Transcultural Nursing This page was last updated on October 27, 2011

INTRODUCTION
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Madeleine Leininger is considered as the founder of the theory of transcultural nursing. Her theory has now developed as a discipline in nursing. Her theory first appeared in her theory book Culture Care Diversity and Universality (1991) but originated in the 1950s. The theory was further expanded in her book Transcultural Nursing (1995) In the third edition of her book Transcultural Nursing (2002) explains the theory-based research and practice applying the concepts of the transcultural theory. Transcultural nursing theory is also known as Culture Care theory. Theoretical framework is depicted in her model called the Sunrise Model (1997).

ABOUT THE THEORIST

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a pioneering nursing theorist and transcultural global nursing consultant. MSN from Catholic University in Washington DC. PhD in anthropology from the University of Washington. She developed the concept of transcultural nursing and the ethnonursing research model. For more details: http://en.wikipedia.org/wiki/Madeleine_Leininger

DEFINITIONS Transcultural Nursing

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

Culture
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Set of values, beliefs and traditions, that are held by a specific group of people and handed down from generation to generation. Culture is also beliefs, habits, likes, dislikes, customs and rituals learn from ones family. Culture is the learned, shared and transmitted values, beliefs, norms and life way practices of a particular group that guide thinking, decisions, and actions in patterned ways. Culture is learned by each generation through both formal and informal life experiences. Language is primary through means of transmitting culture. The practices of particular culture often arise because of the group's social and physical environment.

Culture practice and beliefs are adapted over time but they mainly remain constant as long as they satisfy needs.

Religion
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Is a set of belief in a divine or super human power (or powers) to be obeyed and worshipped as the creator and ruler of the universe.

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

Ethnicity
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a consciousness of belonging to a group.

Cultural Identify
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the sense of being part of an ethnic group or culture

Culture-universals
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commonalities of values, norms of behavior, and life patterns that are similar among different cultures.

Culture-specifies
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values, beliefs, and patterns of behavior that tend to be unique to a designate culture.

Material culture
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refers to objects (dress, art, religious arti1acts)

Non-material culture
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refers to beliefs customs, languages, social institutions.

Subculture
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composed of people who have a distinct identity but are related to a larger cultural group.

Bicultural
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a person who crosses two cultures, lifestyles, and sets of values.

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

Acculturation
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People of a minority group tend to assume the attitudes, values, beliefs, find practices of the dominant society resulting in a blended cultural pattern.

Cultural shock
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the state of being disoriented or unable to respond to a different cultural environment because of its sudden strangeness, unfamiliarity, and incompatibility to the stranger's perceptions and expectations at is differentiated from others by symbolic markers (cultures, biology, territory, religion).

Ethnic groups
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share a common social and cultural heritage that is passed on to successive generations.,

Ethnic identity
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refers to a subjective perspective of the person's heritage and to a sense of belonging to a group that is distinguishable from other groups.

Race
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the classification of people according to shared biologic characteristics, genetic markers, or features. Not all people of the same race have the same culture.

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

Culturally congruent care

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Care that fits the people's valued life patterns and set of meanings -which is generated from the people themselves, rather than based on predetermined criteria.

Culturally competent care

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is the ability of the practitioner to bridge cultural gaps in caring, work with cultural differences and enable clients and families to achieve meaningful and supportive caring.

Nursing Decisions Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. 1. Cultural preservation or maintenance. 2. Cultural care accommodation or negotiation. 3. Cultural care repatterning or restructuring.

MAJOR CONCEPTS [Leininger (1991)]

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Illness and wellness are shaped by a various factors including perception and coping skills, as well as the social level of the patient. Cultural competence is an important component of nursing. Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress. Religious and Cultural knowledge is an important ingredient in health care. The health concepts held by many cultural groups may result in people choosing not to seek modern medical treatment procedures. Health care provider need to be flexible in the design of programs, policies, and services to meet the needs and concerns of the culturally diverse population, groups that are likely to be encountered. Most cases of lay illness have multiple causalities and may require several different approaches to diagnosis, treatment, and cure including folk and Western medical interventions.. The use of traditional or alternate models of health care delivery is widely varied and may come into conflict with Western models of health care practice. Culture guides behavior into acceptable ways for the people in a specific group as such culture originates and develops within the social structure through inter personal interactions. For a nurse to successfully provide care for a client of a different cultural or ethnic to background, effective intercultural communication must take place.

PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR HEALTH CARE PERSONNEL
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To develop understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome. To encourage in developing and maintaining a program of physical, emotional and spiritual self-care introduce therapies such as ayurveda and pancha karma.

HEALTH PRACTICES IN DIFFERENT CULTURES Use of Protective Objects

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

Use of Substances .
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It is believed that certian food substances can be ingested to prevent illness. E.g. eating raw garlic or onion to prevent illness or wear them on the body or hang them in the home.

Religious Practices
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Burning of candles, rituals of redemption etc..

Traditional Remedies
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The use of folk or traditional medicine is seen among people from all walks of life and cultural ethnic back ground.

