NCM 120 | PRELIM |1st Semester
Topic 1 knowledge to provide culturally specific and
Transcultural Nursing and Decent
Work Employment
Introduction
Culture
• The collection of beliefs, values, behaviors,
and practices, shared by a group of people
and passed from one generation to the next.
• Learned from birth.
• Molded by environment.
• Guides thinking, decision and actions.
• Culture is a patterned behavioral response
that develops over time as a result of
imprinting the mind through social and
religious structures and intellectual and
artistic manifestations.
• Are nonphysical traits, that are shared by a
group of people and passed from one
generation to the next
Types of Culture:
1. Material Culture
• Refers to objects (dress, art, religious
artifacts)
2. Non-material Culture
• Refers to beliefs customs, languages,
social institutions.
3. Culture-specific
• Particular values, beliefs and pattern 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.
4. Culture-universal
• Commonly shared values, norms of
behavior, and life patterns that are
similarly held among cultured about
behavior and lifestyles.
Transcultural Nursing
• Focuses on the study and analysis of
different cultures and subcultures with
respect to cultural care, health beliefs and
health practices, with the goal of providing
health care within the context of the clients
culture.
• Defined by Leininger as a “humanistic and
scientific area of formal study and practice
which is focused upon differences and
similarities among cultures with respect to
human care, health (or well-being), and
illness based upon the people’s cultural
values, beliefs and practices.”
• According to Leininger, the ultimate goal of
transcultural nursing is use of relevant
culturally congruent nursing care to people.
Topic 2
Transcultural Nursing and Decent
Work Employment
Theoretical Foundations of Cultural Nursing
Caring
• Action or activity towards providing care.
• Care assists others with real or anticipated
needs to promote health and wellness.
Culture care diversity and universality.
• Diversity – differences in meanings,
values or care of different groups of
people.
• Universality – common care or
similarities among cultures.
Madeleine Leininger
• The founder of the theory of Transcultural
Nursing / Culture of Care Theory.
• Her theory has now developed as a
discipline in nursing.
• Evolution of her theory can be understood
from her books:
o Culture Care Diversity and Universality
(1991)
o Transcultural Nursing (1995)
o Transcultural Nursing (2002)
• Theoretical framework if depicted in her
model called the Sunrise Model (1997)
Beginnings of The Theory
• In mid 1940’s, working with medical surgical
patients, she began to realize how the
concept of human care was important in
nursing.
• After WWII, she worked as a clinical
specialist in child mental health in a child
guidance center. Children were from
culturally diverse backgrounds due to their
immigration.
• She noticed behavioral differences and
questioned the cultural aspects of these
differences in relation to care.
• Her continued observations, questioning,
and linking the concepts of human care and
culture led to her establishing the theory of
culture care and transcultural nursing.

Leininger’s Sunrise Model
• The model is based on the concept of culture
care and shows 3 major nursing modalities
that guide nursing judgements and activities
to provide ‘Culturally Congruent Care’.
3 Major Modalities are:
1) Cultural Care Preservation
Maintenance.
− Professional actions and decisions
that help people of a particular culture
to retain and/ or preserve relevant
care values so that they can maintain
their well-being, recover from illness,
or face handicaps and/or death.
Nurse should be non-judgmental and
should not tell them that their way is
wrong.
2) Cultural Care Accommodation
Negotiation.
− Professional actions and decisions
that help people of a designated
culture to adapt to or to negotiate with
others for beneficial or satisfying
health outcomes with professional
care providers.
− An example would be if an individual
were using a folk remedy to treat a
wound. Instead of telling them it will
not help, a nurse could ask “Is it
working for you or are you getting
better?”
3) Cultural Care Repatterning
Reconstructing.
− Professional actions and decisions
that help clients reorder, change, or
greatly modify their life ways for new,
different, and beneficial health care
patterns while respecting the client's
cultural values and beliefs and still
providing more beneficial or healthier
life ways than before the changes
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were established with the clients. The
nurse could show the patient a
different medicine and give them
information concerning the new
medicine such as it has helped her
and others to heal. Explain that it will
help if they use it on a regular basis
and not just one time.
