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 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 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. 6. Communication. Space. Social organization. Time. Environmental control. 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).

FUNCTIONS OF COMMUNICATION - It establishes a sense of communes with another - It permits the sharing of information, signals, or messages in the form of ideas and feelings. - Communication is a continuous process by which one person may affect another through written or oral language, gestures, facial expressions, body language , space or other symbols. PROCESS OF COMMUNICATION Communication may be conceptualized as a process that includes a sender, a transmitting device, signals , a receiver, and a feedback. A sender attempts to relay a message, an idea, or the use of signals or symbols. The receiver receives the message and then interprets the message. Finally feedback is given to the sender about the message, and more communication may occur. In the event that no feedback is given, there may be no reciprocal interaction.

FACTORS INFLUENCING COMMUNICATON 1. 2. 3. 4. 5. 6. Physical health and emotional wellbeing. The situation being discussed and the meaning it has. Distractions to the communication process. Knowledge of the matter being discussed. Skill at communicating. Attitudes towards the other person and towards the subject being discussed. 7. Personal needs and interests.

8. Background, including cultural, social and philosophical values. 9. The senses involved and their functional ability. 10. The environment in which the communication take place. 11. Past experiences that relate or are related to the present situation. 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. Warmth 2. Humor

LANGUAGE OR VERRBAL COMMUNICATION Language is basic to communication. Without language the higher-order cognitive process of thinking, reasoning and generalizing cannot be attained. Words are to express ideas and feelings or to identify or describe objects. Words shape experiences and influence cultural perceptions. Although words provide a special

way of looking at the world, the same words often have different meaning for different individuals within cultural groups. In addition, word meanings change overtime and in different situations. It is important to ascertain that the message is received and understood as the sender intended it.

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 precipitatecompletely 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. Language reflects the dominant concerns and interests of a people. This can be noted in the number of words for certain things. Some classic studies have reported that certain cultures are many words to describe a particular object of importance. For example, in the Arabic language there are about 6000 names for camels. Another example:- eskimos have many words for snow. Name:- Name have a special psychological and cultural significance. All people have names, and in every culture naming a newborn is considered important. The considerations that go into the naming process vary greatly from culture to culture. For example, the Russian system of naming provides a clue to the significance placed on relating son and father, as well as daughter and father. The mother is left out, with Russians habitually addressing each other by the individual s given name together with father name. The family name is omitted. Spaniards and Latin Americans include women more than other cultures, with children carrying their father s name first and their mother s name second.

Another variation is seen in the Dutch, who have the option ofn using both the husband s and wife s family names jointly.

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. For some cultures patterns of social amenities can create communication problems. Small talk, social chitchat , and discussion of mundane topics that may appear to kill time are necessary as preliminaries for more purposeful discussion. Many patients tend to add irrelevant material because it lessen embarrassment. They may be more comfortable if attention is not focused on their medical problems, so they may intersperse actual symptoms with other biographical datas.

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. The softer volume of Asians or nativeAmericans speech may be interpreted by the nurses as shyness. On the other hand, the nurses behavior may be viewed as loved and boisterous if the volume is loud and if there is a deliberate attempt to accent particular words. It is important for the nurse to remember that paralinguistic behavior is an important cultural consideration when assessing the patient. This behavior can be recognized by the nurse by listening to nonword vocalizations such as sobbing, laughing and grunting, the tone of the voice and finally, the quality of the voice.

INTONATIONS Intonation is an important aspect of the communication message. When people says 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. Techniques of intonation vary among cultures. For example, Americans put commands in the form of suggestions and often as questions, whereas Arabic speech contains much emphasis and exaggeration.

