CHAPTER 20. Transcultural Nursing
Care of Culturally Diverse Patients
Meg Beturne and Myrna Mamaril
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify key perianesthesia transcultural concepts of cultural competence.
2. Define transcultural nursing.
3. Describe seven major components of a perianesthesia cultural assessment.
4. Discuss the importance of communication as it relates to assessment of culturally diverse patients.
5. Discuss the significance of verbal and nonverbal communication in dealing with culturally diverse patients.
6. Summarize important life events that concern culturally diverse patients in their perianesthesia hospitalizations.
I. DEFINITIONS
A. Culture
1. Integrated system that is shaped by learned values, beliefs, norms, and practices
2. Characteristic of a society
3. Guides individual behavior
a. Thoughts
b. Feelings
c. Actions/patterns of expressions
d. Decision-making that facilitates self-worth and self-esteem
4. Passed down from one generation to the next generation
B. Transcultural nursing
1. Used interchangeably with cross-cultural, intercultural, or multicultural nursing
a. “Trans” means across, “inter” means between, and “multi” means many.
b. Goes across cultural boundaries in search for scientific theory of nursing
2. Integrates the concept of culture into all aspects of nursing
3. A humanistic and scientific area of formal study and practice
a. Focuses on differences and similarities among cultures with respect to:
(1) Human care
(2) Health (or well-being)
(3) Illness
b. Based on individual’s:
(1) Cultural values
(2) Beliefs
(3) Practices
C. Cultural competence
1. Definition
a. Dynamic, continuous process
b. Individual and/or organizational process that continually finds meaningful and useful care delivery strategies based on:
(1) Knowledge of the cultural heritage
(2) Beliefs
(3) Attitudes
(4) Skills
(5) Encounters
(6) Behaviors of those to whom care is rendered
2. Health care professionals need to use knowledge gained from conceptual and theoretical models of culturally appropriate care.
3. Cultural competence assists the nurse to devise meaningful interventions to promote optimal health among individuals regardless of race, ethnicity, gender identity, sexual identity, or cultural heritage.
II. CULTURE
A. Values, norms, beliefs, and practices of a society
B. Develops over time
C. Learned responses, actions, words, and thoughts
D. Passed down through the generations
E. Not genetic in nature
F. Guides behavior
G. Affects health care practices
III. THE TRANSCULTURAL NURSING SOCIETY
A. Founded in 1974: Madeline Leininger, founder
B. Publications on transcultural nursing
C. Annual transcultural nursing conferences
D. Certification available
IV. MAJOR WORLD VIEWS OF HEALTH AND ILLNESS
A. Biomedical (scientific)
1. Life is regulated by biomedical and physical processes.
2. Health is absence of disease.
3. Illness is alteration in structure and function of body.
4. Treatment focuses on physical and chemical interventions.
B. Magicoreligious (supernatural)
1. All that exists is dependent on supernatural forces.
a. Includes good and evil
2. Health means person is blessed or favored by the supernatural.
3. The cause of disease is mystical.
a. Not based on scientific fact
b. Foreign object or spirit enters the body.
c. Sign of punishment or possession by the supernatural
4. Treatment aimed at removing foreign object or spirit
C. Holistic
1. Everything governed by laws of nature
2. Health achieved by adapting to constantly changing environment
3. Illness is imbalance or lack of harmony between forces.
4. Treatment aimed at restoring harmony or balance
V. MAJOR SECTORS OF HEALTH CARE
A. Types
1. Popular
a. Lay; nonprofessional, non–folk healer
(1) Define and treat illness.
b. Determine whether additional care is needed (folk or professional).
c. Activities
(1) Self-care is administered using home remedies.
(2) Consult with family, friends, clergy, neighbors, others who have had same condition.
(3) Remedies include over-the-counter medications.
