Leininger (1991) describes transcultural nursing as a formal study and practice which is focused on the differences and similarities among cultures with respect to human care. Providing culturally appropriate nursing care in the modern world has become a complex and modern task for many nurses. A nurse who does not recognize the value and importance of a culturally appropriate care cannot possible be an effective care agent. If nurses do not recognize that the intervention strategies planned for and African-American client with diabetes is uniquely different from that of an American client or a Russian client, and so forth, they will not be able to actively encourage wellness behaviours among these clients (Giger and Davidhizar, 2004:4)
In this essay, the concepts of transcultural nursing to be discussed are those of Campinha-Bacote’s The Process of Cultural Competence in the Delivery of Healthcare Service, Purnell’s Model for Cultural Competence and Giger and Davidhizar’s Transcultural Assessment Model. A case study will also be presented with regards cultural challenges encountered during the period of caring for the client.
Campinha-Bacote (2002) defines her model as the ongoing process in which health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client which includes the individual, family and community. This process involves the integration of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. She defined cultural awareness as the process of conducting self-examination of own biases towards other cultures and the in-depth exploration of one’s cultural and professional background. It is when people interact with people from different culture, where belief and practices they consider appropriate is sometimes inappropriate in another party (Quappe and Cantatore, 2007). On the other hand, cultural knowledge is the process in which the healthcare practitioner searches the information based on the patient’s cultural history specifically health-related beliefs, practices and cultural values, diseases and population specific treatment and outcomes (Campinha-Bacote, 2002). These three components could form the basis for quality indicators that measure the cultural competence of health care providers (Lavizzo-Mourey and Mackenzie, 1995). Cultural skill is the ability to conduct assessment to collect relevant information regarding the patient’s health condition and to conduct culturally based physical examination. Leininger (1978: 85-86) defined a cultural assessment as a “systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values, and practices to determine explicit needs and intervention practices within the context of the people being served”. Cultural encounter, according to Campinha-Bacote (2002), is the process that encourages the health care provider to directly engage in cross-cultural interactions with clients from culturally diverse backgrounds. She added that directly interacting with clients from diverse cultural groups will modify one’s existing beliefs about a cultural group and will prevent possible stereotyping that may have occurred during the process. She noted further that cultural encounters also involve an assessment of the client’s linguistic needs. Using a formally trained interpreter may be necessary to facilitate communication during the interview process in order to prevent faulty and inaccurate data collection.
Cultural desire is the motivation of the health care provider to want to, rather than have to, engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and familiar with cultural encounters ( Campinha-Bacote, 2002:182)
The Purnell Model for Cultural Competence was originally developed as a cultural assessment for nurses that can be applied for primary, secondary, and tertiary prevention (Purnell, 2000). Purnell believes that health care providers who can effectively assess, plan, and intervene in a culturally competent manner have increased opportunities to improve the health of the person, family, or community under their care. He included that the model can also guide nurses in the development of assessment tools including data collection, strategies in planning, and individualized intervention (Tortumluoglu, 2006).
The Giger and Davidhizar Transcultural Assessment Model could help nurses in assessing clients from different cultures. The author finds this model important for the nurse to assess the client through personal interview as an effective strategy to obtain data and observe the client’s behaviour and practices. The model guides the nurse to be aware of the differences, identify cultural beliefs and plan strategies on how he/she will interact with the client. Strategies include interview questions and observational guidelines to assess culturally diverse individuals in order to provide the care they need (Tortumluoglu, 2006).
The Giger and Davidhizar Transcultural Model postulates that each individual is culturally unique thus should be assessed in accordance to the six cultural phenomena: communication, space, social organization, time, environmental control and biological variations. This model is created to help nurses assess and provide care for patients who are culturally diverse (Giger and Davidhizar, 2002a).
Communication is an act or an instance of transmitting. It is the means by where cultures and behaviours are transmitted and preserved. Nurses must also take into consideration the types of communication used, whether verbal and non-verbal, throughout the entire caring process. The American Society of Radiologic Technology (1998) added that in communication; vocabulary, grammatical structure, voice qualities, rhythm, speed, silence, facial expressions and body posture vary from culture to culture. For a nurse to successfully provide care for a client of a different cultural or ethnic to background, effective intercultural communication must take place.