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. Nurses need awareness of possible meaning of a silence so that personal anxiety does not prompt the silence to be interrupted prematurely or untheraputically

NON VERBAL COMMUNICATION Nonverbal communication is an important aspect in communication as 65% of the message received in communication is nonverbal. Through body language or emotions (kinetic behavior), the person conveys what cannot or may not be said in words. For a message to be accurately interpreted, not only must words to translated, but also the meaning held by nuances, intonation pattern and facial expressions. To understand the patient, the nurse may wish to validate impressions with other health team members, since nonverbal behavior is often interpreted differently by different people. It is important for the nurse to be aware not only of the patient s nonverbal behavior, but also of personal nonverbal behavior that may add to, undo, or contradict verbal communication.

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. While the rules to touch may be unspoken and unwritten, they are usually visible to the observer. A nurse should stay within the rules of touch that are culturally prescribed. It is essential that the nurse use touch judiciously and avoid forcing touch non anyone. The nurse must keep in mind that the message conveyed

through touch depends on the attitude of the persons involved and the meaning of touch both to the person touching and to the person being touched. A momentary and seemingly incidental touch can establish a positive, temporary bond between stranger, making them more complaint, helpful, positive and giving. In all cases touch needs to be applied deliberatively, with empathy, and with close attention given to the person s unique and particular needs. All cultural groups have rules, often unspoken, about who touches whom, when and where. The astute nurse must be mindful of the patient s reaction to touch in order to avoid being perceived as intrusive.

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. Eye contact can communicate warmth and bridge interpersonal gaps between people. Lack of eye contact may be interpreted as a sign of shyness, lack of interest, low self-esteem, rudeness, thoughtfulness or dishonesty. In social interaction the speaker glances away from the listener to indicate collecting thoughts or planning what is to be said. If contact is not resumed, disinterest may be interpreted. Pupil dilation and constriction can also be assessed as a clue to anxiety level and positive response.

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. Body posture can provide important messages about receptivity. Body posture can also communicate attitude towards a person. For example, in the US an attentive posture is indicated by leaning toward a person. Physical pain is communicated by rigid muscles, flexed body and cautious movements.

COMMUNICATIONS THAT COMBINE VERBAL AND NON VERBAL ELEMENTS

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. Although warmth is also matter of perception, communication that focuses on human needs is more likely to be related to warmth in the speaker. Verbal recognition (for example, a hallo on meeting) or a statement of genuine concern (for example, how are you feeling) can convey interest and may facilitate a positive relationship between patient and family and nurse. If the patient is from another culture and is having difficulty with understanding communication, the nurse s warmth may be vital promoting a positive relationship.

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. Personality, culture, background and levels of stress and pain may influence reactions to humor. When people are from a different culture, humor must be used in limited and wellthought-out situations, since humor can be an obstacle to a relationship if it is

misunderstood. The nurse must carefully asses the individual patient and the situation to evaluate if humor is appropriate. The ability to laugh at oneself and others can ease the anxiety that may be present in an intercultural situation. IMPLICATIOS FOR NURSING CARE 1. 2. 3. 4. 5. Assess personal beliefs surrounding persons from different cultures. Assess communications variables from a cultural perspective. Plan care based on communicated need and cultural background. Modify communication approaches to meet cultural needs. Understand that respect for the patient and communicated needs is central to the therapeutic relationship. 6. Communicate in a nonthreatening manner. 7. Use validating techniques in communication. 8. Be considerate of reluctance to talk when the subject involves sexual matters. 9. Adopt special approaches when the patient speaks a different language. 10. Use interpreters to improve communication.

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.

SPATIAL BEHAVIOR Spatial behavior is often described in the nursing literature in relations to the universal need for territoriality. People by nature are territorial. Territoriality refers to a state characterized by possessiveness, control and authority over an area of physical space. One can relate territoriality needs to spatial behaviors of or proximity to others, to objects in the environment, and to body movement, and to body movement or position.

