NCM 105- Transcultural Nursing Concepts

Table of Contents:

Learning outcomes

• Determine information needed for cultural competence.

• Describe basic concepts of transcultural nursing
• Explore the process and content needed for a cultural assessment
of individuals, families, and groups.
• Analyze health care challenges

• Implement smart travel activities

Sections

• Transcultural nursing in contemporary society

• Collect information needed for preparation to study in another culture
• Review online websites
• Concepts related to environment, people, health, and nursing.
• Cultural self-assessment
• Review exercise: Cultural self-assessment tool
• Case studies of cultural challenges
o Case study: Childbirth culture shock
o Case study: Work ethic
o Case Study: Magic Words and Rituals
• Review exercise: Communicating with people who speak another
language
• Review exercise: Case Study

• Health Risk Worksheet

Introduction to Transcultural Nursing Concepts

Transcultural nursing in contemporary society

Learning Activities:

1. Two minute lecture: Nice to know or need to know?

2. Review exercise: Cultural competence.

Two minute lecture

Nice to know or need to know?

The global environment of the twenty-first century reflects changes in transportation,
technology, and demographics, and requires that we know how to live and work in a
multicultural environment. Glance at the job postings in the newspapers and online
and you will notice that many of the health and nursing jobs are in the international
market and in remote and/or aboriginal communities. Opportunities are everywhere
if you have the transcultural knowledge and skills!

Increasing numbers of nurses and other health professionals are dealing with the
challenges of providing health care to individuals from another culture. Learning to
provide competent transcultural nursing care requires motivation, openness, energy,
and an understanding of the concepts of environment, health, people, and nursing
(Leininger, 1995b, pp. 19-36).

If you are planning to study in another country, or with people who live in a remote
area of your own country, you will want to be prepared as much as possible for the
new and different health care environment. You will want to learn about transcultural
concepts, become self-aware of cultural values, and continually strive to develop and
enhance your transcultural knowledge. Cultural competence is an ongoing process of
awareness, knowledge, skill, and experiences. This is not as easy as it sounds and
culture clash can sometimes occur before anyone has even started to speak!

Review exercise: Coping in another culture

1.2 Review Exercise: Cultural Competence

Multiple-choice exercise
1 Smiling is an effective way to develop rapport with someone.

Competition is a good way to motivate people.

Competition is a good way to motivate people.

Maintain eye contact whenever possible.
The word "yes" or nodding of the head signifies agreement.
The use of hand gestures increases the chance of
understanding.
Removal of shoes when entering a home is polite.
It is good to be action-oriented.
The use of numbers will increase your credibility during a
presentation.
Patients have a right to know the details of their condition.

Correct! The situation is fully dependent on the country and the

individuals that you are working with as to how they perceive the
action.
Collect information needed for preparation to study in
another culture
Conduct a search of journals, on-line resources, magazines, texts, tapes, videos, and
CDs, to orient yourself to the country/region/location and the people with whom you
will be working.

a. Find photos that give a perspective of the following:

• children and adults

• clothing
• housing
• markets or shopping
• hospitals and clinics
• rural areas
• schools
• accommodation
• food
• ceremonies

b. Listen to tapes or CDs of the typical music of the culture

c. View videos that portray the country/region

oncepts related to environment, people, health, and

nursing.

Learning activities:

1. Environment, People, Health and Nursing

2. Review exercise: Health beliefs quiz.

Environment

The environment includes systems and processes such as physical, social, and
symbolic factors. The physical environment of any culture includes climate,
geography, housing, and water and air quality. The climate, for example, influences
the type of clothing and housing that the people will choose to survive the heat or
cold.

The social environment includes all the groups that we live and work with in our day-
to-day existence. We are a part of families, work, church, and school groups. We
depend on each in different ways to meet our needs.

The symbolic environment refers to the music, art, architecture, and history of a
culture. These aspects of the environment provide us with a sense of our past and
the aspirations of our ancestors.

