TRANSCULTURAL NURSING

SUBMITTED TO: Mrs. MARIA CARVALHO PRINCIPAL

SUBMITTED ON: 8 /11/2011 SUBJECT: Advanced Nursing Practice DATE: 31/10/2011

SUBMITTED BY : Ms. Lisma C. Barneto First year M sc Nursing

OBJECTIVES At the end of the class the students will be able to, Define the term Transcultural Nursing Define the term Culture State the Characteristics of Culture List the goals of transcultural Nursing List the concepts related to culture competent care Explain the cultural diversity among different religions in India & across the world Explain the role of Nurse in transcultural Nursing/Nursing process Relate the application of cultural care theory to culture influence on Health care in Palestine TRANSCULTURAL NURSING Introduction Transcultural Nursing is the essential part of health care today Migration of the people world wide is increasing. Communication & health technology bring diverse cultures closer Increased cultural conflicts, clashes and lawsuits.(health consumers expect their cultural beliefs, values ,and rights to be respected) Provides challenge to the nurse to provide holistic care to the patients. DEFINITIONS Transcultural Nursing

Transcultural nursing is a comparative study of cultures to understand similarities (culture universal) and difference (culture-specific) across human groups (Leininger, 1991).

Culture According to Taylor, culture is that complex whole which includes knowledge belief, art, morals law customs and any other capabilities and habits acquired by man , as a member of society. Characteristics of culture

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. 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. 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.

Goals of transcultural nursing According to Leininger, the goals of transcultural nursing is, 1. To preserve accommodate or repattern the cultures of the patient. 2. To provide culturally congruent care 3. When cultural beliefs and values do not have negative effect on care , nurses must make every effort to help to preserve his or her culture 4. In some situations, it may be necessary to make accommodations to preserve culture of the patient and the family.

CONCEPTS RELATED TO CULTURAL NURSING CARE 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.

Bicultural is used to describe a person who has dual patterns of identification and crosses two cultures, life styles and sets of values (Spector ,2002) eg a young man whose father is Cherokee and whose mother is European American may honor his traditional Cherokee heritage while also being influenced by his mother cultural values Ethnic

refers to a group of people who share a common and distinctive culture and who are members of a specific group. Eg Asian migrants from China, India

Ethnicity

a consciousness of belonging to a group

Stereotyping is assuming that all members of a culture or ethnic group are alike. All Chinese people like rice, all Italians express pain loudly. Ethnocentrism is the belief that ones own culture or way of life is better than that of others. Diversity

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

Acculturation

can be defined as the changes of ones culture patterns to those of the host societys in order to survive. Eg people migrated to USA from any country may be associated to their native countries for many years

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 . eg when a person migrates to another country.

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.

Cultural awareness

It is an in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people.

Concepts of Culturally competence Care Deloughery(1988) set a new phase termed as cultural competence when he has defined as the standard goal of caring for clients whose cultural back ground is different from the nurse. Luck(1999) outlined eight significant hurdles which challenges the nurses efforts in maintaining cultural competence. They are -lack of knowledge -fear and disgust -racism

-bias and ethnocentrism -stereotyping -ritualistic behavior (nursing rituals in patient care) -language barriers Differences in perception and expectation Nurses must have some knowledge about these obstructions in order to over come them. Campinha_Barote (2002) defines cultural competence as a process of development with five interlocking components. 1. 2. 3. 4. 5. Cultural awareness Knowledge Skill Encounters Desire Cultural Awareness It is the indepth self examination of ones own background, recognizing biases and prejudices about other people. Cultural Knowledge It is obtaining sufficient comparative knowledge of diverse groups, including their indigenous values , health beliefs and care practices worldview and bicultural ecology. Cultural skills It includes assessment of social , cultural and biophysical factors influencing treatments and care of clients. Cultural assessment Questions o What do you think has caused your problems? o Why do you think the problem started when it did? o What do you think the sickness does to you?

o o o o o o o o

What are the major problems the sickness has caused? What have you done for the illness until now? What kind of treatment do you think you should receive? Is there anything else that could be done either by you or by others (e.g., family, priest, etc.)? What are the most-important results you hope to achieve from these treatments? What do you fear most about your sickness? What do you fear most about the treatment? Who should be consulted or involved in your care?

