May 6, 2008
Transcultural Nursing: Its Importance in Nursing Practice
By Maier-Lorentz, Madeline M
Abstract: Transcultural nursing is an essential aspect of healthcare today. The ever-increasing multicultural population in the United States poses a significant challenge to nurses providing individualized and holistic care to their patients. This requires nurses to recognize and appreciate cultural differences in healthcare values, beliefs, and customs. Nurses must acquire the necessary knowledge and skills in cultural competency. Culturally competent nursing care helps ensure patient satisfaction and positive outcomes. This article discusses changes that are important to transcultural nursing. It identifies factors that define transcultural nursing and analyzes methods to promote culturally competent nursing care. The need for transcultural nursing will continue to be an important aspect in health-care. Additional nursing research is needed to promote transcultural nursing. Key Words: Nursing, Transcultural Nursing, Nursing Practice, Importance of Transcultural Nursing
Transcultural nursing has become a key component in Healthcare and a requirement for today's practicing nurses because of the soaring multicultural phenomenon occurring in our American population. According to the U.S. Bureau of the Census (2000), over 30% of the total population, or one out of every three persons in the United States (U.S.), is comprised of various ethnicities other than non-Hispanic Whites. This statistic highlights that the U.S. has a significant multicultural population today. Additionally, the U.S. Department of Commerce (2000) projects a steadily growing population of persons from ethnicities other than non-Hispanic Whites, comprising 50% of the whole population by 2050.
Yet, while the U.S. population continues to rapidly grow in diversity, nurses have remained a homogenous group. Approximately 90% of all Registered Nurses are Caucasian. Although Hispanics have become the majority minority in the U.S. (U.S. Bureau of the Census, 2000), it is estimated that there are only 2% Hispanic Registered Nurses in the nursing profession ((Minority Nursing Statistics, 2005). The escalating cultural diversity in the U.S. population and the few number of non-Caucasian registered nurses calls attention to the need for addressing the issue of transcultural nursing.
Because of the escalating multicultural society in the United States, transcultural nursing is a vital constituent of nursing care, mandating that nurses are culturally competent in their daily practice. Culturally competent nurses have knowledge of other cultural ways and are skilled in identifying particular cultural patterns so that an individualized care plan is formulated that will help meet the established healthcare goals for that patient (Gustafson, 2005).
Additionally, nursing practice includes providing care that is holistic. This holistic approach in nursing addresses the physical, psychological, social, emotional, and spiritual needs of patients. It is important to emphasize that nurses must identify and meet these needs in order to provide individualized care, which has been stipulated as a patient's right and a hallmark of professional nursing practice (Locsin, 2001).
Holistic care means planning care to meet patients' individual needs. In order to provide holistic care, nurses must also account for cultural differences in their care plans. This helps ensure that nurses provide holistic care because care plans are formulated based on individuals' needs and cultures. Thus, nurses must be culturally competent in order to provide optimal care for their patients. Most important, nurses need to maintain cultural competency in their daily practice to instill in their patients a feeling of being known and cared for as individuals in a very complex Healthcare system and culturally diverse society.
DEFINITION OF CULTURAL COMPETENCE
Nursing has borrowed from the social work to define cultural competence. Social workers describe cultural competence as a continual process of striving to become increasingly self-aware, to value diversity, and to become knowledgeable about cultural strengths (Bonecutter & Gleeson, 1997). The nursing profession has adopted this concept. Nurses depict cultural competence as having the ability to understand cultural differences in order to provide quality care to a diversity of people (Leininger, 2002). Culturally competent nurses are sensitive to issues related to culture, race, ethnicity, gender, and sexual orientation. Furthermore, culturally competent nurses have achieved efficacy in communication skills, cultural assessments, and knowledge acquisition related to health practices of different cultures. Cultural competence involves nurses continuously striving to provide effective care within the cultural confines of their patients. The most comprehensive definition of cultural competence in nursing practice is stated as being an ongoing process with a goal of achieving the ability to work effectively with culturally diverse persons, and additionally, to care for these individuals with a keen awareness of diversity, a strong knowledge base and skills in transcultural nursing, and especially a strong personal and professional respect for others from various cultures (Leininger, 2002).
