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Chapter: Medical Surgical Nursing: Perspectives in Transcultural Nursing

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Definitions of Culture

The concept of culture and its relationship to the health care beliefs and practices of patients and their families and friends provide the foundation for transcultural nursing.

Definitions of Culture

The concept of culture and its relationship to the health care beliefs and practices of patients and their families and friends provide the foundation for transcultural nursing. This awareness of culture in the delivery of nursing care has been described in different ways, including respect for cultural diversity, culturally sensitive or comprehensive care, and culturally competent or appropriate nursing care (American Association of Colleges of Nursing, 1996; Giger & Davidhizar, 1999; Spector, 2000), or culturally congruent nursing care (Leininger, 2001). Two commonly discussed concepts are cultural diversity and culturally competent care.

The term culture was initially defined by the British anthropologist Sir Edward Tylor in 1871 as the knowledge, belief, art,morals, laws, customs, and any other capabilities and habits acquired by humans as members of society. During the past century, and especially during recent decades, hundreds of definitions of culture have been offered that integrate the themes stated by Tylor and the themes of ethnic variations of a population based on race,nationality, religion, language, physical characteristics, and geography (Spector, 2000). To fully appreciate the impact of culture,aspects such as disabilities, gender, social class, physical appearance (eg, weight, height), ideologies (political views), or sexual orientation must be integrated into the definition of culture as well (Gooden, Porter, Gonzalez, & Mims, 2001). Madeleine Leininger, founder of the specialty called transcultural nursing, indicates that culture involves learned and tranmitted knowledge about values, beliefs, rules of behavior, and lifestyle practices that guide designated groups in their thinking and actions in patterned ways (2001). Giger and Davidhizar(1999) state that transcultural nursing is a practice based on the differences and similarities between cultures in relation to health, health care, and illness, with consideration of patient values, beliefs, and practices. Further, culture develops over time as a result of “imprinting the mind through social and religious structures and intellectual and artistic manifestations”.


The concept of ethnic culture has four basic characteristics:

• It is learned from birth through language and socialization.

• It is shared by members of the same cultural group, and it includes an internal sense and external perception of distinctiveness.

• It is influenced by specific conditions related to environmental and technical factors and to the availability of resources.

• It is dynamic and ever-changing.


With the exception of the first characteristic, culture related to age, physical appearance, lifestyle, and other less frequently acknowledged aspects also adhere to the above characteristics.

Cultural diversity has also been defined in a number of ways. Often, skin color, religion, and geographic area are the only elements used to identify diversity, with ethnic minorities being considered the primary sources of cultural diversity. As stated earlier, however, there are several other possible sources of cultural diversity. In addition, to truly acknowledge the cultural differ- ences that may influence health care delivery, the nurse must recognize the influence of his or her own culture and cultural heritage (Krumberger, 2000). Culturally competent nursing care has been defined as effective,individualized care that considers cultural values, is culturally aware and sensitive, and incorporates cultural skills (Hunt, 2000;Krumberger, 2000; Wilkinson, 2001). Culturally competent care is a dynamic process that requires comprehensive knowledge of culture-specific information and an awareness of, and sensitivity to, the effect that culture has on the care situation. It requires the nurse to integrate cultural knowledge, awareness of his or her own cultural perspective, and the patient’s cultural perspectives into the plan of care (Giger & Davidhizar, 1999). Exploring one’s own cultural beliefs and how they might conflict with the beliefs of the patients being cared for is a first step toward becoming culturally competent (Krumberger, 2000). Understanding the diversity within cultures, such as subcultures, is also important.



Although culture is a universal phenomenon, it takes on specific and distinctive features for a particular group, since it encompasses all of the knowledge, beliefs, customs, and skills acquired by the members of that group. When such groups function within a larger cultural group, they are referred to as subcultures.The term subculture is used for relatively large groups of people who share characteristics that enable them to be identified as a distinct entity. Examples of American subcultures based on ethnicity (ie, subcultures with common traits such as physical characteristics,language, or ancestry) include African Americans, Hispanic/Latino Americans, and Native Americans. Each of these subcultures may be further divided; for example, Native Americans consist of American Indians and Alaska Natives, who represent more than 500 federally and state-recognized tribes in addition to an unknown number of tribes that receive no official recognition.

Subcultures may also be based on religion (more than 1200 exist in the United States), occupation (eg, nurses, physicians, other members of the health care team), or shared disability or illness (eg, the Deaf community). In addition, subcultures may be based on age (eg, infants, children, adolescents, adults, older adults), gender (eg, male, female); sexual orientation (eg, homosexual or bisexual men and women), or geographic location (eg, Texans,Southerners, Appalachians).The nurse should also be sensitive to the intraracial applications of cultural competence. Tensions between subcultures within a designated group could add to the complexity of planning culturally competent care. Some members of one ethnic subculture may be offended or angered if mistaken for members of a different subculture. Similarly, if the attributes of one subculture are mistakenly generalized to a patient belonging to a different subculture, extreme offense could result, as well as inappropriate care planning and implementation (Fields, 2000). It is crucial that nurses refrain from culturally stereotyping a patient in an attempt to be culturally competent. Instead, the patient or significant others should be consulted regarding personal values, beliefs, preferences and cultural identification. This strategy is also applicable for members of nonethnic subcultures.

The term minority refers to a group of people whose physical or cultural characteristics differ from the majority of people in a society. At times, minorities may be singled out or isolated from others in society or treated in different or unequal ways. Although there are four federally identified minority groups—Blacks/African Americans, Hispanics, Asian/Pacific Islanders, and Native Ameri-cans (Andrews & Boyle, 1999)—the concept of “minority” varies widely and must be understood in a cultural context. For example, men may be considered a minority within the nursing profession, but they constitute a majority within the field of medicine. In ad-dition, Caucasians may be in the minority in some communities in the United States, but they are currently the majority group in the country (although it has been projected that by the middle to late 21st century, Caucasians will be in the minority in the United States). Because at times the term minority connotes inferiority, members of many racial and ethnic groups object to being identi-fied as minorities.


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