Cultural encounters Involves the engagements in cross cultural interactions that provide learning of other culture and opportunities for effective intercultural communication development.

Cultural desire It is the motivation and commitment to caring that moves an individual to learn from others , accept their role as a learner , be open and accepting of cultural differences and build upon cultural similarities. Cross cultural communication Language Recent qualitative studies have shown that communication problems were the major reasons nurses were not able to provide culturally competent nursing care (Boi, 2000, Cioffi, 2003). The nurses reported that they were not comfortable with patients from cultures other than their own because of language barriers. More importantly, the nurses explained that they were not able to understand other cues used by these patients to communicate. The nurses expressed a need to receive education and training in transcultural communication skills in order to provide effective care for their patients from various cultures. Although it is not likely that nurses will master many languages, understanding the meaning of certain nonverbal communication

cues used by different cultures may be very beneficial for providing culturally competent nursing care. Non verbal clues SILENCE Respect (Asian cultures) Agreement (Spanish, French, Russian Culture) Need for privacy (English & Arabic Cultures)

GESTURES Thumb upIn America & Europe means good or you will improve. It is considered rude in Asian & Islamic Culture. In Thailand it is rude to show the sole of the feet. Curling the finger- is a gesture to come in, in American & European culture. It is considered rude in Japan. In Singapore it signifies death. Raising your hand-stop in American & England. In Asian culture it is used to ask permission. Hands in pocket-rude in Indonesia, Ignorance in Asian countries. Normal to kiss in Islamic, Asian culture for males but in western it is considered homosexual

SPACE

Usually feel comfortable when not in close contact with any others (European North Americans) Feel very comfortable in close proximity to others (Hispanics ,Asians) TOUCH Some cultures view Touch as healing Touch can revive evil spirits (Native Americans) Pat the head of young person is sign of friendliness (Americans Adults) Serious insult : as head is the seat of wisdom(South East Asians)

 Do not allow male care providers to touch certain parts of female (Arab & Hispanic) EYE CONTACT Direct contact is impolite and aggressive (Arabic ) Regard direct eye contact is improper, staring at the floor during conversation shows that there are listening carefully to the speaker (Native Americans) Elders while speaking to children use direct eye contact but children using direct eye contact to elders not allowed, want nurses to use direct eye contact when interacting with them (Hispanics). Cultural diversity among different Religions in India & across the world Hinduism Health beliefs India's oldest religion (2500BC) is a fusion of traditions and shared beliefs, which have shaped its culture. Belief in karma & Moxsha and rebirth to many Hindu patients will influence their care Purity (Suddha) is very important in Hindu culture, so it reinforces the need for personal cleanliness. Bodily discharges are considered to be impurities. Hindus disapprove of abortion and divorce. Elders are looked after by the family rather than be sent to a care home. Illness may be explained in terms of sorcery and evil spirits. In some cases, faith healers qualified to deal with spirits will be brought in.

DIET The majority of Hindus are vegetarians but non-vegetarians do not eat beef because they regard the cow as a sacred animal, and they do not eat pork. Vegetarian Hindus cannot eat off a plate on which meat has been served, so disposable plates and utensils need to be considered.

