Course Title:

Decent Work Employment and Transcultural Nursing

Course Description:
This course will introduce the student to theory and concepts in transcultural
nursing, and the role of culture in understanding and caring for diverse clients in
health care settings. It will provide an overview of the influence of culture on health
care practices and in the delivery of nursing care for individuals, groups, and
communities. This course is designed to assist nursing students in learning about
culture, belief systems, values, and practices that are specific to identified cultures in
order to better understand and provide nursing care that is both culturally competent
and culturally sensitive in nature. Various cultures and concepts of health and illness
will be examined; special emphasis will be placed on providing health care in
Philippine Setting. Culture will also be defined as behavior and established norms
found in diverse health care settings. Understanding the “culture of nursing”
institutional norms, behaviors, and communication patterns are critical to the
students’ transition into the workplace. Students will gain self-awareness of their
racial, ethnic, and cultural background as a prerequisite for eliciting and responding
to clients' needs. Cross-cultural communication will be addressed to provide the
student with skills to negotiate cultural differences between clients and providers
around health and illness issues.

Course Guide:
This module for Decent Work Employment and Transcultural Nursing was
created for Eastern Samar State University's flexible learning modality system
designed for self-directed learning.

Program Outcomes:
a. Apply knowledge of physical, social, natural and health sciences, and
humanities in the practice of nursing
b. Provide safe, appropriate and holistic care to individuals, families, population
group and community utilizing nursing process
c. Apply guidelines and principles of evidence-based practice in the delivery of
care
d. Practice nursing in accordance with existing laws, legal, ethical and moral
principles
e. Communicate effectively in speaking, writing and presenting using
culturally-appropriate language
f. Document to include reporting up-to-date client care accurately and
comprehensively
g. Work effectively in collaboration with inter-, intra- and multi-disciplinary and
multi-cultural teams
h. Practice beginning management and leadership skills in the delivery of client
care using a systems approach
i. Conduct research with an experienced researcher
j. Engage in lifelong learning with a passion to keep current with national and
global developments in general, and nursing and health developments in
particular
k. Demonstrate responsible citizenship and pride of being a Filipino
l. Apply techno-intelligent care systems and processes in health care delivery
m. Adopt the nursing core values in the practice of the profession
 n. Apply entrepreneurial skills in the delivery of nursing care

Course Learning Outcomes:

Upon successful completion of this course, the students will:
CLO1 - Explore the constructs and the concepts of the discipline of
transcultural nursing (TCN) and their applications within nursing practice.
CLO2 - Explore the social structure dimensions of Leininger's Sunrise
Enabler and essential constructs and tenets of the Theory of Culture Care
Diversity and Universality.
CLO3 - Explore the generic and professional care beliefs, expressions,
patterns, and practices of selected diverse cultural groups predominantly
encountered in health care settings.
CLO4 - Examine the cultural competencies necessary for professional
nursing practice.
CLO5 - Develop communication strategies for the provision of culturally
congruent or culturally competent care.
CLO6 - Explain the use of evidenced-based research and its influence on the
delivery of culturally congruent or culturally competent care.
CLO7 - Evaluate health care policy and the financial and regulatory
environments that affect the integration of culturally congruent or culturally
competent care.
CLO8 - Develop critical thinking skills through submitted written, visual and
oral presentations.

Course Requirements:
Students are expected to submit the following requirements or outputs during
major exams.

Section 1 Chapter Title Requirement or Output

1 Foundations of Transcultural Nursing

Google Classroom
Transcultural Nursing: Across Chapter Activities
the
2
Lifespan Online Exercises
Online Quizzes
Nursing in a Multicultural Health Care Reporting or Group
3
Setting Presentations
Major Examinations for
Contemporary Challenges in Midterm and Final
4
Transcultural Nursing
Title Page i
Preface ii
Table of Contents iv

Unit 1 Foundations of Transcultural Nursing 1

Lesson 1 Theoretical Foundations of Transcultural Nursing
Lesson 2 Culturally Competent Nursing Care
Lesson 3 Cultural Competence in the Health History and Physical
Examination
Chapter 4 The Influence of Culture and Belief System on Health Care
Practices