People
All cultures are comprised of individuals who share some part of the culture but not
all of it. There are many generalizations that one can make about the individuals in a
culture but they should not be mistaken for stereotypes. A stereotype does not lend
itself to learning if a particular statement is appropriate to an individual. A
generalization indicates common trends but leaves it open for the nurse to ascertain
the applicability of the trend or statement (Galanti, 1991, p. 2).

The task facing each health professional is to ask "who is this person that I am
caring for"? It is important to determine each client's health behaviors, illness
behaviors, and sick role behaviors. The individual's health beliefs, personal factors
(age, gender, or education), and past experiences with illness will influence the
course of behaviors and practices.

Health

Health includes the concepts of wellness, disease, illness, and sickness. Theories of
health and illness are based on the prevailing world view of the cultural group. There
are three major worldviews that people abide by: magicoreligious, holistic, and
scientific. The accepted approach to health care in the western world is the scientific
model which proposes that life is controlled by a series of physical and biochemical
processes that can be controlled and manipulated by humans.

In the magicoreligious worldview, the world is seen as an arena where supernatural

forces act and interact. The major categories of events that are believed to be
responsible for illness include sorcery, breach of taboo, intrusion of a disease-causing
spirit, and loss of soul (Andrews & Boyle, 1993, p. 21).
In the holistic health worldview, the forces of nature must be kept in balance or
harmony. Everything in the universe has a place and there is a natural order to the
universe. Health is viewed as a positive process that involves environmental, social,
cultural, and behavioral factors with the promotion of prevention and maintenance
measures.

Nursing

The individuals who enter nursing already have a formed value system about health,
illness, and caring. As they progress through the nursing program, they are expected
to adopt the scientific concepts and learn new behaviors and attitudes related to the
provision of nursing care.

When a nurse works with an individual from another culture, there are several
factors that may have an impact on the relationship. These factors include the
specific expectations and beliefs about health care, the setting or context, and the
degree of congruence between the belief systems.

oncepts related to environment, people, health, and

nursing.

Learning activities:

1. Environment, People, Health and Nursing

 2. Review exercise: Health beliefs quiz.

Environment

The environment includes systems and processes such as physical, social, and
symbolic factors. The physical environment of any culture includes climate,
geography, housing, and water and air quality. The climate, for example, influences
the type of clothing and housing that the people will choose to survive the heat or
cold.

The social environment includes all the groups that we live and work with in our day-
to-day existence. We are a part of families, work, church, and school groups. We
depend on each in different ways to meet our needs.

The symbolic environment refers to the music, art, architecture, and history of a
culture. These aspects of the environment provide us with a sense of our past and
the aspirations of our ancestors.

People

All cultures are comprised of individuals who share some part of the culture but not
all of it. There are many generalizations that one can make about the individuals in a
culture but they should not be mistaken for stereotypes. A stereotype does not lend
itself to learning if a particular statement is appropriate to an individual. A
generalization indicates common trends but leaves it open for the nurse to ascertain
the applicability of the trend or statement (Galanti, 1991, p. 2).

The task facing each health professional is to ask "who is this person that I am
caring for"? It is important to determine each client's health behaviors, illness
behaviors, and sick role behaviors. The individual's health beliefs, personal factors
(age, gender, or education), and past experiences with illness will influence the
course of behaviors and practices.

Health

Health includes the concepts of wellness, disease, illness, and sickness. Theories of
health and illness are based on the prevailing world view of the cultural group. There
are three major worldviews that people abide by: magicoreligious, holistic, and
scientific. The accepted approach to health care in the western world is the scientific
model which proposes that life is controlled by a series of physical and biochemical
processes that can be controlled and manipulated by humans.