 Hindus may fast during Mahashivratri, Ram Nuami and Janmastami but this does not necessarily involve abstaining from all food and liquids, as Hindus who are fasting may eat one meal per day. Very few will insist on fasting when in hospital, but those who do may take hot milk, fruit, tea and salad without salt. MODESTY The women are very modest and they wear a sari. They may be reluctant to undress in front of a male doctor and could ask to be examined by a female doctor. They may refuse to wear an open-back gown. If possible, longer closed gowns should be provided CARE OF THE DYING Most Hindu patients would rather die at home. Some Hindus may receive comfort from readings from the Bhagavad Gita (Holy Book), and may wish to lie on the floor. This symbolises the closeness to Mother Earth If the patient wishes, a Hindu priest may be called to perform holy rites, who may tie a thread around the wrist or neck of the patient, sprinkle blessed water from the Ganges, or place a tulsi leaf in the mouth. They may insist that the eldest son be present before, during and after death, even if he is a small child WHEN THE PATIENT DIES The eyes should be closed and limbs straightened. Religious objects should not be removed from the body. Hair and beard should not be trimmed. Cover the body with a plain white sheet. Do not wash the body, as the family will usually do this as part of the funeral rites, and will put on new clothes before taking the body from the hospital. Adult Hindus are always cremated, but young children may be buried. Wherever possible the funeral should take place within 24 hours.

BUDDHISTS HEALTH BELIEFS Buddhists do not revere Buddha as a god, but as the teacher and founder of a way of life. The aim of Buddhists is to achieve Nirvana, which is a state of liberation, characterized by freedom from suffering, death and rebirth. Central to Buddhist belief is the injunction not to cause harm to others and to help all human beings DIET Buddhists' diet varies according to the climate of the country. Most Buddhists are vegetarians Fasting days occur on New Moon and Full Moon days, but there are also other days. On such days one is required to eat at regular times, which means that one should eat before 12 noon and not after. The taking of anything that mars judgment may be refused including alcohol, opiates, sedatives and tranquillizers as they have an impact on awareness and consciousness.

BLOOD/ORGAN DONATION Most Buddhist would consider blood donation an excellent opportunity to give to another person, and request for organ and tissue donations are likely to be received favorably. WHEN THE PATIENT DIE/ LAST OFFICES When a Buddhist dies, a Buddhist priest should be informed as soon as possible; ideally he should be of the same school of Buddhism as the deceased patient. The body should not be moved too much before the priest arrives. Most Buddhists prefer cremation.

CHRISTIANS HEALTH BELIEFS Christians believe in one God but with a Trinitarian nature Father, Son and Holy Spirit. Most people believe that everyone will have to answer to God, and those who live a good Christian life will go to heaven to be with Jesus Christ. Their main churches are Methodist, Anglican, Pentecostal, Roman Catholic and Church of God. The Church condemns all forms of birth control, abortions and euthanasia. Mental illness and suicide in the family is often kept a secret and is seen as something to be ashamed of. DIET during the period of Lent , some Christians may wish to fast to a greater or lesser extent. Some Christians do not eat meat during the whole period of Lent, but will eat fish dishes. On Fridays some Christians, particularly Catholics, might refrain from eating meat and would prefer fish or vegetarian food. Some Christians may wish to fast for a particular length of time before receiving Holy Communion.. For the majority of Christians (including Catholics, Anglicans , Methodists etc.) there are no specific dietary requirements although individuals may restrict themselves by choice

BLOOD/ORGAN DONATION In Christian religions, there are no religious beliefs banning organ donation or the giving or receiving of blood, but many of them fear contamination and may only choose to receive blood from their own families believing that it is less likely to be contaminated expect for Jehovah witness which refuse to take blood donation.

CARE OF DYING

Practicing Catholics and Orthodox Christians may want a Priest for confession, Holy Communion or Last Rites (Sacrament of the Sick) at such a time. There can be many spiritual issues that a dying patient may wish to explore, Please make sure they are given the opportunity. In some religions, a visit by a Pastor, prayer meetings and singing form part of the preparation for dying. WHEN THE PATIENT DIE/ LAST OFFICES Dying people of Christian denominations should always be offered the services of the appropriate chaplain. In the most of catholic religion, cremation is not condemned, but is rare because of the belief in life after death, so burial is preferred.