Unit 2 Transcultural Nursing: Across the Lifespan

Lesson 5 Transcultural Perspective in Childbearing
Lesson 6 Transcultural Perspective in Care of Children
Lesson 7 Transcultural Perspective in Care of Adults
Lesson 8 Transcultural Perspective in Care of Older Adults

Unit 3 Nursing in a Multicultural Health Care Setting

Lesson 9 Creating Culturally Competent Health Care Organizations
Lesson 10 Transcultural Perspectives in Mental Health Nursing
Lesson 11 Culture, Family, and Community
Lesson 12 Cultural Diversity in the Healthcare Workforce

Unit 4 Contemporary Challenges in Transcultural Nursing

Lesson 13 Religion, Culture, and Nursing
Lesson 14 Cultural Competence in Ethical Decision Making
Lesson 15 Nursing and Global Health
 Lesson 1
Theoretical Foundations of Transcultural Nursing

Learning Objectives:

After this unit, you will be able to accomplish the following:

1. Assess the historical and theoretical underlying principles of transcultural

nursing.
2. Critically examine the role of transcultural nursing in addressing contemporary
nursing issues and trends.
3. Examine Leininger's contributions to the establishment and growth of
transcultural nursing as a theory-based and evidence-based formal area of
study and practice within the nursing profession.
4. Critically evaluate selected transcultural scholars' contributions to the
advancement of transcultural nursing theory and practice.
5. Describe the key elements of the Andrews/Boyle Transcultural
Interprofessional Practice (TIP) Model.

Theoretical Foundation of Transcultural Nursing

Leininger (1970) analyzed the way in which anthropology and nursing are
intertwined and interconnected in her groundbreaking and classic book "Nursing and
Anthropology: Two Converging Worlds" (Brink, 1976; McKenna, 1985; Osborne,
1969). Leininger uses the term Transcultural Nursing (NTP) to describe the
integration of nursing and anthropology within the professional fields of nursing.
Using the concepts of culture and nursing, Leininger established TCN as a formal
theoretical and evidence-based research and practice area in nursing, focused on
people and health, illness, rehabilitation and human care (Leininger, 1991 , 1995;
Leininger & McFarland, 2002, 2006).
TCN is sometimes used interchangeably with cross-cultural, intercultural, and
multicultural nursing. The goal of TCN is to develop scientific and humanistic
knowledge systems in order to provide culturally universal and culture-specific
nursing practices for individuals, families, groups, communities and institutions with
similar and different cultures.

● Culture-specific refers to particular values, beliefs, and patterns of

behavior that tend to be special or unique to a group and that do not
tend to be shared with members of other cultures.

● Culture-universal refers to the commonly shared values, norms of

behavior, and life patterns that are similarly held among cultures about
human behavior and lifestyles (Leininger, 1978, 1991, 1995; Leininger
& McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015).

As many cultural groups are increasingly migrating to different parts of the

world, cross-cultural nursing has become increasingly important and related to
nurses. The concept of globalization of intercultural nursing has become crucial for
nurses to be more aware that intercultural nursing is a global phenomenon that can
affect wherever people live.
The globalization of cross-cultural nursing requires nurses to broaden their
worldview from a local or narrow perspective to a nursing worldview that cares about
and is interested in different cultures and how to function in a cross-cultural nursing
environment. In fact, the main purpose and goal of cross-cultural nursing is to
promote and protect human cultural nursing needs.
Nurses who have received training in cross-cultural nursing know how to
recognize and care for different cultures. They learn how to find and provide safe and
meaningful care to people of different cultures. In essence, cross-cultural nursing
provides nurses with a new way of understanding people around the world and
providing them with culturally coherent and meaningful care. For most nurses, this is
a new and unique path from the perspective of their typical nursing direction and
patient care technique. To become cross-cultural nurses today, nurses must
understand and respect other cultures and their nursing requirements in various life
settings.
When nurses apply culturally applicable cross-cultural nursing concepts,
principles, theories, and research knowledge, they can find evidence of client
satisfaction, rehabilitation, and rehabilitation. Nurses quickly realized the importance
of culture-oriented care, so as to understand and help clients with different cultural
backgrounds.

