Understanding culture and transcultural Nursing
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
Culture practice and
beliefs are adapted over time but they mainly remain constant as long as they
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.
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
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).
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 (culture‐specific) across human groups.
identified three nursing decision and action modes to achieve culturally
preservation or maintenance.
accommodation or negotiation.
repatterning or restructuring.
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
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.
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.
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.
In a culturally diverse
health care setting in a multi‐ethnic 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:
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
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:
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
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 well‐being.
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.
Use of Protective
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
Religious Practices :
Burning of candles,
rituals of redemption etc..
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
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
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.
It is varies for
different cultures groups.
Respect the client's
personal space when performing nursing procedures. The nurse should also
welcome visiting members of the family and extended family.
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
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
Developing awareness of
cultural factors affecting working relationship will help promote understanding
of the reasons behind the conflicting issues, which will re‐establish compatibility between opinions and belief
to put aside and settle the differences.
solution is to assign a counselor to act as intermediary between co‐workers to resolve opposing issues in order to bring
a harmonious working relationship between co‐
workers within the organization.
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.
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
influence of culture, race ðnicity on the development of social
emotional relationship, child rearing practices & attitude toward health.
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
Understanding of the
general characteristics of the major ethnic groups, but always individualize
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.
include the nurse's self‐evaluation of attitudes
and emotions toward providing nursing care to clients from diverse socio‐cultural backgrounds.
Self‐evaluation by the nurse is crucial as he or she
increases skills for interaction.