Leininger’s Theory
• Note: that the model looks like a Sunrise and
the World View encompasses everything
that makes people who they are.
• The 7 Cultural and Social Structure
Dimensions are the large areas that nurses
need to learn about through interview and
living among the people of different cultures.
• Below, the individuals, families, groups,
communities and institutions are the Diverse
Health Systems that all persons deal with in
various ways.
• Generic or Folk Systems
/ − are the everyday remedies an
individual, family or group may use to
promote wellness and healing. Some
examples might include:
o Chicken soup
o Chamomile tea or other herbal teas.
o Voodoo
o Sacrifices of birds or animals to the
spirits.
o Prayer
o Traditional healer.
/ ✓ Nurses needs to assess in all these
areas to plan, safe, effective care.
• Professional Systems
− Are different depending upon the Health
Care Delivery System of that culture.
Whether there is socialized medicine,
private insurance, communal healthcare,
poor economic support vs. great wealth,
all contribute to the influence of the
utilization of professionals to prevent
illness, heal illness and promote health
and wellness.
✓ Nursing must collaborate within the
healthcare delivery system to plan and
/ implement safe, effective, culturally
competent care.
Cultural Competence
• It is a combination of culturally congruent
behaviors, practice attitudes, and policies
that allow nurses to work effectively in cross
cultural situations.
The Giger and Davidhizar – Transcultural
Assessment Model
− In the context of Giger and Davidhizar’s
Transcultural Assessment Model (1990,
2002), transcultural nursing is viewed as a
culturally competent practice field that is
client centered and research focused.
− Every individual is culturally unique, and
nurses are no exception to this remis.
Nonetheless, nurses must use caution to
avoid projecting on the client their own
cultural uniqueness and worldviews if
culturally appropriate care is to be provided.
• This model was developed in 1988 in
response to the need for nursing students in
an undergraduate program to assess and
provide care for patients that were culturally
diverse.
• Giger and Davidhizar have identified six
cultural phenomena that vary among cultural
groups and affect health care.
I. Communication
• Communication is the means by which
culture is transmitted and preserved. Both
verbal and nonverbal communication are
learned in one’s culture.
• Verbal and nonverbal patterns of
communication vary across cultures, and if
nurses do not understand the client’s cultural
rules in communication, the client’s
acceptance of a treatment regimen may be
jeopardized.
Considerations:
• Vocabulary
• Grammatical Structure
• Voice qualities.
• Intonation.
• Rhythm
• Speed
• Silence.
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Vocabulary
• For an Orthodox Jew, the word pig is
synonymous with the word unclean or
unholy and thus should be avoided. On the
other hand, for a pig farmer the word pig
implies clean, wholesome means of making
a living.
Verbal
• Language barriers can create severe
communication problems.
a) Language barrier may arise from the use
of different language system.
− Ex. The sender is speaking English and the
receiver is speaking Spanish.
b) Language barrier also arise when the
sender uses technical terms that are
unfamiliar to the receiver.
− Ex. Nurses use medical terms when
explaining a procedure to a normal person or
patient.
Use of an Interpreter
• Before locating an interpreter, first know the
language the client speaks at home.
• Avoid interpreter from a rival tribe, state and
region.
• Be aware of gender differences.
• Be aware of age differences.
• Ask the interpreter to translate as closely to
verbatim as possible.
• Expect compensation for services rendered.
Non-verbal
− Conveyed through facial expressions and
body language, eye contact, also includes
touch and proxemics.
1. Silence – lack of audible sound.
Consider this:
Many American Indians have this latter view
of silence, as do some traditional Chinese
and Japanese persons. 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 Russian, 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 toward an
elder. Mexicans may use silence when
instructions are given by a person in authority
rather than showing the disrespect of
disagreement (Quarnero, 2005). Nurses
need to be aware of possible meanings of
silence so that personal anxiety does not
promote the silence to be interrupted
prematurely or to be nontherapeutic. A nurse
who understands the therapeutic value of
silence can use this understanding to
enhance care of clients from other cultures.