Anthropology and Culture

To understand the history and foundation of TCN, we first give a brief

overview of anthropology, which is an educational discipline that focuses on scientific
research in the past and present of humanity. Anthropology draws on knowledge of
physics, biology, and the social sciences, in addition to the humanities. One of the
main concerns of anthropologists is the application of information to the answers to
human questions. Historically, anthropologists have concentrated their education in
one of four areas: sociocultural anthropology, biological / physical anthropology,
archeology, and linguistics. Anthropologists often integrate perspectives from several
of these fields in their research, teaching, and professional life.

Concept of Study

Culture
Leininger defines culture as the “learned, shared, and transmitted values,
beliefs, norms, and lifeways of a particular group of people that guide thinking,
decisions, and actions in a patterned way.... Culture is the blueprint that provides the
broadest and most comprehensive means to know, explain, and predict people’s
lifeways over time and in different geographic locations” (McFarland &
Wehbe-Alamah, 2015).
Culture influences a person's definition of health and illness, including when it
is suitable for self-treatment and when the illness is so severe that it needs to seek
help from one or more therapists other than immediate family members. The choice
of therapist and the recovery time of a person after the baby is born or after the onset
of illness is determined by culture.
● The way a person behaves during illness and the help provided by
others to promote recovery are also culturally determined.
● Culture determines who is allowed or expected to care for the sick.
● Likewise, culture determines when a person is declared healthy and
when they are healthy enough to resume activities of daily living
and/or return to work.
● When a person is about to die, culture usually determines where, how,
and with whom the person will spend the last few hours, days, or
weeks.
● Although the term “culture” sometimes means a person’s racial or
ethnic origin, there are many other examples of non-racial cultures,
 such as cultures based on socioeconomic status, such as poverty or
wealth, and women’s culture. Ability or disability, such as the culture of
the deaf or hard of hearing and the culture of the blind or visually
impaired; sexual orientation, such as lesbian, gay, bisexual, and
transgender (LGBT) culture; age, such as adolescent culture, old age
Human culture; occupation or professional culture, such as
occupations in nursing, medicine and other health care, business,
education, and related fields.

In 1984, Edward Hall performed a classic study of culture and was able to
identify three levels of culture:

● PRIMARY
It refers to implicit rules known and followed by group members, but
rarely explained or clear to outsiders.
● SECONDARY
Refers to the basic rules and assumptions that team members know
but rarely share with outsiders.

The primary and secondary levels are the most deeply ingrained and the most
difficult to change.

● TERTIARY
Refers to explicit or public faces visible to outsiders, including
costumes, ceremonies, food, and festivals.

SUBCULTURE
Members of subcultures have their own common customs, attitudes and
values, usually accompanied by the language, slang and / or jargon of a specific
group to distinguish them from others. In the United States, subcultures can include
various races and ethnic groups. For example, Hispanic is a pan-ethnic name that
includes many subcultures made up of people who identify themselves as Mexican,
Cuban, Puerto Rican, and / or other groups that often share the Spanish language
and culture (Morris, 2015).

ETHNICITY
It is defined as the perception of oneself and a sense of belonging to a
particular ethnic group or groups. It can also mean feeling that one does not belong
to any group because of multiethnicity. Ethnicity is not equivalent to race, which is a
biological identification. Rather, ethnicity includes commitment to and involvement in
cultural customs and rituals (Douglas & Pacquiao, 2010).

RACE
In traditional anthropological and biological classification systems, race refers
to a group of people with genetic characteristics such as skin color, hair texture, and
eye shape or color. Race is an arbitrary classification that lacks a clear definition,
because all cultures have their own way of categorizing or classifying members
(Hesmondhalgh & Sala, 2013; Hunt, Truesdel & Kreiner, 2013). Some people define
race as geographically and genetically different people, while others believe that
racial categories are socially constructed (Zimitri, 2013).
Historical and Theoretical Foundation of Transcultural Nursing

More than 60 years ago, Madeleine Leininger

(1925 to 2012; see Figure 1-2) noted cultural
differences between patients and nurses
while working with emotionally disturbed
children. As a doctoral student in
anthropology, she conducted field research
on the care practices of people in Papua
New Guinea and subsequently studied
cultural similarities and differences in the
culture care perceptions and expressions of
people around the world.