JAINISM HEALTH BELIEFS Jains believe that a living being consists of gross physical body, subtle luminous and karmic body and soul. They believe that all souls have characteristics of infinite perceptions, knowledge, energy and bliss. They do not believe in a supreme creator God. DIET Jains usually only eat a strict vegetarian diet which omits root vegetables such as potatoes, onion, garlic, carrots, beetroot, turnips etc. They will not eat figs or take honeys and may not eat cheese or butter, but they do drink milk. They do not eat meat, fish or eggs or any product containing them. Jains who eat any of the above products knowingly or unknowingly may feel revulsion and spiritually polluted.

In food preparation, it is important to keep prohibited products separate from food intended for Jain patients. Some object to sitting with someone who is eating prohibited foods, and may prefer to eat alone. Some Jains only eat during daylight hours. Always discuss their requirements and preferences with the patient. Fasting is an important part of Jain spiritual life and women are especially likely to fast. Some Jains fast regularly on the 5 th and/or 14 th day of each lunar month. During the fast, Jains will not take anything except boiled water during the day, and some may not. Neither will they take solids, except in semi-fasting when they may take one or two meals a day. They may also fast for a week during the festival of Paryusana-parva in August or September WHEN PATIENT DIES/LAST OFFICES Jains like to have all their family present and this may create an accommodation problem. Controlling the volume of visitors may be a major problem.

MUSLIMS HEALTH BELIEFS Islam (an Arabic word) is the religion of Muslims and means submission to the will of God (Allah). For the Muslim there is no other God worth worshipping except Allah who created the Universe and who is Lord. Islam holds that men are protectors of women, and so important decisions such as consent for treatment, require that they be consulted. Homosexuality is condemned and is considered sinful and punishable by Allah. Sex outside marriage is discouraged, but contraception and family planning are allowed. Abortion is not permitted even in the case of rape or incest. Ramazan is the month of fasting when all healthy Muslims should fast from dawn to dusk, so check with patients and arrange services as appropriate.

DIET Only Halal meat is acceptable to strict practicing Muslims as opposed to Haram (non-halal) foods. Haram foods such as pork and their products, cheese, fat or gelatine with non-halal substances, blood products and alcohol are unacceptable. If in doubt Always ask the patient or supply a vegetarian diet. Muslims eat with their right hand and consider it rude to be handed anything with your left hand, as the left hand is used for washing private areas of the body. Food is thought to be contaminated if touched by utensils that have been used to serve non-halal food. Removal of non-halal meat from any dish will have contaminated it and will not be acceptable. During the month of Ramadan which varies, a Muslim eats before observing the fast, which begins 1 hours before sunrise, and is not allowed to eat or drink any lawful things (including water) until after sunset. MODESTY Muslim women usually prefer to be seen by a female doctor. In Islam free mixing of sexes is prohibited and women are required to cover their head and chest to maintain modesty and moral standards. Muslims should be accommodated in mixed sex wards only in emergency situations and with adequate explanation. Blood transfusion/organ donation Muslims are allowed to donate and receive organs. They have no objections to blood transfusions. For strict orthodox Muslims, blood transfusions and transplants may only be accepted with reluctance. The decision lies with the individuals and their families. Staff must never initiate the subject of organ donation for transplants as strict Muslims will not agree, and this may cause offence, unless the relatives initiate the discussion.