(4) Care provided by self, family, and/or friends
2. Folk
a. May be consulted when home remedies and self-care methods fail
b. Ethnomedical and traditional
c. Ethnomedical
(1) The study of non-Western, traditional, or folk medicine
(2) Encompasses cultural traditions, beliefs, and practices related to health and illness
(3) Not related to biomedical theory
d. Characteristics
(1) Defines and removes supernatural causes
(2) Works to restore balance
(3) Strives to restore health and prevent illness
e. Activities
(1) Holistic approach
(2) Treatment of illnesses caused by:
(a) Imbalances in individual, physical, social, and metaphysical environments
(b) Supernatural forces
(3) Treatment of:
(a) Culture-specific illnesses
(b) Illnesses not controlled by home remedies or professional medicine
(4) Rituals
(a) Incorporated to prevent illness, misfortune, and to enhance effects of biomedicine
f. Acts as intermediary between popular and professional sectors
g. May be the only sector consulted, depending on cause, signs, and symptoms
h. Care provided by:
(1) Folk healers
(a) Secular
(b) Sacred
(c) Combination of both
3. Professional
a. Types
(1) Biomedicine—United States
(2) Traditional Chinese medicine—China
(3) Ayurvedic medicine—India
b. Goal: to define, treat, and prevent disease and illness
c. May be consulted when home remedies or folk sector treatments are ineffective
d. Initially consulted if acute trauma, surgery, or restoration of body part necessary
B. Characteristics
1. Each explains and treats illness differently.
2. Each defines who should be the health care provider.
3. Each defines how the provider and patient should interact.
4. Sectors are used individually, in combination, or simultaneously.
C. Use of different sectors
1. Folk sector
a. New immigrants and refugees use as primary source.
b. Used by individuals from all socioeconomic groups
c. Use dependent on cause of illness and availability of healers in other sectors
D. Nurse’s role
1. Understand why different sectors are used
a. Enables nurse to better explain goals of nursing intervention and treatments
b. Ensures patient understands advantages and disadvantages and potential incompatibilities of treatments from multiple sectors
VI. TRADITIONAL HEALERS
A. Description
1. Not part of popular or professional health sector
2. Specialize in forms of healing characteristic of ethnomedicine
3. Deal with secular, sacred, or both
4. Combine methods from both sacred and secular
B. Secular
1. Use organic and technical means to treat conditions resulting from natural causes
2. Types of healers
a. Herbalist
b. Bone setters
c. Granny midwives
d. Tooth extractors
e. Injectionists
C. Sacred
1. Use nonorganic methods to treat supernatural and natural causes.
2. Nonorganic
a. Semimystical and religious practices
b. Influence mind and faith of individual
c. Examples
(1) Chants
(2) Prayers
(3) Rituals
(4) Amulets—object worn or cherished to ward off evil or attract good fortune
d. Types of healers
(1) Sorcerers
(2) Shamans
(3) Spiritualists
(4) Voodoo priests, priestesses
(5) Diviners
D. Nurse’s role
1. Determine whether patient receiving treatment from traditional healer.
2. Inform patient if traditional treatments and biomedical treatments are incompatible (Table 20-1).
| Healer | Preparation | Practice | |
|---|---|---|---|
| African American (southern urban) | Family members, especially grandmother | Word of mouthPractical experience | Secular:
Common, everyday self-limiting illness that respond to home remedies
Illness prevention
|
| Wise woman (“old day”) |
Practical experience of caring for and raising own children, grandchildren, and other kin
Develops reputation among family, friends, and neighbors of being knowledgeable about home remedies for common illnesses
|
Secular:
Treatment and prevention of common, everyday illnesses
Advice about child care and child rearing
|
|
| Herbalist | No formal training | Secular:
Diagnose a variety of natural illnesses
Dispense herbs to neutralize or eliminate harmful substances that impair the power of body to heal or protect itself
|
|
| Spiritualist |
No formal training
Power may be present at birth (twins) or given by God later in life
Usually associated with fundamentalist Christian religion (Holy Ghost, Pentecostal)
|
Sacred:
Cure illnesses sent by God as punishment
Cure ailments beyond the power of biomedical practitioners (e.g., arthritis, hypertension, diabetes mellitus)
Power of God is present in the body of the spiritualist and transferred to the ill person through laying on of the hands
Draws on the faith of the individual
Sacred or secular: May combine laying on of the hands with herbal therapy, massage, and life counseling
|
|
| Root doctor (root worker, conjure man or woman, voodoo priest or priestess) |
Apprenticeship
May be born with magical powers
|
Sacred or secular:
Serves as intermediary between supernatural and natural worlds
Enact or remove spells
Counteract or protect against witchcraft or sorcery
Combine magical powers with use of herbs
Read omens and signs and prescribe therapy or preventive measures
Counseling and magical powers with use of herbs
|
|
| African Caribbean (Haitian) | Family members, primarily female |
Word of mouth generation to generation
Practical experience
|
Secular:
Prevention and treatment of common, everyday illnesses
|
| Doctor feuilles, bocars, dokte feuilles (leaf doctors, herbalists) |
Apprenticeship training
Hands-on experience
Learn “formulas” for healing
|
Secular:
Treats patients with herbs, roots, medical plants, and rituals
Bone setting, burn treatments, and massage
|
|
| Droquistes | Apprenticeship | Secular:
Make and sell potions to prevent or treat illnesses of natural causation
|
|
|
Houngan (voodoo priest)
Mambo (voodoo priestess)
|
Apprenticeship training in rituals
Knowledge of prayers and herbal remedies from elders
Long training in and study of mythology of spirits
|
Sacred or secular:
Treatment of illnesses due to supernatural causation (angry voodoo spirits; dead ancestors; or magic, witchcraft, or sorcery)
Treatment of illnesses that are long lasting or fail to respond to biomedicine
|
|
| Sages-femme, fam saj, matrone (lay midwife, wise woman) | Apprenticeship | Secular:
Performs deliveries, prepartum and postpartum care, treats other “female” conditions related to reproduction
Uses herbs, massage, rituals, baths, and diet
|
|
| Piqurestes (injections) | Training in missions and other medical facilities | Secular:
Give injections, change dressings
|
|
| Hispanic (Puerto Rican) | Family member, especially oldest female |
Word of mouth
Practical experience
|
Secular:
Common, everyday illnesses that respond to home remedies
|
| Curandero or curandera | Apprenticeship Gift from God | Sacred or secular:
Knowledge of herbs, diet, massage, and ritual
Commune with supernatural
Conduct religious curing ceremonies
|
|
| Partera (lay midwife) | Apprenticeship training from older female relatives | Secular:
Prepartum and postnatal care, herbal remedies, massage, treatment of natural illness affecting women
|
|
| Yerbero (herbalist) | No formal training | Secular:
Preventive and curative care
Treats both ethnomedical and biomedical illnesses
|
|
| Santiguadore (sabador) | Apprenticeship | Secular:
Massage and manipulation of body for illness affecting the musculoskeletal and gastrointestinal systems
Treats both ethnomedical and biomedical illnesses
|
|
| Spiritualist (espiritualista, brujera, santero) |
May be born with gift to fortell future
Perfect skills through apprenticeship
|
Sacred:
Prevention and diagnosis of witchcraft, or sorcery; uses amulets, prayers, and other artifacts
Some limited curative functions
|
|
| Moslem (Iranian) | Family members, especially older women | Knowledge handed down generation to generation | Secular:
Self-care measures such as bed rest, diet, herbs, home remedies, and childbirth assistance
|
| Dais (traditional midwife) |
Apprenticeship
Older women who have raised their own families
|
Secular:
Prepartum and postpartum care
Childbirth
Newborn care
Herbal therapies
Massage
|
|
| Mullah (religious healer) | Religious training | Sacred:
Prevention of illness via preparation of tawiz (amulet with verses from the Koran)
Treat illness due to evil spirits
Treat emotional problems, nervousness, excessive anxiety, and mental illness
|
|
| Injectionists | Self-taught | Secular:
Administer medications prescribed by physicians
Purchase and prescribe injectable medications on their own
|
|
| Hakimji (traditional healer) | Apprenticeship | Sacred or secular:
Combine procedures and medicines from Urani and Greco-Arabic medical traditions
|
|
| Bonesetters | Apprenticeships | Secular:
Sets broken bones
Treats sprains, strains, dislocations, and generalized body pains
|
|
| Native American (Navajo Indian) | Family members | Knowledge handed down from generation to generation | Secular:
Common, everyday illnesses of natural origin
Prevention of illnesses
Herbal remedies
|
| Medicine man |
Born with power to heal
Acquire power to heal via vision or quest
Apprenticeship with medicine man once power to heal is known
|
Sacred or secular:
Diagnosis and treatment of supernatural or natural illness (meditation, trance state, divination, or star gazing)
Use combination of herbs and curing ceremonies
|
|
| Diagnostician | As per medicine man | Sacred:
Diagnose underlying cause of illness via divination
|
|
| Herbalists |
Knowledge passed down generation to generation
Apprenticeship
|
Secular:
Diagnose and treat common illnesses of natural causation
|
3. Consult with traditional healer, if necessary, to ensure all have understanding of same goal: assisting the patient to recovery.