In the magicoreligious worldview, the world is seen as an arena where supernatural

forces act and interact. The major categories of events that are believed to be
responsible for illness include sorcery, breach of taboo, intrusion of a disease-causing
spirit, and loss of soul (Andrews & Boyle, 1993, p. 21).
In the holistic health worldview, the forces of nature must be kept in balance or
harmony. Everything in the universe has a place and there is a natural order to the
universe. Health is viewed as a positive process that involves environmental, social,
cultural, and behavioral factors with the promotion of prevention and maintenance
measures.
Nursing

The individuals who enter nursing already have a formed value system about health,
illness, and caring. As they progress through the nursing program, they are expected
to adopt the scientific concepts and learn new behaviors and attitudes related to the
provision of nursing care.

When a nurse works with an individual from another culture, there are several
factors that may have an impact on the relationship. These factors include the
specific expectations and beliefs about health care, the setting or context, and the
degree of congruence between the belief systems.

Review exercise: Health beliefs quiz

Review Exercise 1.3b: Health Beliefs

True-False exercise

The political systems of a group are social in nature and culture-

bound.
Every culture defines what is normal in terms of health and illness.

Sickness is a subjective feeling that a person can describe.

Healers in most cultures are prepared to deal with the spirit world as
well as the natural world.
Various curative and preventive rituals may be conducted to restore
balance when illness occurs.
Families vary in the ways they combine scientific and popular health
care practices.
Ethnocentrism is defined as an inability to accept other cultures' way
of living.
A person's perception of his/her illness will determine compliance with
treatment.

Explore the process and content needed for the cultural assessment of
individuals, families, and groups.

Cultural self-assessment
1. Two minute lecture: Chicken soup or rest in bed?
2. Review exercise: Cultural self-assessment tool

Two minute lecture

Chicken soup or rest in bed?

Each of us has a unique cultural heritage with a variety of customs and values. As
you explore the application of transcultural assessment tools, it is a valuable exercise
to apply the tool to yourself and ask some of the following questions about your
personal and professional worlds:

• What is my personal heritage and how deeply do I identify with it?

• What do I know about holistic health and illness from my own heritage?
• What have I learned about my family and its belief system?
• What are some of our health traditions?
• What customs do we follow on special holidays?
• What do my family members believe about independence, privacy, physical
appearance, discipline, and money?

A cultural self-assessment is useful in setting the stage to understanding other

people's health traditions. "Cultural facts are important if they are used with the
understanding that every belief and behavior has both cultural and individual basis"
(Lipson, 1999, p. 6). One of the most interesting questions to ask a group of people
is what their family did when one of them had a common cold

There will be a variety of answers to this simple question such as chicken soup, "feed
a cold", menthol rubs, rest in bed, linseed poultices, or "sweat it out" depending
upon family customs. Values influence our everyday behavior and promote the things
that we hold as important.

Even though some of the customs that cultures or families follow may no longer have
practical value, they have an important psychological one as they provide a sense of
belonging and identity. The customs serve as a reminder that adhering to the beliefs
and norms of your family keeps you connected to a special group.

When you are in your home culture, your understanding of what's done is intact and
solid. The context within which you operate is logical and coherent. When you arrive
in another country, it quickly becomes apparent that your logic is not shared. "At
that moment, that which was invisible and taken for granted becomes visible and, as
a result, becomes the object of awareness and open to scrutiny and examination for
the first time" (Pratt, 1998, pp. 36-37).

Our frames of reference limit our perceptions and until we encounter a basis for
comparison, our own assumptions remain invisible. It is not possible to forget our
perspectives, any more that it is possible to forget our cultural upbringing- but it is
possible to deal with new perspectives and situations as you can learn about other
perspectives (Pratt, 1998, p.37).

Learning step 1: Discuss cultural self-assessment

Review exercise: Cultural self-assessment tool

Take a few minutes and think about the answers to each of the following questions in
the cultural self-assessment. You might want to answer the questions the first time
from your perspective as a child and your family's values and practices and then as
an adult to see if there have been any changes in your values and opinions.
Download the tool, complete the self-assessment, and keep for future reference.

