Culture is one of the most important determining factors in healthcare preferences and practices. Thus, the need for transcultural nursing is undeniable. “Transcultural nursing requires sophisticated assessment and analytic skills and the ability to plan, design, implement, and evaluate nursing care for individuals, families, groups, and communities representing various cultures” (Andrews and Boyle, 2008, p.4). In order to effectively practice transcultural nursing, one must first understand the need for cultural competence. It is vital for nurses to have a desire to become culturally aware, culturally knowledgeable, culturally skillful, and to seek cultural encounters. Cultural desire is the stimulator in the eruption of the process of cultural competence and the nurse must seek and be open to learn and accept others, understand the process is lifelong, and set aside personal feelings to effectively treat unique patients (Campinha-Bacote, J, 2003). The Giger and Davidhizar (2002) Transcultural Model is a helpful tool that addresses and effectively treats patients who have different cultures. The model takes into consideration 6 important phenomena.
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Communication keeps culture alive by verbal and nonverbal means; it is one of the biggest obstacles in healthcare. Nurses ask questions to determine patient’s views on illness, causes, and possible treatments. They listen and interpret their patient’s level of understanding and ability to follow through with treatment. Also, nurses interact with the patient’s family. Communication varies from culture to culture. Americans are expected to speak Standard English; however, it varies based on region, ethnicity, and social class (United States, 2001). Americans use a variety of nonverbal communication. Eye contact, which is viewed as a sign of trust and honesty, between patients and healthcare professionals is the norm. Expression of emotion varies in American culture. Americans use a combination of verbal language, body language, and gestures. Americans are often straightforward and rather demanding. Unlike Americans, Asians rarely complain. Silence and withdrawal may be the only indication of a problem. Asians tend to not ask for anything, accept pain, and remain stoic (Fernandez V. & K., 2008, Asian Community). Many Asians don’t engage in eye contact with powerful persons; the avoidance of eye contact shows respect and reverence (Non-Verbal Communication, p.4). Asians speak more than 100 languages; they vary based on the geographic regions they descend from (Asian Americans, p. 2). Arab Muslims usually cooperate by answering questions, listening, and following directions until they see improvement. They believe their expression, such as pain, should be quickly met with response (Fernandez V. & K., 2008, The Middle Eastern Community). The Arabic language uses devices that outmatch reality and is not very direct or explicit (Ayish, 2003). Hispanics are very emotionally expressive. Effective communication with Hispanics is not based on just speaking their language; cultural rules allow for certain discussions with certain people (Fernandez V. & K., 2008, The Hispanic American Community). Eye contact is expected on the nurse’s part but will not necessarily be reciprocated (Andrews & Boyle, p.25). Nurses, if available, should undergo cultural competency training. Berln and Fowkes’ LEARN Model can assist; LEARN, represents the process of listening to the patient, explaining your view, acknowledging differences and similarities, recommending and negotiating a plan (Campinha-Bacote, J.,2003). Nurses should enlist the help of trained interpreters, preferably of the same gender, mature, and of no relation to patient; if there is no interpreter, the following but not limited to, is necessary: politeness, slow and concise speaking, simplicity, pantomime, validation of understanding, and instructions in the proper sequence (Andrews & Boyle, p.29).
Space is also important when dealing with various cultures. Nurses are required to interact with patients, often invading personal space. Giger and Davidhizar (2002) state:
Territoriality refers to feelings or an attitude toward one’s personal area. Each person has their own territorial behavior. Feelings of territoriality or violation of the client’s personal and intimate space can cause discomfort and may result in a client’s refusing treatment or not returning for further care. (p. 185)
Americans tend to require a need for personal space. When family and friends are near, Americans tend to be relaxed; however, when a stranger or mere acquaintance invades space, it can become uncomfortable. Asians prefer a great amount of social distance. Many prefer minimum physical contact with acquaintances; excessive contact is viewed as inappropriate. Unlike Americans, who believe touch is a sign of friendliness, Asians view the head as a personal area that contains the seat of the soul and it should not be touched. Arab Muslims seem to require the least amount of space. It is not uncommon for people from the Middle East to stand closely when conversing. However, gender can play a role; Muslim woman may become distraught when a male, even a healthcare professional, stands or sits near her; Arab Muslims expect females to tend to females and males will care for males. Hispanics, unlike Americans, are use to standing or sitting near people they are not well acquainted with (Non-Verbal Communication, p.3). Hispanics and Arab Muslims may unintentionally invade nurse’s space as a means of getting closer and more comfortable (Andrews & Boyle, p.26). Nurses should take the patient’s lead; if the patient seems to gravitate towards you or initiates touch, then it is acceptable to do the same. At all times respect the patient and boundaries.