Silence Across the World:
a. Native North American
• Consider silence essential to
understanding and respecting other
person.
b. French, Spanish, and Eastern European
• Interpret silence as a sign of agreement.
c. African American
• Used in response to a question perceived
as inappropriate.
2. Facial Expressions
− Used as a guide to a person’s feelings.
− Vary from culture to culture.
Facial Expressions Across the World:
a. African Americans and Spanish.
• Use many facial expressions along with
gestures to communicate feelings of
happiness, pain or displeasure.
b. Northern Europeans.
• Tend to use less facial expression and
are generally less responsive.
c. Asians
• Uses facial expression to convey
opposite meaning from the one that is
felt.
• Conceal negative emotions with a smile.
3. Eye Contact
− Important tool in TCN assessment.
− Eye contact is also a culturally
determined behavior.
− “the eyes are the windows of the soul”
− Eye contact is an important tool in
transcultural nursing assessment and is
used both for observation and to initiate
interaction. In the United States, those of
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the dominant culture (predominately
Whites) value eye contact as symbolic of
a positive self-concept, openness,
interest in others, attentiveness, and
honesty.
− McKenzie and Chrisman (1977) reported
that, for some Filipinos, eye contact that
turns away is associated with the
possibility of being a witch. Other groups
who find eye contact difficult include
some Asian people and some American
Indians, who relate eye contact to
impoliteness and an invasion of privacy.
− Many American Indians regard eye
contact as disrespectful because it is
believed that "looking in an individual's
eyes" is "looking into an individual's soul"
(Galanti, 2003; Giger & Davidhizar, 2001;
Henderson & Primeaux, 1981; Poole,
Davidhizar, & Giger, 2003).
− A strong may be interpreted as a sign of
disprespect among Asian, American
Indian, Indo-Chinese, Arab patients who
feel that direct eye contact is impolite or
aggressive.
Eye Contact Across the World
a. American Indian
− patient may stare at the floor during
conversations. That’s a cultural behavior
conveying respect, and it shows that he’s
paying close attention to you.
b. Hispanic
− patient may maintain downcast eyes in
deference to someone’s age, sex, social
position, economic status or position of
authority. deference - humble submission
− Eye contact is expected of you but will
not be reciprocated by patients.
c. Americans
− Assumes that it is a negative sign when
a person avoids eye contact; it means
shyness, lack of interest, and dishonesty.
− Value eye contact as symbolic of a
positive self – concept, openness and
honesty.
d. Muslin Arab Women
− Avoid eye contact with males (except for
ones husband)
e. India
− Amount of eye contact depends on one’s
social position.
f. African-American ; Mexican-Americans
− Comfortable with eye contact.
4. Touch
− The meaning people associate with
touching is culturally determined to a
great degree.
− In Hispanic and Arab Cultures, male
health care providers may be prohibited
from touching or examining certain parts
of the female body; similarly, females
may be prohibited from caring for males.
− Among many Asian Americans, touching
a person’s head may be impolite
because that’s where they believe the
spirit resides.
− Before assessing an Asian American
patient’s head or evaluating a head
injury, you may need to clearly explain
what you’re doing and why.
− Always consider a patient’s culturally
defined sense of modesty when given
nursing care.
− For example, some Jewish and Islamic
women believed that modesty requires
covering their head, arms, and legs with
clothing. Respect their tradition and help
them remain covered while in your care.
Touch Across the World:
a. Asians
• Touching the head is a sign of disrespect
because it is believed that the head is the
source of person’s strength.
b. Vietnamese Americans
• Vietnamese Americans may find touching
shoulders with another to be anxiety
producing, since they believe that the soul
can leave the body on physical contact and
that health problems may result (Rocereto,
1981).
• The Vietnamese regard the human head as
the seat of life and therefore highly personal.
Procedures that invade the surface or any
orifice of the head can frighten the
Vietnamese, who fear that these procedures
could provide an escape for the essence of
life (Stauffer, 2005)
c. Native Americans
• View a firm handshake as aggressive and
offensive.
d. Westerners
• Think nothing of kissing or hugging a friend
as a form of greeting when meeting in public
places.
e. Traditional Asian Cultures
• Kissing and hugging is reserved for intimate
relationships in private settings.