8 Factors that Influenced Leininger to Establish TCN

1. There has been a significant increase in population migration within and

between countries around the world
2. The increase in multicultural identities, people expect nurses and other
healthcare professionals to understand and respect their cultural beliefs,
values ​and lifestyle.
3. Health care providers and patients are increasingly using technology to
connect people around the world at the same time, which may become a
source of conflict with the cultural values, beliefs and practices of some
people receiving care
4. Global cultural conflict , Confrontation, and as more and more cultural
exchanges, violence affects healthcare
5. The number of people traveling and working in different parts of the world
increases by
6. Legal proceedings due to cultural conflicts, negligence, ignorance and
imposing hygiene measures Increase practice
 7. Increased awareness of gender issues and greater demands on the health
system to meet the gender and age-specific needs of men, women, and
children
8. Increased demand for community and culture-based health services in
different environmental contexts (Leininger, 1995).

Leininger's Contribution to Transcultural Nursing

● Leininger uses concepts such as worldview, social and cultural structure,

language, national history, environmental context, and popular and
professional treatment systems to provide a comprehensive and holistic view
of the factors that influence cultural care.
● Cultural congruence is at the core of Leninger's theory of culture care for
diversity and universality. One of the advantages of Leininger's theory is that it
can be applied flexibly to individuals, families, groups, communities, and
institutions in different health systems.
● Leininger's Sunrise Enabler: To help develop, test, and organize the emerging
knowledge system at TCN, Leininger recognized the need to establish a
specific conceptual framework from which to develop various theoretical
statements. It describes the components of the theory of cultural concern for
diversity and universality, provides a visual representation of these
components, and illustrates the interrelationships between these components.
● The Intercultural Nursing Association (TCNS), which generates the TCNS
newsletter, and creates the Intercultural Nursing Journal (JTN), she serves as
the founding editor.
● Leininger established the first nursing master's and doctoral programs at TCN
with a focus on theory and research, and through conferences, publications
and consultations, provides TCN courses and curricula applicable to all levels
of nursing education (undergraduate and graduate) Example.
● Leininger also created a new qualitative research method called
ethnonursing research to investigate phenomena of interest to TCN.

Cultural Competence
It is a combination of attitudes, abilities, behaviors, and policies that allow
organizations and their employees to operate effectively in cross-cultural
environments. It reflects the ability to acquire and apply knowledge of clients' and
their families' health-related beliefs, attitudes, practices, and communication patterns
in order to improve services, strengthen programs, increase community participation,
and close health-status gaps among diverse population groups.

Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model

The conceptual framework, theoretical models and theories in nursing are

structured thoughts about human beings and their health. These models allow nurses
and other members of the health team to organize and understand what is happening
in practice, critically analyze the situation of clinical decision-making, formulate care
plans, propose appropriate care interventions, predict care outcomes and evaluate
the effectiveness of care provided.

The Goals, Assumptions, and Components of the Model

The objectives of the Andrews / Boyle TIP model are:
 ● To provide a systematic, logical, orderly, and scientific process to provide
cultural coherence, cultural competence, safety, and affordability. Accessible
and provide quality care to people of different origins throughout the life cycle.

● Promote the provision of useful, meaningful, relevant, culturally consistent

and culturally competent services with clients of different origins Nursing and
health care consistent with their cultural beliefs and practices.

● Provide a conceptual framework to guide nurses to provide competent and

culturally coherent nursing that is theoretically reasonable, evidence-based,
and uses best professional practices.

These assumptions are thoughts that are formed or assumed to be true

without evidence or evidence. Hypotheses can be used to provide a basis for actions
and create "what-if" scenarios to simulate possible situations until there is evidence
or evidence to confirm or refute the hypothesis. The TIP model consists of the
following interrelated and interrelated components: values, attitudes, beliefs and
practice backgrounds related to people's health; interprofessional health teams;
communication; and problem-solving processes.