Having knowledge of the patient's cultural perspectives enables the nurse to provide more effective and appropriate care. For example, understanding one's religious or cultural beliefs may be a deciding factor against the administration of a blood transfusion for a patient who is a Jehovah's Witness since these individuals are forbidden to receive this medical treatment. It is clear that having specific knowledge about patients' cultures ensures holistic and cultural competent nursing care.
LEININGER'S CULTURE CARE THEORY
Leininger (1978) introduced the concept of transcultural nursing and developed the Culture Care Theory to explain cultural competency. It was the first attempt in the nursing profession to highlight the need for culturally competent nurses. Leininger's theory of Culture Care may be considered the major contribution in support of transcultural nursing as both a discipline and vital component of daily nursing practice. Her theory continues to be used as a credible, holistic model that continually contributes new research-based and advanced knowledge to transcultural nursing.
Leininger (1978) explained that nurses had to acquire an in- depth knowledge of different cultures in order to provide care to people of various ethnicities. Moreover, it is the only theory that explicitly focused on the relationship between culture and care on health and wellness. Leininger points out that the purpose and goal of her theory is for nurses to understand diverse and universal culturally based care factors. These factors influence the health, and well-being of others. An understanding of these factors enable nurses to provide care that is individualized and meaningful to individuals of various cultural backgrounds.
Nurses may encounter patients from numerous cultures in daily practice. It is unlikely that nurses would know about the culturally- based, health-related beliefs and practices of all persons. However, nurses can gain knowledge and skifls in cross-cultural communication to help them provide individualized care that is based on cultural practices. Nurses skilled in cross-cultural communication may then be better equipped to provide culturally competent care to their patients.
Cross-cultural communication includes certain factors that must be considered when nurses interact with patients and their family members from cultural backgrounds that differ from their own (Andrews, 2003). However, it is important that nurses first understand their own cultural values, attitudes, beliefs, and practices that they have acquired from their own families before learning about other cultural ways. This helps nurses gain insight into personal prejudices that may exist. These prejudices must be recognized in order to avoid stereotyping and discrimination, which may jeopardize the ability of nurses to learn and accept different cultural beliefs and practices especially in health-related issues.
Cross-cultural communication involves several aspects that should be understood in order to achieve cultural competency, which is necessary in order to provide optimal nursing care (Andrews, 2003). It is, therefore, necessary to examine ways in which people from diversified cultural backgrounds communicate. This involves more than oral and written communication. Nonverbal cues play a vital role in conveying messages, and these may vary considerably among different cultures. Understanding these communication cues and their meanings to persons of different cultures is necessary in order for nurses to attain and maintain cultural competency.
Recent qualitative studies have shown that communication problems were the major reasons nurses were not able to provide culturally competent nursing care (Boi, 2000, Cioffi, 2003). The nurses reported that they were not comfortable with patients from cultures other than their own because of language barriers. More importantly, the nurses explained that they were not able to understand other cues used by these patients to communicate. The nurses expressed a need to receive education and training in transcultural communication skills in order to provide effective care for their patients from various cultures. Although it is not likely that nurses will master many languages, understanding the meaning of certain nonverbal communication cues used by different cultures may be very beneficial for providing culturally competent nursing care. Eye Contact. Eye contact is an important nonverbal means of communication. It is also the variable that differs the most among many cultures (Canadian Nurses Association, 2000). American nurses are taught to maintain eye contact when speaking with their patients. This is in direct contrast to Arabic persons, who consider direct eye contact impolite and aggressive. Similarly, Native North Americans also regard direct eye contact as improper; in their culture, staring at the floor during conversations shows that they are listening carefully to the speaker. Hispanics use eye contact only when deemed appropriate by their cultural standards. This is based on age, sex, social position, economic status, and position of authority. For instance, Hispanic elders speaking with children use eye contact, but it is considered inappropriate for Hispanic children to look directly at their elders when speaking to them. In a health care environment, Hispanic patients expect that nurses and other health care providers give direct eye contact when interacting with them, but it is not expected that Hispanic patients reciprocate with direct eye contact when receiving medical and nursing care. These are only a few examples to demonstrate that persons of various cultures perceive eye contact differently. It is essential that nurses be cognizant that several meanings may be attached to direct eye contact in order to communicate effectively with their patients.