CARE OF DYING Muslims may wish to lie or sit facing Mecca. At this time prayers are usually said for religious comfort in conjunction with other Muslims from the community. Readings from the Qur'an / Koran (Holy Book) may be recited. Human life is regarded as precious and suicide and euthanasia are considered as major sins. Resuscitation is allowed but is also a matter of choice. WHEN THE PATIENT DIE/ LAST OFFICES Non-Muslims should not touch the body after death, so disposable gloves should be worn. In Islamic culture, the next of kin will want to arrange for the washing of the body before burial. The family usually prepares the body, but in their absence, the following should be done. Wearing disposable gloves, close the eyes and mouth, straighten the limbs and body, and bandage the lower jaw to the head. Turn the head towards the right shoulder (facing Mecca), do not cut hair or nails and do not wash the body. Religious trinkets should never be removed. Cover the complete body with a sheet. It is customary amongst Pakistanis and Arabs to express their emotion freely when mourning a deceased relative. Whenever possible they should be given the privacy to do so; this will avoid disturbing other patients. The funeral is usually as soon as possible after death and certainly within 24 hours after death. It is therefore necessary to have the death certificate available as soon as possible. Muslims believe the body belongs to God and no part or organ should be removed. Post mortems are strictly forbidden, unless then clear reasons and explanations should be given.

SIKHS RELIGIOUS BELIEFS Sikhs believe there is only one God and the Gurdwara (Sikh Temple) is not only a place of worship but also a community centre and a focal point within their society Sikhism encourages people to make the most of the opportunity to achieve reunion with God through truthful conduct, humility, family life, meditation and prayer, and by serving the needs of the community. This includes donating money, clothes, food and shelter to those in need. DIET For Sikhs cows are sacred so beef and beef products are strictly forbidden. However, all dairy products are acceptable. A strict practicing Sikh will not eat any meat products, but for most Sikhs meat, fish and eggs are allowed. Food is thought to be contaminated if touched by utensils which have been used to serve prohibited food. Halal meat is strictly forbidden and so are alcohol, smoking and taking of intoxicating substances, although some Sikhs may indulge in these. DRESS Sikh men wear the Turban and the 5 Ks Kesh (uncut hair & beard); Kangha (wooden or plastic comb); Kara (iron or steel wrist bangle); Kirpan (symbolic dagger) and Kaccha (special underpants). These items of dress must never be removed or placed on the floor. If any of these items need to be removed, the reasons must be clearly explained to the patient prior to removal. It is better for the patient or relative to remove these. Sikh women may wear a scarf (Chuni or Dupatta) to cover their hair. Boys have a plait of hair in a knot (Jura) which is covered with a small piece of cloth (Rumal). Women may dress as men if they wish, but the traditional Punjabi female dress consists of Salwar Kameeze (loose trousers and tunic) and a Chuni.

MODESTY Sikh women usually prefer to be examined by a female doctor, but in the case of emergencies they may not mind being examined by a male doctor provided that there is a female member of staff present CARE OF DYING A Sikh may receive comfort from readings from the Guru Granth Sahib (Holy Book), and a relative or reader from the Gurdwara (Sikh Temple) may be able to oblige if the patient is unable to perform this task . Another practicing Sikh may be able to help if the patient has no objection

WHEN THE PATIENT DIE/ LAST OFFICES Generally Sikhs have no objection to anyone touching the body and carrying out last offices. Someone of the same sex should wash the body paying special regard to the 5 K's which, along with any other holy trinkets, should not be removed . If in doubt do not remove! The eyes and mouth of the deceased should be closed, limbs straightened and the body covered in a plain white sheet without religious emblems. Hair and nails should never be cut. Adult Sikhs are always cremated (wearing the 5Ks), before which the body is washed and white clothes are put on. Cremation takes place as soon as possible after death, and normally within 24 hours. Stillborn babies, neonates and infants may be buried. In Sikhism, post mortem is not liked, but will be accepted if it is a legal requirement. The body should be released as soon as possible to enable the funeral to take place. Zoroastrians HEALTH BELIEFS Zoroastrians believe in heaven and hell, the resurrection of the dead, and the last judgement. Their holy book the Avesta tells of two spirits

