New Life College of Nursing Karachi

Post RN - BScN 1st semester 2013

Faculty: - Sir Rameesh Kumar
Subject: -Sociology
Topic: - Special issues in the delivery of transcultural nursing care
Group Member: 1. Zahid Ali
2. Saima Naeem
3. Azra Noreen
4. Zainab
Date: -

22-11-2013

Special issues in the delivery of transcultural nursing care

Tran
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Objectives

Define culture
Identify the components of an accurate cultural

assessment.
Distinguish between primary and secondary cultural

characteristics.
Identify the advancement of transcultural nursing.
List and define the key aspects of effective intercultural

communication.
Identify the future aspects of cultural diversity in nursing.
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What is Culture?

The sum total of the way of living; includes values, beliefs, standards,

language, thinking patterns, behavioral norms, communications styles, etc.

Guides decisions and actions of a group through time (Tappan, Weiss &
Whitehead, 2007).
Groups acceptance of a set of attitudes, ideologies, values, beliefs, and

behaviors that influence the way the members of the group express
themselves

What is the transcultural nursing

Transcultural nursing is how professional nursing interacts with the concept of
culture. Based in anthropology and nursing, it is supported by nursing
theory, research, and practice.
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Characteristics of Culture
Culture is considered a photocopy machine that makes

duplicates of the original document with minor

differences.
Slight variation in the practices inevitably occurs when

values, beliefs, and customs pass from one society to

another.
Subcultures develop when members of the group accept

outside values in addition to those of their dominant

culture.
(Catalano 2009; Tappan, Weiss & Whitehead, 2007 ).
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What is Diversity?
Term used to explain differences between cultures such as:

psychological, physical, and social differences that occur

among any and all individuals.
Example: race, ethnicity, nationality, religion, economic class,
age, gender, sexual orientation, mental and physical ability,
and learning styles.
Primary Diversity: nationality, race, color, religious beliefs.
Secondary Diversity: socioeconomic status, education,

occupation ( powerful , but hard to identify).

(Catalano 2009; Leininger & McFarland, 2002).
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Major Factors in Transcultural Nursing

Beliefs about illness, causes and cures
Nutrition and dietary practices
Disorders specific to a particular ethnic group
Religious beliefs about illness and death

Asian Americans Demographics

4.3% of U.S. population (12.5 million)
Asian Indians projected to become the dominant
ethnic group within the next decade
2050 ethnic/racial groups will comprise close to
50% of U.S. population

Asian Religions
Christianity-Philippines
Islam-Middle East Asia
Hinduism-India
Buddhism-throughout Asia
Judaism-Israel
Taoism-China
Shamanism-Thailand
Shinto-Japan

Examples of Asian Healthcare Beliefs

Yin and yang balance
Respect for physician
Limited concept of mental illness
Traditional self-care, self-medication, self-dosing
Fearful of blood work, excessive testing, surgery

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More Asian cultural health care belief examples

Self-restraint-may refuse pain medicine out of courtesy
Do not touch the head-private and personal
Modesty
Eye contact
Fasting (Ramadan)
Visiting hours-large groups of family members
Birthing beliefs

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Examples of Asian Healthcare Practices

Coining (Caogio)
Cupping (Giac)
Steaming (Xong)
Acupuncture
Patent Medicines

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What is the role of the nurse?

Provide care that is congruent with cultural
values, beliefs and practices
Perform transcultural assessments
(communication, personal space, diet, religious beliefs,
social orientation, what interventions have they already
done?)

Develop culturally competent interventions

In-service staff on cultural competency
Include teaching of transcultural nursing in
school curriculum

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Example of culturally sensitive interventions:

Arrange nursing care so that it does not interrupt
prayer session
Try to schedule medication administration so that it
does not interfere with fasting
Try to accommodate dietary needs specific to culture
Learn about alternative/complimentary medications

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Women who teach nursing in India must know the

languages, the religions, superstitions and customs
of the women to be taught

Florence Nightingale,
1894

15

Trans-Cultural Nursing
A formal area of study and practice focused on

comparative human-care ( caring) differences and

similarities of the beliefs, values, and patterned life ways of
cultures to provide culturally congruent, meaningful, and
beneficial health care to people.
(Leininger & McFarland, 2002)

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Understanding Trans-cultural Nursing

Care needs to be systematically studied to learn about

human care ( caring) in diverse and similar cultures in the

world and environments.