Touch. Nurses educated in American schools are taught to use touch as a therapeutic means of communication with their patients. (Understanding Transcultural Nursing, 2005). However, nurses must also realize that touch may not have the same positive meaning in healthcare for people who are from other cultures than American. Some cultures prohibit or restrict touching other persons. Patients from Arab and Hispanic backgrounds do not allow male health care providers to touch certain parts of females. Females from both cultures also may be restricted from caring for male patients. Asians do not approve of touching the head, because it is thought to be the source of a person's strength.
It is unlikely that nurses would know all the special meanings attached to touch by persons of many various cultures. However, nurses should recognize that touch has different meanings in different cultures and to be respectful of others' ways with regard to touch. It is advisable for nurses to explain to patients their reason for touching them to prevent these individuals from misconstruing the use of touch in their care. Understanding and respecting other cultural ways of using touch helps nurses maintain cultural competency.
Silence. This is another nonverbal cue, which has a different meaning for persons of various cultures. Nurses may feel uncomfortable when there is a period of silence while talking with their patients. They may interpret silence in a negative way for several reasons. Nurses may conclude that silence represents miscommunication or that the patient is depressed and not willing to respond. They may even question whether their patients have impaired hearing. While these are important explanations for silence and must be considered by the nurse when talking with their patients, they should also realize that silence is used differently in communication among persons from other cultures.
Silence can be a positive nonverbal cue in communication among people in various cultures (Andrews, 2003). It is common for Native North Americans to use silence as a way of showing respect for the person speaking to them. They also use silence much like a pause after being asked a question. This signifies that they are giving careful consideration to the question, responding with meaning and attention to the matter. This is common in Chinese and Japanese people. Silence is also mandatory when speaking to elders in Asian cultures. It is a sign of great respect for older people. Both English and Arab persons use silence out of respect for another's privacy. French, Spanish, and Russian individuals demonstrate their agreement with the use of silence.
Space and Distance. Usually individuals are not consciously aware of space and distance between themselves and others until they come in direct contact with people from other cultures. They then realize their own preferences with regard to space and distance from other people. Individuals of European North American descent usually feel most comfortable when they are not in close contact with any others. In direct contrast, Hispanics, Asians, and Middle Easterners feel very comfortable in close proximity to others (Andrews, 2003).
Nurses should realize that space and distance between themselves and their patients is very important to consider when providing care to individuals from cultures that are different from their own. Patients may either position themselves unusually close or far from the nurse based on their cultural needs for space and distance It may be especially difficult for nurses to distance themselves sufficiently from patients who need the most space because nursing care requires close contact with patients. However, the key point in transcultural nursing is to understand and respect the needs of patients from various cultures with regard to space and distance requirements.
Healthcare Beliefs. There are also variations among people from different cultures regarding certain beliefs in healthcare. These various beliefs are based on the culture's perspective about an individual's relationship with the environment (Understanding Transcultural Nursing, 2005). Persons who believe that they have some control of life events will also believe that they have some control over their healthcare. These individuals will tend to be more compliant in following healthcare regimes prescribed for them and will be more likely to develop positive healthcare habits. Asian Americans are usually of this nature. In contrast, Hispanics feel that they have less control over their lives and tend to be more fatalistic in their views about health. These patients may not be as cooperative about complying to a prescribed diet and medication regime.
Culturally competent nurses would understand these different views and provide care that includes consideration for these differences. For instance, nurses may provide more patient teaching about diet and medications to patients who feel they have less control in their healthcare. Culturally competent nurses are respectful of others' cultural habits especially in healthcare and their nursing care plans should be individualized to account for the various cultural differences. Developing cultural competency requires first and foremost having the interest to become competent culturally, and secondly taking the necessary steps to attain it.