When dealing with patients, there must be consideration of social organizations or what role the patient’s culture plays in his or her life. Family members are often the providers of a patient’s eating habits, sick role behaviors, and medications used. Americans view family as a vital part of their healthcare plans. It is common for Americans to be visited and supported by family; they often discuss and make important decisions. Asians are concerned with family interdependence over independence; family usually likes to assist with patient care. In some Asian cultures, some members, such as men and elders, dominate and consider women and children inferior (Galanti, 2005). Arab Muslims regard family as the foundation of their society. The husband answers questions, makes all major decisions, and gives consent. Often times, Arab Muslims don’t believe in divulging family history. The family cares for the ill. (The Middle Eastern Community). Hispanics have large families who visit for long hours as a way to demonstrate their love and genuine concern. Often times, decisions are made by the entire family or designated members (Galanti, 2003). Religious and spiritual beliefs are important factors during illness, recovery, and death. In the United States, most people consider themselves Christians; Catholics singly dominate, but the Protestant groups combined outnumber them. Americans include religious practitioners such as priest, ministers, and rabbis as well as nontraditional leaders during health related situations. Americans include religious objects, such as the Bible, and also rituals, such as communion. Death and end of life choices are also influenced by religion and practices; typically, Americans consider death a sad and somber time. Asians are host to numerous religions; Christian, Muslim, Buddhism, and Hindu are just a few. Many Asians believe in bad spirits; infants attract them and induce death. If the illness is thought to be caused by spirits, healers are sought (Asian Community). Arab Muslims are usually of the Islamic faith and pray 5 times a day to the Holy Land, Mecca. Muslims recharge their spiritual battery during the month of Ramadan; fasting from dawn to sunset accompanies. Arab Muslims often read from the Al Quran (The Middle Eastern Community). Hispanics are usually Catholics with the recent emergence of Pentecostals. Shrines and religious objects are common in practice. Health is viewed as God’s gift and should be revered (The Hispanic Community). Nurses must be accommodating to patient’s families and the value placed on family within cultures. Nurses must be sensitive to religious beliefs or practices and must not impose personal beliefs. Seeking knowledge is essential. However, exposure to diverse cultures is one the best learning mechanisms.
Understanding a cultures notion of time elapsing, specific periods, and clock time are
necessary for effective healthcare. Cultures may be past, present, or future oriented. Americans use time to provide order. Americans expect care at designated times; appointments are a prime example. Americans are future oriented; they believe they can manipulate the future by taking certain actions. Americans tend to be proactive; the focus is optimism, coping strategies, and preventive measures. Americans often demonstrate this orientation through self examinations, check-ups, and staying informed about healthcare advances. Asians tend to have a past orientation. They prefer to adhere to traditional methods and treatments; they are apprehensive about new innovations. Recently however, Asians are shifting towards future orientation (Galanti, 2004). Arab Muslims are present oriented and are neglectful of preventive measures. They may be late or not attend appointments at all (The Middle Eastern Community). Hispanics also focus on the present. They believe the future arrives in its own time and thus the notion that one cannot be late exist (Galanti, 2004). Nurses must explain the importance of time regarding life processes while being respectful and mindful of cultural views. Nurses should try to refrain from making time oriented promises that can’t be kept.
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Environmental control or the attempt to control nature affects patient’s health practices, values, and the definitions of health and illness (Giger, & Davidhizar, 2002). Americans believe nature can be controlled. Americans equate the body to a machine; if it’s broken, allow healthcare professionals to fix it (Galanti, 2004). Americans conform to the Western biomedical model which defines health as the absence of disease or the signs and symptoms of disease. The holistic paradigm exists in Asian cultures; it deals with the concept of yin and yang, in which forces of nature must be balanced to produce harmony (Andrew & Boyles, 69). Asians tend to view people as part of nature. The land is a resource used to treat disease; herbal remedies are common (Galanti, 2004). Arabs believe the key to good health is personal hygiene and a healthy diet. “They place a high value in modern Western medicine and have confidence in the medical profession” (The Middle Eastern Community). Hispanics believe natural forces are not in their control and preventative measures are not often taken. (Galanti, 2004). Their system, the Curanderismo, combines spiritualistic, homeopathic, and scientific elements; curandero or holistic healers are utilized (The Hispanic Community). Nurses should become familiar with factors. Nurses should not dismiss patient’s view of their power and accountability or lack thereof.
Biological variations exist between races; some groups are sensitive to certain medications, have metabolic differences, and are prone to certain diseases or factors that can affect healthcare. African Americans are three times more likely to get tuberculosis than whites; they also have higher rates of hypertension. Sensitivity to cardiovascular effects from Propranolol occurs more in Asians than Whites. Ethnic minorities, such as Hispanics, have higher HIV rates (Giger and Davidhizar, 2002). Middle Easterners or Arab Muslims have a lower percentage of sweat chlorides (Andrews & Boyle, 54). The list of variations is broad and extensive. “Accurate assessment and evaluation of clients require knowledge of normal biocultural variations among healthy members of selected populations” (Andrews & Boyles, 49). Nurses must acquire skills that will allow the recognition of variations.
A nurse must always remember that the focus should remain on the patient’s well being and recovery. It is necessary to understand that individuals will never be the same. A patient’s health status and treatment is directly influenced by their culture and it is this reasoning, which has been proven through testing and the development of theories that has led to the conclusion that culture cannot and will not be ignored. “Human diversity makes tolerance more than a virtue; it makes it a requirement for survival” (Dubos). Healthcare will not suffice without negotiation, adjustment, and respect of differences. Transcutlural concepts in nursing care have made cultural competency an expected standard and it is the duty of every nurse to help maintain this standard.
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