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Chapter: Sociology of Health : Hospital

Understanding culture and transcultural Nursing Care

What is transcultural Nursing Care: Although it is a common knowledge and it is widely accepted that people differ in culture among various racial groups, yet this established fact is hardly ever considered when administering nursing care.

Understanding culture and transcultural Nursing Care:


·              What is Culture :


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 one’s 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.



Illness and diseases as a social phenomenon also greatly influenced and shaped by culture and belief system of that particular society.


Two types of care is highly necessary in a health care setting so far as culture is concerned: Culturally congruent care:


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.and culturally competent care:


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.


·              What is transcultural Nursing Care:


Although it is a common knowledge and it is widely accepted that people differ in culture among various racial groups, yet this established fact is hardly ever considered when administering nursing care.


Due to the apparent relevance on the emerging challenge in the lack of attention to these cultural differences in health care practice resulted in an inferior nursing care.


More and more health care organizations including educational institutions and nursing associations are becoming more aware of the significance of culture to nursing practice, which led to the development of Transcultural Nursing Care.


Madeleine Leininger is considered as the founder of the theory of transcultural nursing. Her theory has now developed as a discipline in nursing. Evolution of her theory can be understood from her books: Culture Care Diversity and Universality (1991), Transcultural Nursing (1995) and Transcultural Nursing (2002).


Transcultural nursing theory is also known as Culture Care theory. Theoretical framework is depicted in her model called the Sunrise Model (1997).


According to Leininger Transcultural nursing is a comparative study of cultures to understand similarities (culture universal) and difference (culturespecific) across human groups.



Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care.


·              Cultural preservation or maintenance.


·              Cultural care accommodation or negotiation.


·              Cultural care repatterning or restructuring.



Major concepts of Leininger regarding transcultural nursing:


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. 



Significance of cultural diversity in health care practice:


Every patient’s attitude and behaviour towards their health and illness differ in many ways, but the most profound difference that must be religiously considered is the role of the underlying cultural factors affecting the patient’s outlook on their health condition. Even biological differences as a result of both hereditary and environmental factors which forms the genetic diversity among human beings is a contributing factor that varies greatly in determining why some individuals are more susceptible to certain diseases and why specific drugs have differing effects to certain individuals. Thus, awareness of the nurse on the prevalence and susceptibility of specific individuals to certain types of diseases, or the suitability of certain medication with a certain group of people enables the nurse to detect early signs and symptoms for effective intervention and immediate prevention.


Society and Culture:


It should also be taken into serious consideration to recognize the fact that even though culture with its existing structure are subject to change brought about by the effect of social shifts as immigrants learn to adapt to their host culture, yet still, we cannot ignore or dismiss the possibility that culture change occurs in unpredictable stages, that people in a growing culturally diverse population strive to maintain their traditional cultural habits and beliefs even with the prevailing dominant values and traditions of the host society. Failure to recognize this logical truth is the very reason that substantiates for the failure of the health care system resulting in a substandard patient care.


Since there is a wide variation of culturally influenced health behaviours and beliefs as a result of culturally induced traditional interpretation of illness and disease and their causes, the need to develop a diverse nursing approach to consistently meet each distinct behaviour and belief is essentially important to serve as determinants from which a careful analysis and conclusion can be derive from, and to relate them to these individual preferences in order to render a careful nursing assessment and diagnosis, which when not appropriately recognized and not carefully applied to nursing practice may cause tension and confusion between the nurse and the patient, wherein the nurse would most likely rely only on pure assumptions and make inaccurate assessments which would result in the delivery of unsuitable nursing care.


Factors affecting health care intervention resulting from cultural diversity:


In a culturally diverse health care setting in a multiethnic society, health care providers can only accomplish optimal patient care by developing a sense of deeper understanding, patience and tolerance on the variation of cultural beliefs and practices of culturally diverse individuals. The exhibited effects on individuals influenced by their cultural values and beliefs are manifested in their behaviour ranging from the way they seek medical attention or by the way they view or respond to the care and treatment of the health care provider


The following examples provide some insights about these culturally influenced behaviours:


Expression of pain:


There are many forms of habits and behavior that the health care provider must learn to recognize in a multicultural health care setting. For instance, the most obvious response of most hospital patients is to immediately complain upon feeling any slightest discomfort wherein the most common reaction of the patient would be to seek immediate medical attention the very instant they feel even the smallest amount of pain, yet patients from Asian countries exhibit calm endurance of pain and may not ask for any medication at all.


The Chinese are particularly known to endure pain without medication. It is a part of their traditional discipline to hold back the pain and strongly believe that it is an act of courtesy on their part to refuse pain medication for the sake of the greater good of the majority who have greater need of the pain medication. In other words, it is traditionally impolite and shameful for a Chinese to be prioritized just to relieve his own discomfort while there are others who are suffering with much worst condition than him.