STEPS TO ATTAIN CULTURAL COMPETENCE
There is a current focus on eliminating disparities in healthcare to ensure that persons of diverse cultural backgrounds receive effective care. The government enacted the Healthy People 2010 to enforce this standard of treatment (Office of Disease Prevention and Health Promotion, 2000). Regulatory, accrediting, and professional organizations are also supporting this effort (Office of Civil Rights, 2000; Joint Commission for Accreditation of Healthcare Organizations [JCAHO], 2000; American Nurses Association [ANA], 1999). Additionally, certain national policies have been established to provide equitable and effective treatment for people from diverse cultures entering the health care system (Office of Minority Health, 2000).
The nursing profession has been actively involved in meeting the goal of eliminating discrepancies in providing health care to minorities for the past decade. Nurses have been leaders in this pursuit. They have emphasized the need to provide culturally competent care to their patients five years before the legislative Healthy People 2010 was initiated by the government (ANA, 1999). The Nursing profession upholds this focus on cultural competency not only to comply with regulatory enactments, but also to promote patient satisfaction. When nurses provide care that is in accordance with patients' cultural beliefs, values, and practices, the assumption is that patients will be more likely to adhere to the plan of care than if cultural needs were not addressed by nurses. Cultural competency is best achieved by taking three progressive steps that help nurses provide care for patients from diverse backgrounds (Narayan, 2001).
Step 1. Adopt Attitudes to Promote Transcultural Nursing Care
Certain attitudes have been associated with effective and culturally competent nursing care (Narayan, 2001). Caring is one of four important attitudes necessary for promoting transcultural and culturally competent nursing care. Nurses demonstrate a caring attitude when they take time to understand and appreciate their patients' cultural needs and perspectives. This also shows true respect and concern for these individuals. Patients feel confident that they are being cared for because nurses have addressed their cultural preferences. Empathy is the second quality for nurses to adopt for cultural competency. This requires that nurses view problems or situations from the patients' cultural perspectives. This gives patients a sense of security, knowing that their cultural ways are understood and appreciated by their nurses caring for them. Openness is the third attitude for nurses to cultivate for effective transcultural nursing. Having openness to others' cultural perspectives shows patients that nurses give consideration to their particular ways. It also demonstrates that nurses appreciate these different perspectives and value cultural diversity. Flexibility is the fourth attitude nurses should adopt to become culturally competent. They need to integrate their patients' cultural beliefs, values, and practices into nursing care plans for these individuals and not impose their own cultural desires in caring for these persons. Nurses demonstrate flexibility by showing their willingness to provide care based on their patients' cultural ways, which helps them feel reassured that their care is individualized, and consequently, helps achieve mutually set goals. Step 2. Develop Awareness for Cultural Differences
To provide culturally competent care, nurses should be aware that their patients may have various cultural differences. Certain variables are important for nurses to know in order to design a care plan that meets the needs of their patients while complying with their cultural requirements. As stated earlier, cultures vary on communication patterns and social etiquette (Narayan, 2001).
Although it is helpful to obtain information about patients' cultural norms, nurses need to remember that even within a cultural group, there is still diversity. No person is a stereotype of a culture. Individuals have beliefs, values, and practices that may deviate from their cultures. This points out the need for nurses to take the next step toward cultural competency, which is to perform cultural assessments on their patients.
Step 3. Perform a Cultural Assessment
A concise cultural assessment is an effective way to obtain pertinent information about patients' perspectives on important aspects of their care (Narayan, 2001). It is important for nurses to learn which foods are culturally acceptable andif there are certain foods that are not tolerated. These questions guide nurses in planning care. More important, it gives nurses better insight as to which foods are considered healthy and helpful when experiencing an illness. Nurses will also gain pertinent information when they conduct a medication assessment. A thorough investigation will identify whether these patients subscribe to alternative medicine, as well as traditional medicine. Pain Assessment is especially important for nurses to conduct on persons from diverse backgrounds. Pain is a very subjective feeling because patients describe the sensations differently and have different tolerance levels for pain. Nurses need to assess pain by asking patients' to describe how they feel, but it is also necessary to include facial expressions and body language in their assessments. This helps nurses better identify pain in patients from cultures that are expected to be stoic about pain, such as the Native Americans. In contrast, Mexican Americans exhibit high levels of emotion and anxiety with pain (Munoz & Luckman, 2005). Nurses need to examine their own beliefs and values about pain and pain control in order to be objective when performing pain assessments on their patients. Learning about patients' family structures is important to understand when performing a cultural assessment. Family is the basic social unit, and it defines how persons of various cultures view health and illness. It also gives nurses insight about the support systems for their patients (Spector, 2000). These factors play a significant role in restoring and maintaining the health of patients.