Another cultural phenomenon that should be considered in assessment is space. This refers to the distance between individuals when they are interacting with each other. Personal space is an individual matter and varies with the situation; dimension and personal space comfort proximity varies from culture to culture (Giger & Davidhizar, 2004). Health care worker with direct care of the client must be aware of this and respect how people of various cultural background views with their personal space (American Society of Radiologic Technology, 1998).
Social Organization refers to the manner how people of different culture gather themselves around as a family. Family is a unit in the society which is composed of members as a subsystem. Giger and Davidhizar (2004) consider family as a system. A system as defined is a group of interrelated parts or units that form a whole. Within the family system, the subsystems refer to the ways in which the members relate themselves with one another. How a particular culture views the family unit possibly affects how a member of the system is treated when one experiences health imbalances (Giger and Davidhizar, 2004).
Time is considered as an integral part in the cultural phenomenon. People perceive time uniquely, though awareness and concept of time is only a product of human mind. People of some cultures consider time as past, present and future. Various cultures focus on the past and are tradition-based: others are present-oriented and “live for today”; others look towards the future and tend to postpone immediate gratification in favour of future gain. In some cultures, for instance, among Asian origin, time is out looked as “flexible”, and so there is no need to rush or be prompt except for emergency cases. Nonetheless, nurses are expected to be time conscious. Emphasis is given to the importance of punctuality and good time keeping so as not to disrupt the routines being practiced in the workplace.
Environment control refers to the ability of a person to control over nature, plan and direct the environment. Some cultures believe that man overpowers nature; others perceive that they are dominated by nature, while others see nature and human in smooth relation (Giger and Davidhizar, 2002a). This cultural phenomenon plays an important role in determining client perception towards illnesses, its ability to seek alternative medical resources either derived from science or nature (Spector, 2000).
The last phenomenon in Giger and Davidhizar Transcultural Model is biological variation which includes physical and biological characteristic of a person such as body structure, skin colour, enzymatic and genetic variations, electrocardiographic patterns, susceptibility to disease, nutritional preferences and deficiencies and psychological characteristic (Giger and Davidhizar, 1991).
For the author, Giger and Davidhizar’s Transcultural Model provided a useful tool in assessing the culturally diverse client in the following situation. It serves as a guide of the extent of data gathering. Each phenomenon was used to relate with the given case. Real name is not given in order to preserve the confidentiality.
Lumana is an eighty-seven year old woman from a town in the southern part of England. She has been admitted for over a year now in Cattleya Nursing Home. She has been diagnosed with rheumatism and has very limited mobility due to old age. As the author reviewed the client’s history, she found out that Lumana was married for 50 years and had only one child. When her husband died two years ago, she was left to the care of her daughter Strawberry. But because of the pressure and demands of her job, Strawberry decided to admit her mother to a nursing home. Strawberry also revealed that her mother has a history of Diabetes Mellitus Type II that is managed through diet and regular exercise.
Based on the initial assessment data obtained on admission, the author found out that the client was an active member of Iglesia ni Cristo and used to participate on church and community services. She was born in Wales and spent over half of her life there. She is a multilingual. She usually communicates in English but can also very well speak native Welsh.
For Lumana, time is precious. She has a daily routine from the time she wakes up until the time she retires to bed. During her spare time she is fond of knitting and watching television. Alteration of this routine makes her day miserable all throughout.
After only a few months following her admission, she already started to enjoy doing a lot of activities together with other residents. She gets along with them and is able to recognize them with their names. She enjoys nature and loves to go out on a coach outing. During dinner, she prefers to join the rest of the residents in the dining room.
Due to old age, her skin has gotten thinner which makes it more prone to tearing. Decreasing mobility causes body resistance to drop and compromises blood circulation. When she had an infection on her right ankle three months ago, she started to become confused, agitated and bothered. Her wound has been referred to her GP who ordered to start her on antibiotic therapy. However, she is not responding well to the treatment which only worsened her sadness.