Heritage background

1. In what country was your mother born?

2. In what country was your father born?
3. In what countries were both sets of your grandparents born?
4. Were your parents and grandparents born at home or in a health setting?
5. If your parents immigrated to this country as children/adults, how old were
they when they arrived?
6. Did your parents speak a second language?
7. Has your original family name changed?

Social

1. What setting did you grow up in (rural, urban)?

2. When you were growing up, who lived with you?
3. What were the attitudes towards development in your family (from
babies to the elderly?
4. How were children disciplined?
5. Was it considered important to maintain contact with members of the
nuclear and extended family?
6. What activities did your family participate in when you were growing
up?
7. What ceremonies did your family celebrate each year?
8. What were considered "special" foods?
9. As an adult, do you live in a neighborhood where the neighbors are the
same religion and ethnic background as yourself?
10. Do you prepare foods of your ethnic background?
11. Do you listen to the music of your ethnic background?
12. Do you speak another language?

Health and Illness

1. What activities did your family follow to maintain health and well-being?
2. What lifestyle values were followed by all members of the family (eg three
meals a day, regular exercise, or regular checkups)?
3. Did your family believe in seeing a doctor at the first sign of illness or waiting
to see how the illness progressed?
4. What treatments were used for the common cold, the flu, or a stomach ache
when you were growing up?
5. What did your family consider to be illnesses that should not be openly
discussed with others?
6. What were your family's beliefs about healing practices?
7. What beliefs did your family have about controversial issues such as abortion,
euthanasia, or suicide?
8. What were the family customs regarding death?

Gender

1. What was the primary role of your mother, your grandmother?

2. What roles and responsibilities did the men and women in your family have?
 3. What decisions were made by both the men and women in your family and
what decisions were made by only the men?
4. Did the women in your family have a comparable level of education as the
men?

Work

1. What was considered to be "women's" work in your home?

2. What did your grandparents do for an occupation?
3. What did your parents do for an occupation?
4. If the women worked outside the home, did they have a comparable position
and income as the men in the family?
5. Were children and the elderly expected to work?
6. What were the family values associated with work?
7. Did the men in your family assist with household work?

Time

1. What did your family value regarding punctuality?

2. How did your family ensure its history and past would be maintained?

Religious beliefs

1. What was the role of religion in your family in sickness and health?
2. What were the ritualistic practices?
3. What were the attitudes toward ethical situations such as abortions,
suicide, abuse, and euthanasia?
4. Did your family perceive a difference between spirituality and religion?
5. How would a nurse have recognized spiritual distress in a member of
your family?

Attitudes towards space

1. What were your family norms related to modesty, social conduct, or privacy?
2. What was considered a comfort zone when talking to someone in your family?
3. What behaviors were frowned upon?
4. What were the general taboos in your family?

Communication

1. Which family member did the talking for a sick child or elder?
2. What were accepted lines of communication?

Nutritional values

1. What was considered a normal diet when healthy? When ill?

2. What were considered ceremonial meals?
3. What was a usual diet for the children in your family?
4. What were there any specific beliefs about certain groups of food?
5. What was the attitude toward breastfeeding?
Growth and development patterns

1. How were the growth and development stages such as puberty,

menopause handled in your family?
2. What were special dates in a child's or adolescent's development?

Drug interaction and metabolism

1. Are there any types of drugs that affect your family in an unexpected
manner?

Illnesses and diseases

1. Are there any diseases that have a higher incidence of occurrence in your
family?
2. What genetic diseases are more frequent in your family?

Pain

1. What were the cultural expectations of how members of your family manage
pain?
2. What were the acceptable expressions of pain?