Healers
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Within a given community, specific people are known to have the power to heal.

Immigration
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Immigrant groups have their own cultural attitudes ranging beliefs and practices regarding these areas.

Gender Roles
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In many cultures, the male is dominant figure and often they take decisions related to health practices and treatment. In some other cultures females are dominant. In some cultures, women are discriminated in providing proper treatment for illness.

Beliefs about mental health

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Mental illnesses are caused by a lack of harmony of emotions or by evil spirits. Problems in this life are most likely related to transgressions committed in a past life.

Economic Factors

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

Time orientation
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It is varies for different cultures groups.

Personal Space
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Respect the client's personal space when performing nursing procedures. The nurse should also welcome visiting members of the family and extended family.

NURSING PROCESS AND ROLE OF NURSE

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First, determine the client's cultural heritage and language skills. Determine if any of his health beliefs relate to the cause of the illness or to the problem. Collect information that any home remedies the person is taking to treat the symptoms. Nurses should evaluate their attitudes toward ethnic nursing care. Self-evaluation helps the nurse to become more comfortable when providing care to clients from diverse backgrounds Understand the influence of culture, race &ethnicity on the development of social emotional relationship, child rearing practices & attitude toward health. Collect informationabout the socioeconomic status of the family and its influence on their health promotion and wellness Identifiy the religious practices of the family and their influence on health promotion belief in families. Understanding of the general characteristics of the major ethnic groups, but always individualize care. The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture. The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background. Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds. Self-evaluation by the nurse is crucial as he or she increases skills for interaction. .

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CONCLUSION
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Nurses need to be aware of and sensitive to the cultural needs of clients. The practice of nursing today demands that the nurse identify and meet the cultural needs of diverse groups, understand the social and cultural reality of the client, family, and community, develop expertise to implement culturally acceptable strategies to provide

nursing care, and identify and use resources acceptable to the client (Andrews & Boyle, 2002).

CAO GIO (Coin Rubbing or Coining) by Lan Pich

Date: 10/14/2006

What is it? Who practices it?

Over the years, there have been mass migrations of Southeast Asians to the United States who have brought along with them their traditional ideas of health and forms of healing. One of the most common folk remedies practiced among the Southeast Asians is cao gio. Regardless of the availability of western biomedicine, cao gio continues to be a popular form of alternative medicine practiced among these ethnic groups. Cao gio, also called coin rubbing or coining, is a dermabrasive therapy used to relive a variety of illnesses such as aches, pains, fevers, colds, cough, nausea, abdominal pain, chills and symptoms related to changes in the weather (Ostensen). Christian Ostensen, http://www.ouraim.cnc.net/GuaSha.html

Treatment/Methods
Cao gio involves an oil or ointment and a coin. Balms or oils such as tiger balm or liquid herbal medicines containing camphor, methanol, winter green oil, eucalyptus oil, peppermint oil, and cinnamon oil are most commonly used (Sullivan, 2005). The skin is first lubricated with a balm or oil and the coin is rubbed firmly and repeatedly in a linear pattern until blood appears under the skin. These skin abrasions are usually generated along the spine and ribs (Sullivan, 2005). The technique is considered effective when it produces prominent marks and these marks usually only last a few days. Tara Sullivan, http://altmed.creighton.edu/coining/default.htm

How does it work?

Cao gio is translated as catch the wind. Illnesses are believed to be caused by an excess of wind, and coining is believed to release the excess wind and restore balance to the body. To better understand this concept of wind, an understanding of the Southeast Asian cultural beliefs in health and medicine must be first established. There are a variety of beliefs and practices among the different ethnic groups; however, there is a common theme in their medicinal beliefs and practices that originates from the Chinese concept of yin and yang

(Sullivan, 2005). The belief states that the universe consists of opposing elements that are held in balance. Illnesses are interpreted as a disruption of this balance. Thus, health practices attempt to restore balance between these opposing elements. According to Lance Rasbridge, the imbalance can be a result of physiological state, such as pregnancy or fatigue, or it could be brought on by intrinsic factors like diet or over exposure to wind, one of the body forces or humors. This excess of wind in the body can cause ailments such aches, pain, colds, etc. and can be treated by releasing wind from the body. Cao gio is believed to do just that by pulling the wind to the surface of the body and creating a pathway in which it could be released. The amount of wind is measured by the degree of redness that appears on the body after coining, which also measures the severity of the illness. If the red marks that appear are mild, the illness is believed to be minor because there is a small amount of excess wind in the body and vice versa. Tara Sullivan, http://altmed.creighton.edu/coining/default.htm Lance Rasbridge, http://www3.baylor.edu/~Charles_Kemp/vietnamese_health.htm