Interprofessional Health Care Team

The intercultural and interprofessional healthcare team takes the client as the
core and the client is the reason for the team being (the reason for its existence). In
addition to the client, the team may have one or more of the following members:

● Significant others: the client’s family and other important people in their
lives, including legally designated guardians, but may not have a genetic
relationship
● Registered healthcare professionals: nurses; physics, occupation,
respiratory, music, art, dance, entertainment, and other therapists; social
workers; health navigators; public and community health workers;
professionals related to formal academic preparation, bachelor's and/or
certification Imitation, and sometimes even unlicensed individuals who learn
the art and practice of healing by inheriting the ability to heal,
● Religious or spiritual therapist: a priest or lay minister who performs
healing through prayer, religious or spiritual rituals, belief therapy practices,
 and related actions or interventions Lay members of religious groups, for
example, priests, priestesses, elders, rabbis, imams, monks, Christian
science. And others who are believed to have healing powers derived from
faith, spiritual power, or religion.
● Other people that the client considers important to their health,
well-being, or recovery, such as culturally appropriate companion animals or
pets.

Interprofessional Collaboration

It is defined as multiple healthcare workers from different professional

backgrounds who work with patients, families, caregivers, and the community to
provide the highest quality care.

Core Competencies:

● values and ethics related to interprofessional practice

● knowledge of the roles of team members
● a team approach to health care

Requirements:

Communication
Cooperation
Collaboration

Aspects of Communication

A. Language
More than 6,000 languages ​are spoken around the world; Most Filipinos
speak eight (8) major dialects: Tagalog, Cebuano, Ilocano, Hiligaynon or Ilonggo,
Bicolano, Waray, Pampango, and Pangasinense. With about 76 to 78 major
language groups, with more than 500 dialects.

B. Interpreters

When nurses and clients speak different languages, one of the greatest
challenges of cross-cultural communication for nurses arises. After assessing the
language skills of a client who speaks a different language with the nurse, the nurse
may find herself in one of two situations: either it is difficult to communicate effectively
through an interpreter, or she can communicate effectively without an interpreter.
Even people from other cultures or countries have basically mastered the
language spoken by most nurses and other health professionals, but they may also
face being admitted to the hospital, encountering unfamiliar symptoms, or discussing
anxiety situations. An interpreter is required. Sensitive topics, such as birth control or
gynecological or urological problems. A trained medical interpreter understands
interpreting skills, understands medical terminology, and understands the rights of
patients. Well-trained interpreters can also understand cultural beliefs and healthy
practices. This person can help bridge the cultural gap and can advise on the cultural
suitability of medical and nursing advice.
 Although the nurse is responsible for the focus and process of the interview,
the interpreter should be regarded as an important member of the medical team. It
can be tempting to ask relatives, friends, or even other clients to interpret because
this person is always available and may be willing to help. However, this violates the
confidentiality of customers, and customers may not want to share personal
information. In addition, although friends or family members can speak a common
language fluently, they may not be familiar with medical terminology, hospital or
clinical procedures, and healthcare ethics. Ideally, ask the interpreter to meet with the
client in advance to establish a relationship and obtain basic descriptive information
about the visitor, such as age, occupation, education level, and attitude toward
healthcare. This makes the relationship between interpreters and clients easier and
allows clients to talk about relatively non-threatening aspects of their lives.
 C. Greetings

Some cultures value formal greetings at the beginning of the day or at the first
meeting of the day, and this practice even exists among close family members. When
communicating with people from more formal cultures, it is important to address
someone by title, such as Mr., Mrs., Mrs., Ph.D, Pastor, and related titles to show
respect. Until the individual allows these issues to be addressed in a less formal way.
When a nurse first meets with a client or new member of the medical team, the
recommended best practice is to say their name, and then ask the client or team
member how they prefer to be called.

D. Silence

There are wide cultural differences in the interpretation of silence. Some

people find silence very uncomfortable and do their best to use words to fill in the
delay in the conversation. On the contrary, many Native Americans believe that
silence is essential to understanding and respecting others. A pause after a question
means that the question asked is important enough to require careful consideration.
In traditional Chinese and Japanese cultures, silence may mean that the speaker
wants the listener to consider what has been said before proceeding. Other cultural
meanings of silence can be discovered. Arabs may use silence out of respect for the
privacy of others, while people of French, Spanish and Russian descent may
interpret silence as a sign of consent. Asian culture often uses silence to show
respect for the elderly. In some African Americans, silence is used to answer
questions that are considered inappropriate.

E. Eye Contact and Facial Expression

Eye contact and facial expressions are the most prominent forms of
non-verbal communication. Eye contact is a key factor in determining the tone of
communication between two people, and there are great differences between
different cultures and countries.