4. Modify plan of care if no compromise is reached.
VII. PREOPERATIVE INTERVIEW AND NURSING ASSESSMENT (see Chapter 15)
A. Develop culture sensitivity.
1. Clarify own culture and value systems.
a. Reflect on actions, thoughts, communications, and beliefs of own culture.
2. Examine personal negative opinions of different cultures.
3. Increase awareness of other cultures through churches and schools.
B. Do not project own views on patients through verbal and nonverbal communication cues (Box 20-1).
1. Verbal communication
a. Voice quality
b. Intonation
c. Rhythm
d. Speed
e. Pronunciation used
2. Nonverbal communications
a. Facial expressions
b. Gestures
c. Posture
BOX 20-1
VERBAL AND NONVERBAL COMMUNICATION
Language or Verbal Communication
▪ Vocabulary
▪ Grammatical structure
▪ Voice qualities
▪ Intonation
▪ Rhythm
▪ Speed
▪ Pronunciation
▪ Silence
Nonverbal Communication
▪ Touch
▪ Facial expression
▪ Eye movement
▪ Body posture
Communications That Combine Verbal and Nonverbal Elements
▪ Warmth
▪ Humor
From Giger JN, Davidhizar RE: Transcultural nursing: Assessment and intervention, ed 4, St Louis, 2004, Mosby.
C. Observe client’s family and support system.
D. Respect the patient.
1. All cultures are unique.
2. All individuals are unique.
E. Tips for effective communication
1. Introduce yourself.
a. Exhibit confidence; avoid arrogance.
b. Shake hands if appropriate.
c. Explain reason for your presence.
d. Explain upcoming sequence of events (admission assessment, preoperative holding, intraoperative, postoperative).
2. Avoid assuming where the patient comes from; the patient will tell you if he or she wants you to know.
3. Show respect, especially to males.
a. Males are often the decision-makers.
b. If patient is child or woman, male may be the one making decisions regarding care and follow-up.
4. In some cultures, it is customary for children to go everywhere with parents.
a. Poorer families may not have childcare options available to them.
b. Include children in perioperative experience.
5. Understand traditional health-related practices.
a. Do not show disapproval of them.
b. If practice is potentially harmful, inform patient.
6. Be cognizant of folk illnesses and remedies for the cultural population in your service area.
7. When possible, involve leaders of local groups.
a. Leader may have understanding of problem.
b. May be able to assist in offering acceptable interventions
c. Ensure confidentiality is maintained.
8. Accept diversity as an asset, not a liability.
a. Listening and verbal interactions need to be made with an appreciation of cultural differences (Box 20-2).
BOX 20-2
GUIDELINES FOR CULTURALLY SENSITIVE INTERACTIONS
Nonverbal Strategies
▪ Invite family members to choose where they would like to sit or stand, allowing them to select a comfortable distance.
▪ Observe interactions with others to determine which body gestures (e.g., shaking hands) are acceptable and appropriate. Ask when in doubt.
▪ Avoid appearing rushed.
▪ Be an active listener.
▪ Observe for cues regarding appropriate eye contact.
▪ Learn appropriate use of pauses or interruptions for different cultures.
▪ Ask for clarification if nonverbal meaning is unclear.
Verbal Strategies
▪ Learn proper terms of address.
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