·              Similarly, it is also a common practice for most Asian women to refrain from showing their feelings of pain or discomfort during childbirth, because crying out in pain is an emotional outburst of complaint; hence it would be a disgrace not to gratify oneself to appreciate the suffering of childbirth as a wonderful experience of motherhood. By being aware of such traditional Asian customs and belief, the nurse must learn to be observant to check for any signs of restlessness in the patient in order to determine the need for treatment or medication even if the patient persistently refuses to submit to medical procedures by trying to conceal their pain or discomfort.


·              But while it is a customary habit for most Asian women to be tolerant to the pain and discomfort of childbirth, Middle Eastern and Hispanic women tend to express their childbirth experience (including any other feelings of pain) very loudly. But health care providers should be very careful not to always confine their thoughts to theoretical assumptions base on this cultural pattern by categorizing loud expression of pain as a normal condition based on the conception of the cultural traits inherent with this particular group of people. It would be wrong to ignore the Middle Eastern and Hispanic women’s loud screams by assuming this expression as their usual traditional response to pain without doing any further nursing assessment on the cause of the excruciating pain which could potentially be an indication that something is really very wrong.



Coin rubbing as self medication:


Health care providers may also find that the Asian’s traditional practice of rubbing their body with a coin to be a very disturbing act of inflicting pain to the body. Coin rubbing is a traditional type of healing which is widely practiced by most Asians that often gives the impression of human torture. The purpose of coin rubbing is an attempt to quickly stimulate the healing of illness but would result in the presence of red welts on the surface of the skin where the coin is rubbed. This practice is also often mistaken for child abuse when applied by the elders to a child. The result of coin rubbing is also known to cause incorrect diagnosis due to the deceptive appearance of the noticeable red welts, which is often firstly identified and initially assumed as some form of distinguishable symptom despite its irrelevance to the real cause of illness.



In this case, If the health care provider is aware that the red welts were caused by the traditional healing practice of coin rubbing, then the health care provider will not be distracted away from the real cause of the illness, allowing them to explore other possibilities instead of the visible red welts by focusing on the other symptoms associated with the illness to determine a correct diagnosis and a suitable course of action.


Women and family honor:


Another unique traditional practice and belief influenced by culture that must be expected and respected by the health care provider is the effect of a strictly practiced tradition owing to a firm conviction to the value of female purity as the foundation of family honor, like that of the restricted Middle Eastern culture that strictly prohibits male nurses to examine their women. In this case, health care institutions should make appropriate arrangements to exclusively provide only female nurses and staff to attend exclusively to Middle Eastern women patients. The room of the Middle Eastern women patient should also be treated with utmost privacy that permission to enter the room should always be with the informed consent of the husband or with the eldest male of her immediate family. Strict compliance to ask permission from the husband or the eldest male in the family should also be adhered to when performing other activity that requires the Middle Eastern women to undergo any medical procedures.


Eye Contact:


Another culturally influenced behaviour which can often be misunderstood by the nurse as a strange mannerism is the avoidance of eye contact by the Asian patients, a behaviour which is often regarded offensive and misinterpreted as a sign of rejection of trust, but when perceived correctly as a culturally influenced behaviour is in fact an act of acknowledging respect for the superiority of the nurse over the individual’s health and wellbeing.


Thus, health care providers should also be aware that direct eye contact may be regarded as sexually provocative and should be avoided between men and women when tending to Middle Eastern patient or when conversing with their immediate family.



Health practices in different cultures :


Use of Protective Objects :


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:


It is believed that certain 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 :


Burning of candles, rituals of redemption etc..


Traditional Remedies:


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




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




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


Gender Roles:


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:


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:


It is varies for different cultures groups.


Personal Space:


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



Effect of cultural diversity among health practitioners and effective solutions:


In a multicultural health care setting, difference in cultural values and belief is also known to cause disagreement among health care workers. Known occurrences of such conflict and misunderstanding have transpired as a result of work related issues involving differences in opinions and practices among cultures.


The conflict often arises from a huge gap on the understanding of how a particular culture should appropriately behave or interact to the other culture, each imposing their own cultural value to the other. When such conflict resulting from cultural differences among the health care workers is not resolved, the health care system will suffer thus affecting the delivery of health care to the general patient population.



To eliminate all possibilities of cultural factions among cultures in the organization, it would be helpful for health care institutions to provide trainings and seminars to bridge the gap in order to cultivate understanding between cultural differences.


Developing awareness of cultural factors affecting working relationship will help promote understanding of the reasons behind the conflicting issues, which will reestablish compatibility between opinions and belief to put aside and settle the differences.


Another effective solution is to assign a counselor to act as intermediary between coworkers to resolve opposing issues in order to bring a harmonious working relationship between co workers within the organization.


Nursing process and role of nurse:


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.


Selfevaluation 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 information about the socioeconomic status of the family and its influence on their health promotion and wellness


Identify 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 selfevaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds.


Selfevaluation by the nurse is crucial as he or she increases skills for interaction.


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