood. A depressed person will tend to talk slowly and quietly, whereas aggressive, dominating person is more apt to talk rapidly and loudly.

PRONOUNCIATION Persons from some culture groups may be identified by their dialect.

SILENCE The meaning of silence varies among various cultural groups. Silence may be thoughtful, or they may be blank and empty when the individual has nothing to say. A silence in a conversation may also indicate stubbornness and resistiveness, or apprehension or discomfort. Persons in some cultural groups value silence and view it as essential to understand a persons need. Therefore when one of these persons is speaking and suddenly stops, what may be implied is that the person wants the nurse to consider the content of what has been said before continuing. Other cultures may use silence in yet other ways. For example, English and Arabic persons use silence for privacy, whereas Russians, French, and Spanish persons may use silence to indicate agreement between parties. Some persons in Asian cultures may view silence as a sign of respect, particularly to an elder.

TOUCH

Touch or tactile sensation, is a powerful form of communication that can be used to bridge distances between name and patient. Touch has many meanings. It can connect people, provide affirmation, be reassuring, decrease loneliness, share warmth, provide stimulation, and increase self-concept. Being touched can be highly valued and sought after. On the other hand, touch can also communicate frustration, anger, aggression and punishment.

FACIAL EXPRESSION Facial expression is commonly used as a guide to a person s feelings. A constant stare with immobile facial muscles indicates coldness. During fear, the eyes open wide, the eye brows raise, and the mouth become tense with lips drawn back. When a person is angry, the eyes become fixed in a hard stare with the upper lids covered and the eye brows drawn down. An angry person s lips are often tightly compressed. Eyes rolled upwards may be related to tiredness or may show disapproval. A direct gaze with raised eye brows shows surprise. Facial expression also varies with culture.

EYE MOVEMENT Eye movement is an important aspect of interpersonal communication. Generally during social interaction, most people look each other in the eye repeatedly but for short periods of time. People use more eye contact while they are listening and may use glances of about 3-10 seconds in length. When glances are longer than this, anxiety is aroused.

BODY POSTURE

Communication is also affected by body posture. A nurse can bridge distance in an interaction by placing the fore arms on the table, palms up.

WARMTH Warmth is a quality or state that promotes feelings of friendship, or pleasure. Warmth can be communicated verbally ( you really lay still during the procedure, and that surely helped in to do it as quickly as possible ) and may also be communicated non verbally, as by a pat on the shoulder or a gentle smile.

HUMOR Humor is a powerful component if verbal and nonverbal communication. Humor can create a bond of shared pleasure between people, can decrease anxiety and tension, can build relationships, can promote problem solving and learning, can provide motivation, and can enable personal survival.

II.

SPACE

Personal space is the area that surrounds a person s body; it includes the space and the objects within the space ( Sommer, 1969 ). An individual s comfort level is related to personal space and discomfort is experienced when personal space is invaded. While personal space is an individual matter and varies with the situation, dimensions of the personal space comfort zone also vary from culture to culture. Generally, in western culture there are 3 primary dimensions of space: the intimate zone (18 inch to 3 feet) and the social or public zone (3-6 feet). The intimate zone may be used for comforting, protection and counseling and is reserved for people who feel close. The personal zone usually is maintained with friends or in some counseling interaction. Touch can occur in the intimate and personal zone. The social zone is usually used when impersonal business is

conducted or with people who are working together sensory involvement and communication are often less intense in the social zone. Wide variations to these general dimensions do occur and are often influenced by cultural background.

III.

SOCIAL ORGANIZATION

Cultural behavior, or how one acts in certain situations, is socially acquired, not genetically inherited. Patterns of cultural behaviors are learned through a process called enculturation( also referred to as socialization), which involves acquiring knowledge and internalizing values. Children learn to behave culturally by watching adults and making inferences about the rules for behavior. Children learn certain beliefs, values, and attitudes about these life events, and the learned behavior that results persists throughout the entire life span unless necessity or forced adaptation compels the learning of different ways. It is important for the nurse to recognize the value of social organizations and their relationship to physiological and psychological growth and maturation.

IV.

TIME

CULTURAL PERCEPTIONS OF TIME Appreciating cultural differences regarding time is important for the nurse in relating to both peers and patients, as is frequently the case in health care settings, there is a great potential for misunderstanding. If nurses are to avoid misreading issues that involve time perceptions, they must have an understanding of how other persons in different cultures view time. Present-oriented individuals do not necessarily adhere strictly to a time structured schedule. Whatever is occurring at a precise moment may be more important for the nurse to avoid labeling such individuals as lazy, disrespectful, or lacking interest. Giger and Davidhizar state that when caring for clients who are present-oriented , it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments. for example, instead of telling the client

to take digoxin every day at 10:00 AM, the nurse might tell the client to take it every day in the morning, or every day after getting out of bed.

V.