Learning step 1: Discuss cultural self-assessment

1.2 Review Exercise - Answer Key

This exercise is designed to assist you in identifying aspects of your own culture that
are very evident and part of your value system and those aspects that you are not as
aware of. As a registered nurse, you bring culture bound definitions of health and
illness to a client-nurse relationship. As a registered nurse educated within a
Canadian health care system, you bring your practices and lifestyle values to
situations requiring prevention of illness and treatment of illness.

You have been socialized to believe in the theory and research of modern nursing.
You will more than likely believe in the germ-transmittal of disease, benefits of
technology, and importance of compliance to treatment.

Close this window to continue.

Learning outcome 4: Analyze cultural challenges

Case studies of cultural challenges

Learning activities:

1. Two minute lecture: Shades of gray

2. Case studies
3. Review exercise
Two minute lecture

Shades of gray

You will experience challenges in both your personal and professional roles after your
arrival. Even under the best of circumstances, it is difficult to enter another culture
where customs and values are different. Some the most basic rules of living become
a source of concern. For example, how do you greet people, when is it appropriate to
leave a home or event, what should be said when leaving, what is expected at the
birth of a baby, a marriage, or death, and what table manners are expected? Nothing
is black or white- there are variations to every aspect of living!

One of the ways to adjust to this diversity is to interact with the people from the
other culture and spend some time observing and reflecting on situations you do not
understand or where something went wrong.

Some of the attitudes that will assist you when dealing with cultural challenges are
as follows:

• Willing to learn
• Being patient
• Being flexible
• Willing to take some risk
• Having a sense of humor
• Accepting that life is different in the new culture
• Trying to work out situations in a calm, collected manner

"We begin to scratch the surface of transcultural understanding when together we

shop, eat, play, worship, ride the train, share our workplaces, and stay in each
other's homes (Vance, 1999, p. 13). These relationships will begin to close the gap in
transcultural understanding.

Learning step 1: Discuss case studies of cultural challenges

Case studies
The case study approach is a strategy that can help to prepare you for work in
various settings. There are no right or wrong solutions to a case study. They provide
a way of responding to unique situations and if you have an opportunity to discuss
the challenges and issues within a group setting, you will arrive at a greater number
of options and solutions.

Learning step 1: Discuss case studies of cultural challenges

Case study: Childbirth culture shock

Situation:
The far west of Nepal is a remote mountainous area where the people eke out a
living cultivating rocky terraces. The land does not produce enough food to feed the
local population. There is virtually no industry. People are very poor, many are
illiterate - their primary link to the outside world is an occasional radio in the village.

Driving along the highway in this remote part of Nepal, we passed a group of men
carrying a woman slumped on a sedan chair. Sedan chairs are chairs with long poles
fastened underneath to facilitate transporting someone on the shoulders of four
porters. In Nepal, they are frequently used to carry someone who is too ill to walk
when there are no cars or motorcycles for transportation.

After stopping we stopped we determined the woman was very weak, she had been
in labour for 2 days, her labour had stopped, and the midwife had given up on her.
The men had carried her to the road and were hoping a bus would come along so
they could take her to the mission hospital an hours drive away. We were able to
determine her history through rudimentary questions and much gesturing. When we
tried to get the woman into the vehicle the Nepalese men who had been travelling
with us tried to force her into the back of the station wagon. They refused to sit with
her. We finally managed to get both the woman and her husband in the vehicle and
raced along the narrow, switchback mountain roads to the hospital.

When we finally reached the hospital she was taken to the labour room. About an
hour later we inquired about her and were told the baby had been delivered and
while the mother would 'likely recover', the baby was dead. When we looked shocked
the doctor said 'Oh well, it was only a girl!'.

Questions:

1. Describe the differing values placed on male and female children in rural
Nepal and compare these values to your own values.
2. What are the impacts of the Hindu religion on traditions related to childbirth.
How do these traditions differ from those of your religion?
3. Imagine yourself working this situation and describe ways you might balance
your cultural values with those described in the case study.