PROXIMITY TO OTHERS 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 peoplewho 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. Elderly are now likely to experience separation from others through the death of a spouse and the moving away of offspring, their spatial need may appear to change; that is they may withdraw or may reach out more for others. Interpersonal messages are communicated not only by body proximity, but also by the location and availability of the nurse during the day. A patient who knows that the nurse will answer when the call bell is pressed feels differently than the patient who does not understand how the call bell works of feels it is an imposition to ask for help and waits for the nurse to ask what can be done. A person who wishes to maintain distance will indicate this by body language. Individuals who step back, do not face the nurse directly, or pull their chair back from the nurse are sending messages indicating additional space requirements. It is important that the nurse be aware if the effects of culture on the patient arespecial needs and use sensitivity in responding to the patients need for personal territory. Americans, Canadians and the British require the most personal space, whereas Latin American, Japanese and Arabic persons need the least.

OBJECTS IN THE ENVIRONMENT Objects in the environment offer additional dimensions to communication and can provide both positive and negative qualities to verbal communication. Easily movable chairs in a waiting room or office can be pulled together to provide physical closeness or, if the patient prefers it, separated to provide distance. Positioning chairs at a 90 degree angle can communicate a cooperative stance,

where as a side-by-side arrangement of chairs can decrease communication.Cleanliness in the environment may also be a significant factor in creating a healthy and comfortable milieu. Comfortable air conditioning in a patient waiting room on a hot day can facilitate a patients ease and decrease anxiety. On the other hand, when the air conditioning is absent or malfunctioning on a hospital ward on a hot day, patient and staff anxiety can escalate. Discomfort and consequently emotional distance can be created by uncomfortable furniture. The nurses position during the conversation( for example, behind a desk or leaning against the corner of the desk looking down on the patient seated at a lower level) can also promote the perception of psychological distance. In any case, the nurse needs to be aware of the effect culture may play on the patients reaction to objects in the environment and should respond in a way that patient comfort will be increased. The nurses clothes, hair, and jewelry also affect the message that the patient receives. For example, a child may be fearful of white, relating it to being hurt. A male patient may perceive any female nurse with red hair as sexy. Medical symbols such as a stethoscope around the nurses neck or a name pin may indicate to the patient that the nurse is a knowledgeable professional. On the other hand, lack of a cap or uniform, if the patient expects nurses to have caps or uniforms, may cause the patient to doubt the competency or professionalism of the nurse.

STRUCTURAL BOUNDARIES A boundary separates a person from others and also helps define a person s space. Fences, doors, curtains and walls, as well as desks, chairs, and certain objects, may create a boundary between the individual and others. The purpose of the boundary is to facilitate individuation or separation from the environment. Structural boundaries can help the individual adapt to both internal and external stresses. On the other hand, when structural boundaries are violated anxiety may increase. The nurse needs to assess whether the patient has rigid or flexible boundaries. If a patient has open boundaries, less anxiety will be encountered in interactions with health professionals that may violate personal boundaries. If the patient has rigid boundaries, the nurse should guard against approaches that may be perceived as threatening. Doors, curtains, and furniture arrangements may define patients territories.

Nursing staff also have professional territorial imperatives. Nurses stations and lounges may be designated as staff territory. The best example is a locked psychiatric nurses station.

BODY MOVEMENT OR POSITION Body movement or position can also communicate a message to others. It is well known that body movements may be of particular importance during periods of stress. Expressions of self through movement are learned before speech; therefore when stress is experienced, a person may revert to a form of expression used at an earlier level. Attention to body movement can facilitate understanding of a person experiencing stress. There are endless expressions of body movement, such as finger pointing, head nodding, smiles, slaps on the back, head and general body movements and even body sounds, including belching, knuckle cracking, and laughing. Body motions or kinetic behaviors, can be categorized as follows: 1. EMBLEMS: Nonverbal actions that have a verbal translation into a word, phrase or symbol. This includes sign language used in the operating room or the gesture of thumb and forefinger to form a circle to say A- OK in America. 2. AFFECT DISPLAYS: Facial expressions such as a frown, smile, or lips pulled down at corners. 3. ILLUSTRATIONS: Nonverbal acts accompanying speeches. Examples of this include an up-turned thumb to indicate a ride is desired or pointing a finger to indicate a direction. 4. ADAPTERS: Nonverbal behavior that modifies or adds to what is being said. For example, folded arms may indicate disgust or that a person is feeling closed to others, a wave may and be used as a friendly greeting. 5. REGULATORS: Movements that maintain interaction and provide feedback. Head nods or changing gaze can indicate that it is the other person s turn to talk. A head nod can also indicate listening.