Nurses should develop their plan of care with their patients in order to derive mutual goals that are compatible with their cultural norms. Patients will develop trust with their nurses and be comfortable with the nursing care plan because it is consistent with their cultural values and practices. They will likely adhere to the plan of care because they feel respected for their different cultural practices, promoting a positive outcome.
At times, nurses may assess that their patients' cultural patterns are in conflict with their health needs. It is then necessary for nurses to try to create and implement new health patterns for these patients. This is best achieved when nurses listen with openness and understanding regarding their patients' perspective about their illness. Nurses must then try to educate their patients about using therapeutic means different from their cultures that are helpful for restoring and maintaining health. Culturally competent nurses design care plans that promote patients' compliance and incorporates safe and effective cultural practices.
FACTORS OF TRANSCULTURAL NURSING
The changes occurring in the U.S. population can be attributed to demographic, social and cultural changes. A growing elderly population and the escalating number of immigrants have attributed significantly to the overall increased total population in the United States. The large number of immigrants has had the major impact on the changes in the population. It has created a very diverse cultural population in recent years. The large number of persons from diverse cultures has enforced the need for social changes as well, such as routinely providing bilingual translations wherever needed.
Additionally, the health care system has had to also make changes to accommodate a diversified patient population. One of these changes in the health care system was to protect health care beliefs of persons from various cultures. The Nursing profession has shown support for accommodating other persons from different cultures by promoting transcultural nursing in daily practice. This is also referred to as culturally competent nursing.
A model that encompasses six factors can be used to promote transcultural nursing and assess nurses' cultural competency (Campinha-Bacote, 2002). The first factor is awareness. Nurses need to be aware of personal biases and prejudices toward others from different cultures. Skill is the second factor. Nurses must have the skill to conduct cultural assessments in a sensitive manner. The third factor is knowledge. Nurses must adopt a broad perspective regarding different points of view to accommodate patients' various cultural views. Encounters is considered the forth factor for transcultural nursing. It is important for nurses to expose themselves to patients from diverse backgrounds and provide effective care that is congruent with their cultural ways. The fifth and most important factor is desire. Nurses must want to achieve cultural competency. This means having an enthusiastic attitude to learn about others' cultural ways and integrate them into the nursing care plans. The last factor is assessment. Nurses must perform a self-assessment to determine whether they are culturally competent in their nursing care.
TRANSCULTURAL NURSING AND ETHICS
Nurses encounter difficult ethical situations in daily practice. These situations may be even more challenging for nurses when the patients involved are from various cultural backgrounds. One ethical dilemma is whether nurses should discuss advance directives to patients who are uncomfortable about this because of cultural differences in their health beliefs.
One of the roles of nurses is to provide patients with in formation about advance directives. These are to protect patients' autonomy in circumstances when they can no longer make a decision. Advance directives are readily accepted by the American culture. Other cultures do not view advance directives as a positive measure in healthcare. Some cultures subscribe to the belief that the fate of human beings is beyond their control. Filipinos are one such group who feel that planning for one's death should not be in their control. Their view is that to do so, it is tempting fate and will bring death for sure. American nurses may feel uncomfortable obtaining information for advance directives without understanding that in times of illness Filipinos rely on fate for the outcome (Pacquiao, 2001).
Nurses encounter an ethical dilemma as to whether they should carry out their responsibility to discuss advance directives with Filipino patients knowing that Filipinos feel that it is very taboo to discuss such matters and even believe that any discussion of this will result in death. Nurses have a difficult decision in this situation, especially because above all, they are required to be sensitive and protect their patients' cultural health beliefs.