ENVIRONMENTAL CONTROL

It refers to the ability of an individual from a particular cultural group to plan activities to coordinate with nature. Environmental control also refers to the individuals perception of his or her ability to control factors in the environment. what a person believes about the causes of illness will affect his or her behavior in preventing and treating illness. These beliefs and practices are important and must be considered when caring for culturally diverse clients. People and their environment have a reciprocal relationship. There is a continuous exchange between individuals and environment.

VI.

BIOLOGICAL VARIATIONS

It is a well-known fact that people differ culturally. Cultural differences are evident in communication, spatial relationships and needs, social organization , time orientation and ability or desire to control the environment. Less recognized and understood are the biological differences that exist among people in various racial groups. So it is very much important for nurses to have a sound knowledge regarding the biological variations in order to give culturally specific care. DIMENSIONS OF BIOLOGICAL VARIATIONS 1. BODY STRUCTURE: In regard to body structure and size, the face is perhaps one of the most fascinating areas of the body because it has many parts that compare to make the whole. The face tense to be the one prominent area that can visibly categorize people by race.

Ears are another fascinating part of the face because, they have a variety of shapes. Earlobes can be free and floppy, or attached close to the face as if the intent were to make sure the lobe stayed in place. Noses come in all sizes and shapes; however, nose size and shape correlate directly with one s racial ancestry. It has been postulated that small noses were an evolutionary result of living in cold climates. On the other hand, noses with high bridges were a result of living in climates developed broad, flat noses such as those found in African and American blacks. Teeth offer another important variation in body size and shape. Tooth size, which is important because the teeth help shape the size of the lower face, varies among racial groups. For example, Australian aborigines have the largest teeth in the world, as well as four extra molars. There is also a tendency among some racial groups, for example, some racial groups do not have 3rd molar or maxillary lateral incisors. Another variation in body size and structure is attributable to muscle size and mass. In certain racial groups specific muscles are absent altogether. The peroneus tertius muscle, which is found in the foot, and the palmarislongus muscle which is found in the wrist are absent in individuals in some racial groups. In general, the conclusions are that people by virtue of race vary in height and muscle mass. In regard to physical growth and development rates, blacks are generally advanced. 2. SKIN COLOR Skin color is probably the most significant biological variation in terms of nursing care. Nursing care delivery is based on accurate patient assessment, and the darker the patient s skin, the more difficult it becomes to assess changes in color. If possible, dark skinned patients should always be given a bed by a window in order to provide access to sunlight. 3. DRUG INTERACTIONS AND METABOLISM

Reaction to drug varies with race. There is some evidence suggesting that drugs are metabolized by different races in different ways and at different rates. Isoniazid is a drug commonly used to treat tuberculosis. There are two ways in which people will react to metabolize this drug; they will inactivate it either very slowly or very rapidly. Those persons who inactivate this drug very slowly are at risk for developing peripheral neuropathy during therapy. Rapid inactivation of this drug occurs in 40% of whites, 60% of blacks, 60%-90% of American Indians, and 85-90% of Orientals. 4. ELECTROCARDIOGRAPHIC PATTERNS A common finding in black Americans, particularly in black men, is the occurrence of inverted T waves in the precardial leads of the electrocardiogram. This aberration is a normal variant in the black population but would suggest a pathological condition if found in other racial groups, for example whites. 5. SUSCEPTIBILITY TO DISEASE Another category of differences between racial groups is susceptibility of disease. The increased or decreased incidence of a particular disease may be genetically determined. Black Americans have a tuberculosis incidence three times higher than that of white Americans. The increased susceptibility of blacks to tuberculosis may be a result of their tendency towards overgrowth of connective tissue components concerned with protection against infection, since tuberculosis is a granulomatous infection. Other conditions that appear to have bio-cultural or racial prevalence include diabetes mellitus, hypertension, sickle cell anemia, and systemic lupus erythematosis. 6. NUTRITION Nutrition status also varies with the cultural difference. People of different culture consume their culturally related foods that vary from culture to culture.

CONCLUSION

We are entering a new phase of nursing as we value and use transcultural nursing knowledge with a focus on human caring, health and illness behaviors focus. With the migration of many cultural groups and the rise of the consumer cultural identity, and demands in culturally based care, nurses are realizing the need for culturally sensitive and competent practices. Most countries and communities of the world are multicultural today, and so health personnel are expected to understand and respond to clients of diverse and similar cultures. Immigrants and people from unfamiliar cultures expect nurses to respect and respond to values, beliefs, lifeway s, and needs. No longer can nurses practice unicultural nursing.

REFERENCES 1. GigerDavidhizar. Transcultural nursing. 1st edition. Mosby publications, page no:1 to 146 2. Barbara k timby. Fundamental skills and concepts in patient care. 7th edition. Lippincott publications, page no:326 to 338 3. Kozier, erb, berman, burke. Fundamentals of nursing. 6th edition. Parson education publications, page no: 203 to 208 4. Lewis, heitkemper, dirkson. Medical surgical nursing. 6th edition. Mosby publications, page no:19 to 22.