Effectiveness and Complications

The effectiveness of coin rubbing is a really complex issue. According to numerous alternative healthcare websites and articles, cao gio is safe and its efficacy is only verified by testimonials of Southeast Asians who practice this form of healing. An extensive search of scientific articles was done by Dr. Tara Sullivan and she found no articles that verified its effectiveness. Sullivan states, coining is a cultural folk remedy with no basis in scientific evidence (Sullivan, 2005). Even though coining has no scientific basis, there were numerous articles set up in websites that concern ethnomedicine and cultural relativity because coining has been highly criticized by western doctors. I also attempted to find scientific articles on the subject of coining. The only articles available deal with complications associated with cao gio and the controversial issue of abuse due the misunderstanding of the red marks found on patients. Because of the lack of understanding and suspicion of its effectiveness among western physicians, there have not been any known attempts to conduct further research and only the failures tend to show up in medical records. For more information on complications, see: Amsh Amshel CE, Caruso D. (2002). Vietnamese Coining: A Burn Report and Literature Review. J Burn Care Rehabil 21(2), 112-114. Davis R. (2000). Cultural Health Care or Child Abuse? The Southeast Asian Practice of Cao Gio. J Am Acad Nurse Practitioners 12(3), 89-95. Rampini SK, Schneemann M, Rentsch K, Bachli EB. (2002). Camphor Intoxication After Cao Gio (Coin Rubbing). The Journal of the American Medical Association 288(1), 45. http://jama.ama-assn.org/cgi/content/full/288/1/45

Other Perspectives
1. Even though there is no evidence for its effectiveness, cao gio can be analyzed through another perspective. Coining uses balms and oils, such as tiger balm or other oils that contain camphor, that are absorbed trandermally when applied or rubbed against the skin with a coin. The effectiveness of cao gio to treat ailments such as aches and pains can be attributed to these balms and oils. Tiger balm is a topical analgesic that is believed to have a soothing action that relives aches and pain and is sold nationwide in pharmacies and health stores (http://www.tigerbalm.co.uk/ )A clinical study was done by Schatter and Randerson to test the efficacy of this product for the treatment of acute tension headaches. The study was a randomized, double blind study with a three-group comparison. Patients were recruited by newspaper advertisement and by general physicians who first subjected these patients to pretreatment assessments. The three different groups were given either tiger balm, topical placebo, or paracetamol and the outcome was measured by self report on a scale basis. The results showed a statistically significant difference (p<0.05) in headache relief between tiger balm and placebo; however, there was no significant difference between tiger balm and paracetamol (Schatter and Randerson, 1996). Schattner P, Randerson D. (1996). Tiger Balm as a Treatment of Tension Headache. A Clinical Trail in General Practice. Aust Fam Physician 25 (2), 216, 218, 220. 2. In addition, Hempel B, Kroll M, and Schneider did a study that involved the efficacy of camphor in hypotension and orthostatic circulatory disorders. Korodin Herz-Kreislauf, a herbal drug containing D-camphor, and an extract of hawthorn berries were tested against a placebo using a retrospective cohort study, which was performed in 46 medical practices in Germany. Four hundred and ninety healthy volunteers and patients between 11 and 102 years of age were recruited for this study. Three hundred and ninety-nine patients were treated with the test drug and 91 patients were treated with a control drug. Their files were later reviewed by physicians who assessed the improvement in symptoms. The data was controlled by using anonymous copies of the files and the heterogeneities in baseline conditions were adjusted. In conclusion, the test drug proved to be an effective form of treatment for orthostatic hypotension (Hempel, Kroll, and Schneider, 2005). Hempel B, Kroll M, Schneider B. (2005). [Efficacy and safety of a herbal drug containing hawthorn berries and D-camphor in hypotension and orthostatic circulatory disorders/results of a retrospective epidemiologic cohort study.] Arzneimittelforschung, 55 (8), 443-50. German. Camphors ability to improve blood pressures, as the study above shows, relates back to the belief that by releasing the excess wind, cao gio can improve circulation in the body. 3. Another perspective that can shed light on the effectiveness of coining is the placebo effect. Cao gio has been one of the most common forms of healing among Southeast Asians for a long time. Its effectiveness is firmly established among these cultural groups. Thus, the strong belief in its ability to heal and the outcome can be explained as a placebo effect. In addition, some of the illnesses that cao gio seeks to treat are minor ailments, such as colds and coughs, that are usually treated by the bodys natural defenses and the symptoms will eventually disappear if left untreated.

4. Another factor that affects the efficacy of cao gio is the combined use of western medicine. In particular, Vietnamese people view illnesses from a variety of perspective. Because they also recognize more western forms of disease causations, it is common for them to interpret their illness as an imbalance in the body in addition to an infective process (Rasbridge). Thus, cao gio is performed in addition to taking pain medications such as Tylenol or Aspirin and other western drugs according to the illness they wish to treat. (http://www3.baylor.edu/~Charles_Kemp/vietnamese_health.htm )

Conclusion
With all this said, is cao gio an effective form of healing? Unfortunately, there is not an answer to this question. Although the tiger balm and camphor oil studies provide some evidence on its effectiveness, there are too many external variables that prevent any conclusions from being drawn. On the other hand, the efficacy of cao gio cannot be denied because there is no solid evidence to dispute its curing powers. Through the alternative perspectives mentioned above, we can gain a better understanding of this cultural treatment and make our own assessments on its efficacy.