 Spanta Mainyu, the good spirit representing the forces of creation, and Angra Mainyu, the evil spirit representing the forces of destructionSacred symbols include cattle, earth, water and plant DIET Some Zoroastrians may not eat pork or beef and may prefer a vegetarian diet in hospital, although there are no dietary restrictions DRESS Zoroastrians have a sacred dress, the Sadra (shirt) and Kusti (girdle), which is to be worn at all times. Daily prayers are fundamental, and the girdle is tied and untied during the prayers. Very sick patients may need help to do this. BLOOD TRANSFUSION AND ORGAN DONATION Zoroastrians consider that pollution of the body is against the will of God.They will not accept or donate blood, and likewise for organs as it is forbidden in strict religious law. For similar reasons intermarriage is also strictly forbidden. WHEN THE PATIENT DIE/ LAST OFFICES Zoroastrians/Parsees do not accept post mortems or donation of organs as they are forbidden.Body donation or parts of, are also forbidden. Most families will provide a special Sadra (shirt) which is to be worn next to the skin under the shroud, with the sacred Kusti (girdle). In Mumbai and Karachi at least, for dead Parsis to be taken to the Towers of Silence where the corpses would quickly be eaten by the city's vultures. The reason given for this practice is that earth, fire and water are all considered as sacred elements, which should not be defiled by the dead. Therefore, burial and cremation have always been prohibited in Parsi culture. The family may wish the head to be covered with a cap or scarf.

Hispanics
RELIGION/HEALTH BELIEF The majority of Hispanics are Catholic . Health is a gift from God . The prevention of illness is an accepted practice that is accomplished with prayer, the wearing of religious medals, or amulets, and keeping relics in the home. Many homes have shrines with statues and pictures of Saints. The candles are lit here and prayers are recited SOCIAL CUSTOMS Elders have a prestigious status in the Hispanic family because of their experience. Family members look to elders for advice. An individual who becomes sick will turn first to family members, especially elders, for support, comfort and advice.They may recommend safe, simple home remedies. In the traditional household, the man is the head of the family and makes all major decisions. There is a strong sense of Paternalism what most Westerners call "Male Dominance", but the females role is equivalent and she is the Maternal powerhouse in her home. The truth is women are sacred and revered, often protected, not because she can't handle herself or has no voice, but because the solidarity of the family unit depends on her well being. HEALTH BELIEFS Hispanics are far more emotionally expressive. They expect to be pampered when ill, it is one way the family shows love and concern. This is a present oriented society, and as such they may neglect preventive health care, and may also show up late, or not at all, for appointments. birth control methods other than rhythm are unacceptable.

Most Latin Americans see thinness as a problem and plumpness as the ideal. Advice that a patient lose weight might not be followed because it would create a negative body image. Curanderismo is defined as a medical system. The curandero is a holistic healer; the people who seek help from him do so for social, physical, and psychological purposes. Since the curandero has a religious orientation, much of the treatment includes elements of both the Catholic and Pentecostal rituals and artifacts: offerings of money, penance, confessions, lighting candles, wooden or metal offerings in the shape of the afflicted anatomic part and laying on of hands

PRIVACY Personal matters should be handled only within the family. Modestly is valued in Hispanic culture, and not just for women. The area between the waist and knees is considered particularly private . BIRTH To attend a woman during delivery is a woman's job, ideally the job of her mother and midwife. Cultural tradition dictates that a husband not see his wife or child until the delivery is over and both have been cleaned and dressed. In general, Hispanic women prefer that their mothers attend them in labor.

CHINESE HEALTH BELIEFS Health may be viewed as finding harmony between complementary energies such as cold and hot, dark and light. These forces are called yin and yang Some traditional Chinese therapies, including massage, acupuncture are commonly used as an adjunct to western medicine. patient may prefer to drink only hot liquids (water or tea) when sick or postpartum.