IMPLICATION FOR NURSING CARE It is important for the nurse to remember that territoriality, or the need for space serves four functions:1. 2. 3. 4. Security Privacy Autonomy Self-identity

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.

TERMS RELATED TO THE CONCEPT OF SOCIAL ORGANIZATION 1. CULTURE-BOUND: As children grow and learn a specific culture, they are to some extent imprisoned without knowing it. Some anthropologists have referred to this existence as culture bound. (give example) 2. ETHNOCENTRISM: For the most part, people look at the world from their own particular cultural view point. Ethnocentrism is the perception that one s own way is best. In populations throughout the world, people are bound by common ties, elements, life patterns and basic beliefs particular

to their country and they consider their life is the best. ( give example :malayalam language and tamil language) 3. HOMOGENEITY:- In a homogenous culture all individuals would share the same attitudes, interests and goals. 4. BICULTURE/ETHNICITY:- The term biculture is used to describe a person who crosses two cultures, life styles and sets of values. Ethnicity in its broadest sense refers to groups whose members share a common social and cultural heritage passed in to each successive generation. 5. RACE:-ethnic and racial groups can and do overlap, because in many cases the biological and cultural similarities reinforce one another. 6. MINORITY:- A minority can consists of a particular racial, religious, or occupational majority of the population. Often a minority group is designated because of its lack of power, assumed inferior traits, or supposedly undesirable characteristics. Persons who belong to a bicultural group may share ethnic and racial characteristics of the larger group of which they are a part but at the same time have common cultural differences from the larger group.

IMPLICATIONS FOR NURSING CARE When nurses provide care to patients from a sociocultural background other than their own, they must have an awareness of and a sensitivity to the patients sociocultural background, including knowledge of family structure and organization, religious values and beliefs, and how ethnicity and culture relate to role and role assignment within group settings.

IV.

TIME

Since the beginning of life on earth, time has been the greatest mystery of all. Our experience with time continuously leads us into puzzles and paradoxes. The

concept of the passage of time is very familiar to all people regardless of cultural heritage. 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. The orientation refers to an individual s focus on the past, the present, or the future. Most cultures combine all three time orientations, but one orientation is more likely to dominate. The American focus on time tends to be directed to the future, emphasizing time and schedules. Nursing students know what times they must be in class or clinical. They know what courses they will take in future semesters. European americans often plan for next week, their vocation, or their retirements. For these people adhering to a time-structured schedule is a way of life, regardless of whether the schedule involves work or leisure. For the nurse who works with future-oriented individuals, it is important to talk about events in relation to the future and to adhere to the schedule for planned events in a timely and precise manner. 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. The culture of nursing and health care values time. Appointments are scheduled, and treatments are prescribed with time parameters(eg; changing a dressing one a day). Medication orders include how often the medicine is to be taken and when (eg, digoxin 0.25mg, once a day, in the morning). Nurses need to be aware of meaning of time for clients. 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.

PERCEPTION OF HEALTH AND ILLNESS How are experiences and copes with illness is based on the individuals explanation of sickness. Nurses must incorporate both personal and cultural reactions of the client to illness, disease and discomfort to give culturally appropriate nursing care. Nurses must keep in mind the fact that perceptions of health and illness are shaped by cultural factors. As a direct result of cultural shaping , individuals vary in health care behaviors , health status and health seeking attitudes.