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II. Space
− Space refers to the distance between
individuals when they interact. All
communication occurs in the context of
space.
− There are four distinct zones of interpersonal
space:
1. Intimate Zone (extends up to 1 ½ feet)
2. Personal Distance (extends up to 1 ½ to 4
feet)
3. Social Distance (extends from 4 to 12 feet)
4. Public Distance (extends 12 feet or more)
Proxemics
• The term for the study of human use and
perception of social and personal space
(Hall, 1974)
• Individual tends to divide surrounding
space into regions of front, back, right
and left. (Franklin, Henkel, and Zangas,
1995))
Territoriality
• Refers to the behavior and attitude
people exhibit about an area they have
claimed and defend or react emotionally
when other invade it.
Space Across the World:
a. Middle Class Americans, Canadians, British
− When forced to stand or sit close to
people they do not know well.
− They feel that their space is being
violated.
b. Latin Americans, African, Black Americans,
Indonesians and French.
− Prefer to stand close to one another
when holding conversation.
III. Social Organization
− Social organization refers to the social
group organizations with which clients
and families may identify.
Types of Family Structure:
• Traditional nuclear family.
• Nuclear dyad family.
• Extended family.
• Skip-generation family.
• Alternative family.
• Single-parent family.
• Reconstituted or blended family.
• Special forms of families: communal and
gay family.
Religion
− is a social phenomenon (Carroll,
Johnson, & Marty, 1979). Religious
practices, therefore, are usually rooted in
culture, and each culture typically has a
set of beliefs that define health and the
behaviors that prevent or treat illness
(Davidhizar, Bechtel, & Cosey, 2000).
1. Jehovah’s Witness
2. Seventh Day Adventist.
3. Islam
4. Christianity.
Selected Culture-Bound Syndrome
− These are mental conditions or
psychiatric syndromes whose
occurrence or manifestations are closely
related to cultural factors and which thus
warrant understanding and management
from a cultural perspective.
− Recent suggestions to rename it as Whites
“Culture Related Specifc Syndromes” • Anorexia nervosa
Example:
• Amok, a mental or emotional affliction
known in the Philippines that causes one • Bulimia
to become a killer.
• Susto, an ailment widely associated with
Spanish-speaking groups in which the
soul is believed to leave the body as a Japanese
result of a frightening event. (Bonder,
Martin, and Miracle, 2002)
Hispanic
• Empacho Blacks
− When a fragment or portion of food
sticks or settles to the inside of the
intestine making it difficult to process,
creating serious problems for the
digestive tract.
− Food forms into a ball and clings to the
intestines, causing pain and cramping.
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• Mal de ojo
− “Mal de ojo” or “evil eye”, is a folk
illness primarily affecting children,
with infants being particularly
vulnerable. This supernatural beliefs
holds that an admiring look or a stare
can weaken the child, leading to bad
luck, sickness and even death.
− Fitful sleep, crying, diarrhea in
children caused by a strangers
attention; sudden in onset.
• Pasmo
− Paralysis – like symptoms of face or
limbs, prevented or relieved by
massage.
• Susto / fright sickness.
− Anxiety, trembling, phobias from
sudden fright.
− Symptoms include nervousness,
anorexia, insomnia, listlessness,
despondency, involuntary muscle
tics, and diarrhea.
− Thought to be caused by fright that
results in loss of soul from the body;
causes can be natural or
“supernatural”.
− Natural Susto may occur after a near
accident.
− Supernatural susto may occur after
witnessing a supernatural
phenomena such as a ghost; and
might be sent by sorcerers.
− Those most likely to suffer from
susto are culturally stressed adults –
women more than men.
− Excessive preoccupation with thinness;
self-imposed starvation.
− Gross overeating and then vomiting or
fasting.
• Wagamama
− Apathetic childish behavior with
emotional outbursts.
• Blackout
− Collapse, dizziness, inability to move.
• Low blood
− Weakness or not enough blood
• High blood
− Blood that is too rich in certain things.