 Patients may try traditional approaches first, and will seek western medical care if these treatments fail. Patients may occasionally delay seeking care out of concern for communication barriers, costs, etc. As a result, patients may present at the medical center acutely ill. patient may believe that western medicine is too strong and may not take the full dose or complete the course of treatment. patient may cut the dose in half or stop taking the medicine whether he/she feels better or not Describe the need to take the full dose whether your patient feels better right away or not. Talk about side effects. Share your plan in dealing with side effects. Ask open-ended questions to ensure understanding.

FAMILY RELATIONSHIP The Chinese culture emphasizes loyalty to family and devotion to traditions and puts less emphasis on individual feelings. Assess your patients kinship relationships and determine which family members are most influential in decision making. When possible, engage the whole family in discussions that involve decisions and education about care Bad medical news is often shielded from the patient by the family in the belief that telling the patient will only make the patients condition worse. - Ask your patient whom they want included in medical decisions. patient may seem hesitant to make a decision about surgery because of preference to retain full complement of body parts (eg., uterus, gall bladder, etc.). Whenever possible, allow time for the patient to gain perspective and make decisions.

COMMUNICATION patient may nod, smile, and/or say yes or ya to acknowledge he/she heard you, rather than that he/she understands or approves.

 patient may be reluctant to say no to a doctor or health care provider because it may be considered disrespectful or cause disharmony. - Ask your patients open-ended questions to verify understanding and encourage them to ask questions. - Ask them to repeat what they understand in their own words. NON VERBAL CLUES Respect is shown to authority figures by giving a gentle bow and avoiding eye contact. Nonverbal cues are an important part of communication. For example, smiles when appropriate may be one way to build rapport. Your patient may highly value emotional self-control, appearing stoic. Be aware that your patient may not show pain or ask for pain medications. - Instead of asking your patient about pain, ask, May I get you something for pain? - Be respectful of your patients desire to keep emotions in control when asked about upsetting subject matters. MODESTY Consider the modesty of women and girls when giving a pelvic exam. Many young women are modest about having an exam and may prefer a female doctor to do it. Before you begin a gynecological exam, it is important to ask your patient, May I examine you? Ask your patient if she prefers a female doctor, attendant, or interpreter to remain in the room during the exam. Nursing process/Role of the nurse The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills. Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture. 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. 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 The clients educational level and language skills should be considered when planning teaching activities. 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. Evaluation continues throughout the nursing process and should include feedback from the client and family. Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds.

Relate the application of Culture Care Theory to Culture Influence on Health care in Palestine. Dr. Leininger was the first professional nurse with a graduate preparation to complete a PhD in anthropology. She brought nursing and anthropology together and coined the term transcultural nursing as an essential formal area of study and practice. Her Culture Care Diversity & Universality theory was one of the earliest nursing theories and it remains the only theory focused specifically on transcultural nursing with a culture care focus. Her theory is used worldwide. The Theory The Culture Care Diversity and Universality theory, according to Dr. Leininger, focuses on describing, explaining and predicting nursing

similarities and differences focused primarily on human care and caring in human cultures. The Culture Care Diversity & Universality theory does not focus on medical symptoms, disease entities or treatments. It is instead focused on those methods of approach to care that means something to the people to whom the care is given. Leininger (1978) explained that nurses had to acquire an in depth knowledge of different cultures in order to provide care to people of various ethnicities. Her theory continues to be holistic model that contributes to new research based & advanced knowledge to transcultural nursing. Development of the theory Developed in the mid-1950s and early 1960s. Developed particularly to discover the meanings and ways to give care to people who have different values and lifeways. Designed to guide nurses to provide nursing care that fits with those that are being cared for. Culture Care theory not only focuses on nurse-client interaction but the focus also includes care for families, groups, communities, cultures and institutions.

The theory includes an enabler ( Dr.Leininger prefers it not be called a model), serves as a conceptual guide or cognitive map to guide nurses in the systematic study of all dimensions of the theory. This map or guide is called the Sunrise Enabler. Metaparadigm concepts defined Nursing: care has the greatest meaning which explains nursing Person: should refer to families, groups, and communities Health: not distinct to nursing as many disciplines use this term Environment: included events with meanings and interpretations given to them in particular physical, ecological, sociopolitical or cultural setting. The sunrise enabler symbolizes the rising of the sun (care). The upper half of the circle depicts components of the social system of the social structure & world view factors of that influence health through language, ethno history & environment context.