Learning step 1: Discuss case studies of cultural challenges

Case study: Work ethic

Situation:

For the poor residents of Nepal, health care is primarily provided through a network
of government hospitals and health posts. Although the cost of the services provided
in these institutions is generally low, supplies and equipment are frequently
nonexistant or are at best extremely limited.

As well, health care workers are paid very low salaries they frequently leave their
assigned posts to seek other employment to supplement their incomes. It is not
unusual to find a health post closed for an extended period with no staff available or
to find the trained staff, including the nurses, have all left and an untrained person is
managing - prescribing treatments and/or dispensing whatever medications are
available.

Questions:

1. Describe your personal work ethic.

2. Identify potential conflicts for a Canadian registered nurse working in health
posts in Nepal.
3. Identify ways you could ameliorate conflicts between your work ethic and the
case study described above.

earning step 1: Discuss case studies of cultural challenges

Case Study: Magic Words and Rituals

There is a word that most Canadian children are taught by their parents in the early
years of their lives. It makes things happen! And if the child does not say the word,
there is usually some type of reaction from the parent. The word of course is
"please". Each culture has its own magic words and actions- if you do not follow
them when living in that country, you can get into trouble.

We arrived late in the afternoon to an Asian country. A message was waiting at our
hotel room that we were invited to a banquet with several of the planning committee
members from that country. As we were the guests, the food was put in front on us
and they non-verbally indicated that we should start. Being left-handed, I picked up
the serving chopsticks in that hand and started to transfer the food to my plate. The
hosts were quiet and did not seem to eat very much during the meal.

What happened here?

In many of the Asian countries, the left hand is never used to eat food as the left
hand is used for personal toilet hygiene. I should never have put the serving
chopsticks in my left hand and used them to transfer the food.

What could have been done to avoid this situation?

An in-depth orientation to the Asian countries and the proper protocols would have
warned me about this situation. I should have followed the general rule of observing
before acting!

Learning step 1: Discuss case studies of cultural challenges

Review exercise: communicating with people who speak

another language
One of the cultural challenges that you may experience is communicating with
individuals who speak another language. What are some ways to effectively
communicate when you know only a few words of the language?
After you have answered this question for yourself by writing down the answers,
click here for some further comments.

Learning step 1: Outline required travel preparations

Review exercise: Case Study

You are chosen to travel to Malawi for a five week practicum as one
of the criteria of a five-year contract between the educational
institution and the hosting country.

You seem to be the "perfect" candidate in that you are

knowledgeable about the country and excited about the trip. You
are a very outgoing and personable candidate. Shortly after
arriving, you e-mail the organizers, indicating that you want to
come home as soon as possible. You are weepy, indicating that you
cannot eat anything, and saying that it was a mistake to go to the
country.

What has happened in this situation?

After you have responded to these questions, click here for further comments.

Review exercise: Case Study Comments

Culture clash can occur when an individual comes into contact with a different
culture. It can lead to fatigue, depression, and feelings of anxiety. The conflict that
you are experiencing is provoking strong physiological and psychological responses.
You may be reacting to fatigue from the energy spent concerning sanitation, using
the telephone, catching the bus, or deciding what to eat.

Try some of the following actions:

• Try to connect her with a mentor who will help you cope with the different
aspects of being in the culture
• Be reassured that the stresses and strains you are experiencing are real
• There is a pattern to your feelings and being aware of the feelings is one step
toward coping with the change
• Try some of the suggestions in the “Ready, set, go!” manual to help cope with
culture shock.
• If you cannot overcome her feelings of helplessness, make arrangements to
come home

Learning step 2: Describe specific health risks related to country

Review exercise:
Health risk worksheet for the country/location to which you are going.

Note: this is not an interactive form. Please download it and fill out the items.
Leading 3 health risks in Ways to minimize risk of
selected country (Nepal) contracting each disease

1. 1.

2.

3.

2. 1.

2.

3.

3. 1.

2.

3.