Nurses are to be knowledgeable about their own cultural

care heritage and of biases, beliefs, & prejudices to work

effectively with clients.
Nurses need to use trans-culture- specific and comparative
knowledge to guide caring practices for culturally
congruent care.
Maintaining an open learning discovery process about
care and culture is imperative.
Nurses need creative ways to provide culturally congruent
care practices.
( Leinniger & McFarland, 2002)

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Advancement of Cultural Diversity in Nursing

A hallmark behavior and action that focused on cultural

diversity within nursing gave rise to the transcultural

nursing movement.
The early focus of the transcultural nursing movement was
to bring sensitivity to the differences between nurses own
culture and that of the people to whom they were providing
care
(Leininger, 1979).
Successes of the transcultural nursing movement included

incorporating culture to the nursing curricula and to the

licensure and certification exams.

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Advancement of Cultural Diversity in Nursing

The advancement of cultural diversity is clear in the goal

and mission of the ANA (1986, 1991), which is a

commitment to serve the health needs of all people. In
addition, the ANA has included cultural diversity as a
priority in its strategic plans.

Historically, cultural issues were addressed through the

ANAs interaction with minority organizations and

minority leadership within the ANA.

Cultural diversity issues have been addressed through

ANA groups, such as the Committee on Intergroup

Relations, Affirmative Action Task Force, and the Council
of Cultural Diversity.
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Advancement of Cultural Diversity in

Nursing
The Nursing Workforce Development programs were
developed to increase opportunities for individuals who are
from disadvantaged backgrounds, including economically
disadvantage families, as well as racial and ethnic minorities
underrepresented in the nursing profession (ANA, 2007).

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The Need for Tran-Cultural Nursing!

Leininger and McFarland (2002) discussed many reasons, but
let us go through few:
1. The steady marked increase in the migration of people
worldwide.
2. The rise in cultural identities with health consumers
expecting that their cultural beliefs will be respected,
understood, and appropriately responded to in health care.
3. Increased signs of cultural conflicts and clashes, wars and
violent acts among and between different cultures and
nations influencing the health, survival, or death of people
of diverse cultures.
4. The marked increased number of nurses, physicians, and
other health care providers working in many different
places in the world
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How do you feel about your ethnic and/or

cultural and/or religious grouping stereotype?
Stereotyping:
is an oversimplified belief, conception,
or opinion about another person
based on limited amount of
information.

Respect for cultural diversity and

intercultural dialogue is one of
the surest guarantees for
development and peace.
UNESCO (2006)
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Multiculturalism
Many people cling tenaciously to their traditions (cultural

practices) and language when they migrate to new country.

Healthcare providers need to be aware of and learn ways to adapt

their practices to allow for these differences.

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Developing Cultural Awareness

One of the most challenges for nurses who work

in a culturally diverse environment is to

understand clients perspective of what is
happening in the healthcare setting.
Awareness starts with an understanding of ones
own cultural values and healthcare beliefs.
Beliefs are based on knowledge and often
religious beliefs. Ex, knowledge of bacteria.
Try changing the clients healthcare values by
first, identifying his/her culture and practices that
are similar or different from your practices, in
order to decide whether it is desirable or possible
to change.
Tappan, Weiss, & Whitehead (2007); Marquis & Hustom (2003); Fawcett (2005).
24

Language Impact
The problematic in UAE healthcare units larger due to the

absence of enough professional medical interpreters 30%

of the population are locals
70% divided between 10% (Arabs) and 90% (speakers of
other languages)
Poor communication is a barrier to good patient centered
care.
Non verbal communication taken for granted and can lead
to false diagnosis
In emergency cases , language barriers can be serious
(The Emirates Center For Strategic Studies and Research, 2008)
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Language and culture barriers result in:

Poor patient-healthcare provider relationships
Incorrect diagnosis
Lack of informed consent
Lower patient satisfaction
Malpractice suits
Marquis & Hustom (2003)

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Solutions
Needs for interpreters
Respect privacy
Cultural Competency: awareness and emphasis for all

parties involved in the process

Increase diversity of healthcare professionals (avoid

bias/ethnocentrism/stereotyping
Training to support cross-cultural care

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Providing a Cultural Competent

Care
Cultural competence is the attitudes, knowledge, and

skills necessary for providing quality care to diverse

populations

Becoming culturally competent is an ongoing process in

which an individual or organization develops along a

continuum until diversity is accepted as a norm and the
nurse has acquired greater understanding and capacity in a
diverse environment.

Acceptance of various beliefs, behaviors, and values in

determining a persons physical and/or mental

wellness/illness and incorporating those
variables
into the
(AACN,
2008)
individuals assessment and treatment
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Providing Culturally Competent

Care
Trans-cultural Understanding: The primary skills required for
cultural competence include communication, understanding,
and sensitivity. It is an ongoing process that continues
throughout the nurses career.
Trans-cultural Communication: It is a highly complex process
that requires both verbal and non-verbal exchanges.
a. Non-verbal Responses: nurses must be cautious when
interpreting the nonverbal responses from some cultural
groups.
(Catalano, 2009)
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Individual Recommendations
The Registered Nurses Association of Ontario (2007)

proposed that for each individual, embracing diversity means

development of the following competencies and behaviors.
Tools to assist in developing these skills are:
1. Self Awareness, To learn to embrace diversity in individuals.
2. Communication, To develop communication skills that
promote culturally diverse settings.
3. New Learning, To attain cultural competence in individuals.

The Registered Nurses Association of Ontario (2007)

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Communication To develop communication

skills that promote culturally diverse settings.
1. Are aware of different communication styles and the
2.
3.
4.

5.

influence of culture on communication.

Are aware of ones preferred communication style, its
strengths and limitations, and how it affects colleagues and
recipients of care.
Seek feedback from clients and colleagues, and participate in
communication validation exercises (e.g. role-playing
exercises, case studies).
Use a range of communication skills to effectively
communicate with clients and colleagues (e.g. empathetic
listening, reflecting, non-judgmental open-ended
questioning).
Seek and participate in learning opportunities that include a
focus on communication and diversity.
The Registered Nurses Association of Ontario (2007)
31

New Learning To attain cultural

competence in individuals:
1. Acquire knowledge of the range of cultural norms, beliefs and
2.

3.
4.
5.

values relevant to clients and colleagues as a starting point to

foster understanding and further inquiry.
Are aware of the disparities (e.g. health outcomes, access to
care, economics, job opportunities) that exist for diverse
populations and understand the factors and processes that
contribute to them.
Recognize how culture and diversity influence behaviors and
interactions.
Develop and apply cultural competence knowledge and skills in
the areas of communication, care planning, conflict resolution
and change management.
Access, utilize, and partner with cultural resources.
The Registered Nurses Association of Ontario (2007)
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Anticipated Outcomes:
A workforce composed of nurses who are open-minded,

inclusive, and respectful of all colleagues and recipients of

nursing services. Individual members of the workforce
identify and are co-operative with one another to address
barriers to equity and diversity, and build practice
environments in which every persons contribution is
valued thus allowing the full potential of all to be
maximized. These individuals refuse to participate in
discrimination, harassment or bullying and address the
issue in a way that will effect change
The Registered Nurses Association of Ontario (2007)
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Healthcare Workers Responsibilities

Learn and use a few phrases of greeting and introduction in the

patients native language. This conveys respect and

demonstrates your willingness to learn about their culture.
Tell the patient that the interpreter will translate everything that

is said, so they must stop after every few sentences.

When speaking or listening, watch the patient, not the

interpreter. Add your gestures, etc. while the interpreter is

translating your message.
Reinforce verbal interaction with visual aids and materials

written in the clients language.