● In most of the United States, Canada, Western Europe, and Australia, the
interpretation of eye contact is similar: expressing interest, active contact with
one another, openness, and honesty.
● People who avoid eye contact when speaking are seen as negative people
and can be seen as withholding information and / or lack of confidence.
● In certain regions of Asia, Africa, and the Middle East, as well as in certain
Native American countries, direct eye contact can be seen as a sign of
disrespect, aggression, or defiance of the authority of others.
● In some cultures, staring at someone for a long time indicates that the person
looking has a sexual interest in the other person.
● People who make eye contact, but only briefly, are considered respectful and
polite. In some Native American cultures, when a person in authority speaks,
the person may look at the ground to show respect and concern.
● In some African American and white cultures, the occult (rolling eyes) occurs
when someone speaks or acts in a way that is considered inappropriate.

F. Gestures

Types of Gestures

● EMBLEMS - gestures that serve the same function as words.

 ● ILLUSTRATORS - gestures that accompany words to illustrate a verbal
message. It mimics the spoken word, such as pointing to the right or left while
verbally saying the words right or left.
● REGULATORS - include head nodding and short sounds such as “uh huh” or
“Hmmmm” and other expressions of interest or boredom.
● ADAPTORS - are non-verbal behaviors that can satisfy certain physical
needs, such as scratching or adjusting glasses, and can also represent
psychological needs, such as biting nails when nervous, yawning when
bored, or clenching fists when angry.

G. Posture

Posture reflects people's emotions, attitudes, and intentions. The posture can
be open or closed and is believed to convey personal confidence, status, or
acceptance to another person.

H. Chronemics

Chromic is the study of the use of time in nonverbal communication. The way
a person perceives and values ​time, constructs time, and responds to time
contributes to the context of communication. Social scientists have discovered that
individuals are divided into two broad categories in the way they approach time:
monochronic or polychronic. In monochronic cultures, such as many groups in the
United States, Northern Europe, Israel, and most parts of Australia, time is
considered a commodity, and people tend to use things such as "waste time" or "lose
time" or "time is money", as a way of expression.
People in polychronic cultures, such as some groups in Southern Europe,
Latin America, Africa, and the Middle East, have very different views on time. People
in these cultures often think that time is uncontrollable and time is flexible. Dates are
planned based on events rather than clocks. For many people in these cultures,
when one event ends, it is time to start the next, no matter what time it is.

I. Proxemics

The study of space and how differences in space make people feel more
relaxed or anxious is called proxemics, a term coined by anthropologist and
intercultural researcher Edward T. Hall in the 1950s.

Different kinds of Proxemics:

● Intimate - touching to 1 foot

● Personal - 2 to 4 feet
● Social - 4 to 10 feet
● Public space - 12 to 25

J. Modesty

Modesty is a mixed form of verbal and nonverbal communication, which

refers to reservation or decentness in speech, dress or behavior. The message is
intended to avoid attracting sexual attention or attraction from others (except one’s
spouse).
 K. Technology-Assisted Communication

From a cross-cultural perspective, one of the biggest challenges facing

technology is the gap between regions and countries that have more resources than
other countries. Although some progress is being made, it will take many years to
mobilize technological capabilities in a way that benefits people all over the world by
improving safety, quality, accessibility, affordability, evidence-based medicine and
care, cultural consistency, and cultural capabilities. . This is a social justice issue that
must be resolved as an integral part of the NTP.
Although linguists know that languages ​will change over time, digital
languages ​are changing faster than any other language in history. For example, the
first chat room was invented at the University of Illinois in 1973. In 1992, the first
mobile phone message was sent. By 2012, people in the world were sending
200,000 text messages per second (Eisinger, 2012).

L. Literature, Art, Music, and Dance

The literature, art, music, and dance of various cultural groups convey to the
world the values, beliefs, history, traditions, and contributions that people in
countries, tribes, and population groups cherish. Creative products in the form of
books, poems, works of art, music and dance describe the social atmosphere of the
time; they represent religion, race, gender, politics, class, and other points of view;
and they serve as unique historical documents and cultural relics to better help
people. See, hear, recognize, understand and appreciate the richness of global
multiculturalism, because they are communicated through literary works, artistic and
musical creations, and dances of people from all over the world. Cultures from
around the world.

Transcultural Interprofessional Practice Model