Since then, her behaviour has gradually changed and she has become more withdrawn. Seldom does she go down to the dining room to have her dinner and never attended on residents’ activity. She is now very quiet and aloof and prefers to stay alone on her room. She is even refusing her medications which only worsens her present situation. She has also become rude to her carers. She tends to be quiet during morning as she gets up and does not express her wants.
When Lumana’s daughter and grandchildren came in to visit her, she opened her worries about her unhealed wound and expressed fear of death because she does not want to leave her daughter. Based on the changes noted on her, the assigned RGN contacted the GP and consulted Lumana’s behavioural change. A psychiatrist has also been consulted regarding her depression and gradual withdrawal.
For the author and other carers, caring for Lumana gets even harder each day. She does not communicate with them and she’s deteriorating socially. Although non-verbal cues are easily noted, these may imply differently to the carers. Sometimes she communicates with them in Welsh and slang English accent which obviously the carers do not comprehend.
For the author, communication is the main barrier in caring for this culturally diverse individual. “Communication embraces the entire world of human interaction and behaviour” (Giger and Davidhizar, 2002:page). Hence, nursing must act in response to the challenges of meeting the needs of different ethnic groups and fulfil the requirements of the Code of Professional Conduct (Cortes, 2000).
Communicating with Lumana seems to be difficult. There are many things a nurse must consider. For example, eye contact for some culture signifies respect. In some culture it is important because insufficient or excessive eye contact can create communication barriers. For the British culture, eye contact conveys interest, attentiveness and trust, though prolonged eye contact make them feel uncomfortable. In many other parts of the world, Asians for example, lack of eye contact signifies disrespect and deference to authority or people of high rank (Levine & Adelman, 1993).
British people and Filipinos have an obvious cultural difference, from food preferences, etiquette and customs even there value of time.
The three models considered on this case has helped the author to be initially aware of the differences and distinctions between her and the client’s cultures. She was able to minimize her prejudices and biases towards her client’s race and therefore was able to intervene in a culturally competent manner.
With cultural understanding ,the author’s prejudices and biases of the British culture were minimized. This is particularly important because caregivers who can assess, plan, and intervene in a culturally competent manner will improve the care of their clients (Purnell, Journal of Transcultural Nursing, 2002).
Learning culture is an ongoing process and develops in a variety of ways but primarily through cultural encounters (Campinha-Bacote, 1999).
As the author reviewed the care plan of Lumana, she found out that an anti-depressant drug has been ordered for her. She became careful in dealing with her non-verbal cues so that information would not be misinterpreted. She made sure to even spend time communicating with her. This is in accordance to what Cortes (2000) suggested that nurses should fulfil an active role in relationship building and in manifesting acceptable behaviour toward recipients of their care.
Being so patient to her, the author noted significant changes on the client’s behaviour. She would now request to join the other residents for dinner and she also started to show interest in participating with the residents’ activities. It is a good indication that Lumana has developed trust and now feels support and protection. She would even express gratitude for the care been given to her.
“As users of nursing services, their voice is an important and irreplaceable source of nursing expertise” (Cortes, 2000).
In conclusion, the models of transcultural nursing serve as guidance in dealing with culturally diverse individual without biases and prejudices. It gives nurses the steps and scope of assessment. To be culturally competent, nurses must increase their own awareness and prepare themselves of the challenges and even criticisms they might encounter even criticism. To be effective, health care providers must reflect the unique understanding of the values, beliefs, attitudes, life ways, and worldview of diverse populations to the recipients of their care (Purnell, Journal of Transcultural Nursing, 2002). Nevertheless, becoming culturally competent is a process and requires internal desire to be one. The time to learn differing perspectives about culture is at hand. As professional health care providers, nurses will be asked to step forward to provide the leadership to ensure that all people have equal access to high-quality, culturally appropriate, and culturally competent health care. This task can be accomplished aonly through culturally diverse nursing care. (Giger and Davidhizar, 2004:4)
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