 These factors influence the folk, profession & nursing system, which are the middle part of the model. The two halves together form a full sun, which represents the universe that the nurses must consider to appreciate human care & health. According to Leininger, Nursing acts as a bridge between folk (generic) & the professional system. Application of Theory Care always occurs in a cultural context Culture is viewed as framework people use to solve human problems Culture is the lifeways of an individual or a group with reference to values, beliefs, norms, patterns, and practices (Leininger, 1997) ASSESSMENT OF CLIENT Information on culture is essential for holistic assessment of an individual, family, or community The assessment process must be comprehensive, accurate, and systemic Individuals, familys, or communitys perspective of their culture is needed for an accurate assessment. Culture care theory Cultural Influences on Health care in Palestine This article is constructed using Cultural care Theory, which depicts the importance of culture on the health behavior of the individual, and will focus on how cultural values of Palestinian patients with cancer and their families affect attitudes towards and decision about cancer care. In Palestine 42% of cases were reported in stage III and 18% were in stage IV In the Culture Care theory, culture is viewed as a framework people use to solve human problems (Leininger & Mcfarland, 2002) The sunrise Model helps visualize the different dimensions of the Culture Care theoryCulture care theory

Technologic factors In 2009,in Palestine households 92% Television 92% At least I mobile 29% internet access 49% Computer Mammography screening available in religious & social organization Radiation only at the limited number of sites Religious & Philosophical factors Islam 98% Christianity 2% Religious beliefs are important View cancer as punishment from God Take comfort on reading Korean Strong beliefs in Religion helps them to accept illness Diet & Religion :prohibits consumption of pork & pork products Fasting during Ramzan (Implication for oral medication & injection Christians may fast & eat non vegetarian foods Kinship & social factors 2 distinct families Aila-all of a person blood relative plus who were brought into kinship through marriage. Clan (hammula) decents from same great grand parent. Concept of family greatly valued Male head of the family Do not rely on the social workers Family is the caregiver Holds information of cancer from the patient (good prognosis directly inform, negative prognosis approach head of the family) Palestine women like same sex providers Woman do not discuss personal information or concerns about themselves rely on the male family members Cancer is stigma labeled as that disease Diagnosis is concealed

Cultural values, beliefs and lifestyles Woman tend to keep secrets, their cancer remain undiagnosed Less access to health information outside because of traditional norms, modesty ,embracement, religious practice beliefs fatalism Do not discuss sexually as it is considered shameful Fear negative stigma associated with breast cancer because of daughters marriage Follow folk remedies (mint tea, chamomile tea and cinnamon) Medical care is accessed after the patient care is deteriorated Political and legal factors Living wills and advance directives are not available Male make decisions Off springs will decide for older parents In some conservatives families women of any age cannot sign consent form, instead they have a father ,older brother, husband or son sign their form. Economic factors 60% are poor Rely on the male head for household income. Reconstructive surgery is very limited with Palestine Hospital Educational factors Although the literacy rate for younger 91% (2002),older clients generally have limited education and do not seek health care as often Because of societys lack of knowledge about the nature of the disease, cancer remains one of the greatest challenge in the middle Eastern region

Conclusion of the study This article elaborates on the cultural values of the Palestinian and provides an understanding of the aspects of the Palestinian culture that influences health seeking behavior and healthcare delivery.

 The model provides the nurse an outline of various cultural aspects, particularly the importance of family in Arab countries regarding care of the loved ones & to involve the family in planning of care to the delivery of cultural competent care . CONCLUSION Nurses need to be aware of and sensitive to the cultural needs of clients. 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

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