Nurses learn that veracity and fidelity are ethical princi ples that guide their interactions with patients and families. Nurses are taught to support individual autonomy to benefit the patient. In the American culture, nurses provide truthful information to the patient in order that they can then make a decision about their healthcare. However, in other cultures, family members are the decision makers about the patient's health matters. This is especially true when an illness is terminal. In certain cultures, it is the family's role to protect the patient from the anxiety and distress associated with the knowledge of impending death. Families from Eastern cultures are especially protective of the terminally ill. They believe it is their responsibility to protect the patient, allowing the patient to die in peace (Moazam, 2000).
American nurses may encounter an ethical conflict when caring for terminally ill patients. They have learned to be truthful to dying patients in order to give them control. Yet, caring for patients from Eastern cultures would prevent them from being open and honest about their terminal illness. It would be important for nurses to recognize the cultural values and beliefs when making ethical decisions.
Nurses must maintain cultural competency in their care. It is important for nurses to be always aware of cultural differences in health beliefs. It is necessary for nurses to attain information about their patients' cultural perspectives in order to provide care that is culturally congruent with their patients' views and wishes. In making ethical decisions, nurses need to safeguard the health of their patients, yet still provide culturally competent nursing care in these situations. EDUCATION AND TRANSCULTURAL NURSING
Nurses have repeatedly expressed their frustration that they lack the education necessary to provide culturally competent care for a diverse mix of patients from other cultures (Labun, 2001). They have also acknowledged their limitations in caring for these individuals because they do not have enough transcultural knowledge and skills to enable them to deliver culturally sensitive nursing care. Nurses have stated that their basic nursing education did not prepare them to be culturally sensitive or enable them to provide care to patients of various cultures (Boi, 2000).
Practicing nurses should be offered a staff development program that focuses specifically on the knowledge and skills needed for transcultural nursing. In this program, nurses would first develop an awareness of their own cultural values and beliefs. This is necessary to do before nurses can go to the next step of accepting different cultural ways in healthcare. Nurses, who are able to accept others' cultural beliefs, would then be able to learn to conduct cultural assessments. The last segment of this program would be for nurses to evaluate themselves regarding their ability for providing culturally competent nursing. Patients showing trust in their nurses and satisfaction with their care may be proof of culturally competent nursing care.
Transcultural nursing is essential in daily nursing practice. The ever-growing number of patients from various cultural backgrounds creates a major challenge for nurses to provide individualized and holistic care based on each patient's cultural needs. This requires nurses to understand cultural differences in healthcare values, beliefs, and customs. Nurses must be open-minded and have a positive interest as well as a sincere desire to learn other cultural ways. Transcultural knowledge is important for nurses to acquire in order for them to become sensitive to the needs of patients from various cultures especially as societies become increasingly global and complex.
Since nurses have the most intimate contact with patients and are responsible for formulating care plans that help meet the individual needs of patients, it is a necessity for nurses to understand, appreciate, and respond to the patients' cultural preferences. The most effective way to accomplish this is for nurses to increase their awareness of cultural differences and become knowledgeable about the cultural preferences of their patients under their care.
This highlights the need for nursing education to include transcultural nursing in the curriculum. It should instill in nursing students an appreciation for cultural differences in healthcare values, beliefs and customs. The curriculum in transcultural nursing should also teach the knowledge and skills needed to provide culturally competent nursing care. Furthermore, hospitals and other health care facilities should offer nurses frequent in-service programs on cultural competency in order to increase their level of confidence and knowledge of transcultural skills.
In addition, there is a need for future research to expand the knowledge base of culturally competent nursing care. One area to investigate in particular may be the meaning of quality nursing care from different cultural perspectives. Continued research should also focus on determining effective nursing interventions that advocate and provide culturally competent care to patients in a meaningful and acceptable way.
More federal and state funding should be appropriated to educate, research, and apply the findings to nursing practice. This will help promote transcultural nursing and ensure cultural competency in nursing care.
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MADELINE M. MAIER-LORENTZ, MSN, RN
Madeline M. Maier-Lorentz, MSN, RN, has a bachelor of arts degree in psychology, a bachelors and masters degrees in nursing, and is a doctoral candidate in human services. Ms. Maier-Lorentz is an adjunct nursing faculty member at National University in San Diego, California. Ms/ Maier-Lorentz may be reached at: Madeline. [email protected]
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