CULTURAL HEALTH PRACTICES Cultural health practices are categorized as efficacious(beneficial), neutral, dysfunctional, or uncertain. Efficacious cultural health practices are those practices that are viewed as beneficial to the clients health status, although they can differ vastly from modern scientific practices. Because efficacious health practices can promote effective nursing care, nurses need to actively encourage the use of these practices among and across cultural groups. For example, some Mexican American may subscribe to theory of hot and cold. For example headaches may have a causative agent that is believed to have a hot or cold quality not related to temperature. If the causative or agent is believed to have a hot quality, then cold herbs may be placed on the persons head to absorb the heat.

Neutral cultural health practices have no effect on the health status of an individual. Nurse must remember that such practices may be extremely important because they may be linked to beliefs that are closely integrated with an individual s behavior. For example, southeast Asian women believe that sitting in a door frame or on a step will complicate labor. Therefore when they are in waiting or examination rooms, these women will avoid sitting near a door. Dysfunctional cultural health practices are harmful. The nurse must be aware of practices that are dysfunctional and should work to establish educational training programs that will help individuals identify dysfunctional health practices and develop beneficial practices. For example, a Canadian study noted that women of Canadian native population did not participate in routine gynecological screening and that their mortality from cervical cancer was higher than in other groups. In this example the nurse needs to teach the client about the benefits of routine screening and assist the client in blending cultural beliefs with contemporary screening practices. Uncertain health practices are those that have no proven effect. These include such things as swaddling a newborn infant to maintain body temperature and infant to prevent umbilical hernias. However, these practices are based on tradition and provide comfort to the individuals who practice such activities. FOLK MEDICINES: It is one of humankind s earliest uses of the natural environment and is the use of herbs, plants, minerals, and animal substances to prevent and treat illness. Folk medicine is practiced in a variety of countries and cultural groups.

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 area 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 a 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 When working with people from diverse cultural backgrounds, the nurse should have an understanding of how different races evolved in relation to the environment. Biological differences noted in skin color may be attributable to

the biological adjustments a person s ancestors made in the environment in which they lived. For example, it has been scientifically postulated that the original skin color of human on earth was black. Further postulations suggests that white skin was the result of insulation and environmental pressures exerted on persons living in cold, cloudy climate. The mutation is thought to have occurred because light skin was bitter able to synthesize vitamin D, particularly on cloudy days. 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. OTHER VISIBLE PHYSICAL CHARACTERISTICS In addition to looking for changes in pallor and cyanosis, it is important for the nurse to note other aberrations in the skin. For example, Mongolian spots may be present on the skin of black, Asian,native American or Mexican American newborns. Mongolian spots are bluish discolorations that vary tremendously in size and color and are often mistaken bruises.

4. ENZYMATIC AND GENETIC VARIATIONS The basic genetic makeup of an individual is determined from the moment of conception. A person can be only what he or she is genetically determined to be more specifically, growth and development cannot go beyond what the genes make possible. An individual will not grow 1 inch taller than genetic structure regardless of the amount of exercise or vitamins consumed. The incidence of dizygote twinning is highest in BLACKS, occurring in 4% of births. Dizygote twinning occurs in approximately 2% of births in whites and in 5% of births in Asians (Bulmer, 1970)

5. DRUG INTERACTIONS AND METABOLISM Reaction to drug vary with race. There is some evidence suggesting that drugs are metabolized by different races in different ways and at different rates. In the body there are three classes of reactions to foreign chemicals or drugs: hydrolysis, conjugation and oxidation. 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.

6. ELECTROCARDIOGRAPHIC PATTERNS A common finding in black Americans, particularly in black men, is the occurrence of inverted Twaves 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.

7. 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 concernedwith 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.

8. BLOOD GROUPS Blood groups also differentiate people in certain racial groups. A prevalence for type O blood has been found among American Indians, with some incidence of type A blood and virtually no incidence of type B blood. Almost equal incidences of types A, B and O blood are found in Japanese and chinese peoples with AB group found in only about 10% of Japanese and chinese population.

9. NUTRITION Nutrition status also vary 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.