Repeat important information more than once.
Tappan, Weiss, & Whitehead (2007); Marquis & Hustom (2003); Fawcett (2005).
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Healthcare Workers Responsibilities

Always give the reason or purpose for a treatment or

prescription.
Make sure the patient understands by having them explain it
themselves.
Ask the interpreter to repeat exactly what was said.
Personal information may be closely guarded and difficult to
obtain.
Patient often request or bring a specific interpreter to the clinic.
In some cultures it may not be appropriate to suggest making a
will for dying patients or patients with terminal illnesses; this is
the cultural equivalent of wishing death on a patient.
Avoid saying you must... Instead teach patients their options
and let them decide, e.g., some people in this situation
would...

Tappan, Weiss, & Whitehead (2007); Marquis & Hustom (2003); Fawcett (2005).

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The Future of Cultural Diversity in

Nursing
To evaluate the movement of nursings cultural diversity

intention, the attitudes and beliefs about cultural diversity

should be examined for its impact on behavior and actions that
have resulted in the operational definition and actualization of
cultural diversity.
In process, reflection, and practice, nursing science should

embody characteristics of cultural diversity; in that way, the

science would serve as a process for understanding all aspects
of cultural diversity.

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The Future of Cultural Diversity in Nursing

Nursing as a profession and discipline can conceptualize
cultural diversity as more than just an awareness of diverse
cultures through basic nursing curricula.
The curricula need to go beyond simply teaching categories
of cultural content where categories of beliefs and practices
of cultural characteristics are developed and implemented
for nursing assessment and intervention purposes.
According to Zoucha and Housted: the health care
provider
ought to treat a patient who happens to be from a particular
culture, as an individual from a particular culture rather
than, in effect, to treat the culture through the patient
(2000, p. 326).

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The Future of Cultural Diversity in Nursing

Future nurses need to be taught how to apply culture
and diversity in the clinical setting. This will begin
when nursing faculty are prepared in the cultural
diversity dimension and are fully persuaded/ passionate
about the cause.
Increasing the diversity among nursing faculty within
nursings educational programs is needed so that
students have diverse role models.
Diversity among nursing faculty can also help to
disseminate and interpret cultural knowledge and needs
of diverse nursing students. Additionally, nursing
curricula need to reflect culturally diverse learning
styles .
.(Crow, 1993; Lowe, 2002).

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The Future of Cultural Diversity in

Nursing
Chalanda
(1995) described culture brokering as the act of
bridging, linking, or mediating between groups or persons
through the process of reducing conflict or producing change

Through culture brokering, patients will be able to mediate

between their beliefs and practices and the beliefs and practices
promoted by Western biomedicine about how they should resolve
their particular health or illness situation.
(Chalanda (1995)
Nurses in clinical practice have been expected to use a recipe or
formula approach to delivering culturally competent patient care.

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The Future of Cultural Diversity in

Nursing
Often, this approach does not adequately address

cultural diversity because of preconceived and

prescribed stereotypical notions and assumptions.

Patients must be viewed as individuals outside of

stereotypical characteristics and categorized to a

particular cultural group. In this way, it would
become clear that there are views and practices that
conceptualize diversity between and within cultures.

Nursing, from a cultural diversity approach and

perspective, has been more descriptive in nature.

Research approaches need to move from descriptive
research to applied, programmatic, or biocultural in
nature.
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It is because we are different

that each of us is special.

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References
Putsch III RW. Cross-cultural communication: The special case of
interpreters in health care. JAMA 1985;254(23):3344-48
Fawcett, J.(2005). Contemporary Nursing Knowledge analysis and
evaluation of Nursing Models and Theories. 2nd edition. F.A.Davis
company. Philadelphia.
John , L. Cynthia , A. (2009)Cultural Diversity: The Intention of Nursing.
Nursing Forum Volume 44, No. 1.
Leininger, M., McFarland, M., (2002). Transcultural Nursing. Concepts,
theories, research, & practices. 3rd edition. McGraw Hill.
The Registered Nurses Association of Ontario. (2007). Embracing
Cultural Diversity in Health Care: Developing Cultural Competence
http://www.rnao.org/Storage/29/2336_BPG_Embracing_Cultural_Divers
ity.pdf
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ACKNOWLEGEMENT

SIR RAMESH KUMAR

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