IV. Time Orientation
− Time is an important aspect of • Psychological characteristics.
interpersonal communication. Some
cultures are considered future oriented, A. Measurement
others present oriented, and still others
past oriented.
− These differences in time orientation may
become important in health-care
measures such as long- term planning
and explanations of medication
schedules.
− eg: Latin Americans, Native Americans,
and Middle Easterners are present
oriented cultures and may neglect
preventive health care measures. They
may show-up late or not at all for
appointments. B. Vital Sign
Campinha-Bacote (1997)
− Compared time orientation among
certain groups in relation to future-time
and present-time orientation:
• Dominant American: future over present
• African Black: present over future C. Skin
• Puerto Rican American: present over future
• Mexican American: present
• Chinese American: past over present
• American Indian: present
V. Environmental Control
− Environmental control refers to the ability
of the person to control nature and to Skin Condition:
plan and direct factors in the
environment.
− Some groups perceive man as having
mastery over nature; others perceive
humans to be dominated by nature, while
others, see harmonious relationships
between humans and nature.
− For example, Asians and Native
Americans may perceive that illness is a
disharmony with other forces and that
medicine is only capable of relieving the
symptoms rather than curing the disease.
These groups are likely to look for
naturalistic solutions, such as herbs and
hot and cold treatments to resolve or cure
a cancerous condition
VI. Biological Variations
Biological variations are:
• Body structure
• Skin color
• Other visible physical characteristics.
• Enzymatic and genetic variations.
• Electrocardiographic patterns.
• Susceptibility to disease.
• Nutritional preferences and deficiencies
− Height and weight vary among cultural
group.
− Black men have lower BP than their white
counterparts from age 18 to 34.
− Black women have a higher average
systolic BP than White counterparts at
every age.
− Normal skin color ranges widely.
− Observation is labeled with the following
adjectves:
• Copper
• Olive
• Tan
• Brown
• Mongolian Spots
− Irregular areas of deep blue
pigmentation usually located in the
sacral and gluteal areas.
− Present in 90% of Blacks, 80% of
Asians, and 9% of Whites.
• Vitiligo
− Characterized by unpigmented skin
patches.
− Affects an estimated 2-4 million
Americans primarily dark-skinned
individuals.
• Cyanosis
− The most difficult clinical sign to
observe in darkly pigmented persons.
− Exercise caution when assessing
person from Mediterranean descent,
because their circumoral region is
normally dark blue.
• Jaundice
− Exercise caution to avoid confusion
other forms of pigmentation with
jaundice.
− Example: African Americans, Filipinos
have heavy deposits of

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 subconjunctival fat that contains high
levels of carotene in sufficient
quantities to mimic jaundice.
• Pallor
− When assessing for pallor in darkly
pigmented patients you might
experience difficulty because the
underlying red tone are absent.
− Brown-skinned individual will
manifest pallor with a more yellowish
brown color.
− Black-skinned person will appear
ashen or gray.
• Petechiae
− In dark-skinned patient: are best
visualized in the area of lighter
myelinization, such as the abdomen
and buttocks.
− Black or very dark brown patients: E. Laboratory Tests
Petechiae are most easily seen in the
mouth; buccal mucosa and
conjunctiva.

D. Variations in Illness
• Aland Islanders – ocular albinism.
• Amish – Hemophilia B.
• Blacks – sickle cell disease.
• Chinese – thalassemia.
*The Amish are a group of traditionalist
Christian church fellowships with Swiss
Anabaptist Origins.
• Costa Ricans – Malignant Osteopetrosis.
• Eskimos – congenital Adrenal
Hyperplasia.
• Jews – Tay-Sachs disease.

Biocultural Aspects of Disease:

• Anemia – high incidence among
Vietnamese.
• Asthma – six times greater for Native North
American.
• Lactose Intolerance – present among 66%
of Hispanic women.
• Sickle cell anemia – increased incidence
among Blacks.

Cancer
• Nasopharyngeal – high among Chinese
North American.
• Esophageal – No. 2 cause of death for Black
men.
• Cervical – 120% higher in Black women.

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