Transcultural Nursing Research Paper

Transcultural Nursing Research Paper

Transcultural nursing is an essential aspect of healthcare today. The ever-increasing multicultural population in the United States poses a significant challenge to nurses providing individualized and holistic care to their patients. This requires nurses to recognize and appreciate cultural differences in healthcare values, beliefs, and customs. Nurses must acquire the necessary knowledge and skills in cultural competency. Culturally competent nursing care helps ensure patient satisfaction and positive outcomes. This article discusses changes that are important to transcultural nursing. It identifies factors that define transcultural nursing and analyzes methods to promote culturally competent nursing care. The need for transcultural nursing will continue to be an important aspect in healthcare. Additional nursing research is needed to promote transcultural nursing.Transcultural Nursing Research Paper

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With the modern emphasis on evidence-based practice, it’s easy to imagine nursing as a universal discipline that can be applied in the same ways to any group of patients. Madeleine Leininger, RN, Ph.D., FAAN knew better. As the founder of transcultural nursing, she recognized early in her career that patients’ cultural background can have a profound effect on the way they describe symptoms, respond to pain and understand diagnoses. This in turn requires nurses to reconsider how they provide care and what “care” even means.

Nebraska Farm Girl
Although she is best known today for what she called the theory of culture care, diversity and universality, Madeleine Leininger’s early life was far from cosmopolitan. Born in Nebraska, she grew up on a homestead farm and attended small rural schools. She entered nursing school in Denver through the U.S. Cadet Nurse Corps, receiving her diploma in 1948.Transcultural Nursing Research Paper

While working as a nurse, she continued her education, earning her master’s degree in psychiatric nursing from the Catholic University of America in 1954 and becoming an associate professor of nursing at the University of Cincinnati. During this period, she was responsible for developing one of the nation’s first graduate child-psychiatric nursing programs after realizing that there was a general lack of understanding among nurses of the connections between cultural factors and behavior.

Next Stop: New Guinea
Around this time, Leininger became friends with well-known anthropologist Margaret Mead, who inspired Leininger to study cultural and psychological anthropology at the graduate level. In 1966, Leininger became the first nurse to complete a Ph.D. in that field. Her field work involved three years of study in two Gadsup villages in Papua, New Guinea.

That experience helped to codify Leininger’s basic philosophy: that beneficial nursing care could only occur when the nurse understood and related appropriately to the patient’s cultural values and expressions. Nurses who did not, Leininger argued, would find their patients noncompliant and their care ineffectual.

As a teacher and academician, Leininger worked to develop models for formally instructing nurses in understanding and interacting with patients from different cultural perspectives, the basis for what today are called culturally competent care practices.Transcultural Nursing Research Paper

“Culturally Meaningful” Care
Over the next decade, Leininger served as the director of the nurse-scientist Ph.D. program at the University of Colorado and then as dean of nursing at the University of Washington. In 1970, she published Nursing and Anthropology: Two Worlds to Blend, the first book to elucidate her concepts of transcultural nursing. Four years later, she founded the Transcultural Nursing Society and the Journal of Transcultural Nursing. She also played a key role in establishing transcultural nursing programs at several universities.

In 1978, while serving as the dean of nursing at the University of Utah, Leininger published the first textbook on transcultural nursing and care, Transcultural Nursing: Concepts, Theories, and Practices. In that book’s second edition in 1995, she described the goal of transcultural nursing as “providing culture-specific and universal nursing care practices in promoting health or well-being or to help people to face unfavorable human conditions, illness or death in culturally meaningful ways.”

Patients are entitled to culturally competent care. Nurses must be prepared to recognize patients’ needs that derive from their culture and to develop skills that will facilitate their achievement. Nursing curricula therefore need to include a cultural content and student nurses need to be culturally competent. The aim is to use cultural knowledge to deliver culturally sensitive and congruent care. Transcultural nursing education does not exist as a course in undergraduate or postgraduate nursing programs in Slovenia. In an effort to advance the diversity of elective courses in the postgraduate nursing program at the Faculty of Health Sciences of the University of Primorska, we tried to develop and introduce transcultural nursing into the existing curriculum. The aim of the paper is to outline the development of transcultural nursing content as it was set in the course curriculum and planned teaching and learning approaches.Transcultural Nursing Research Paper

The Transcultural Nursing Questionnaire (TNQ) was used for pre-and post-test comparisons of all participants in four areas of cultural knowledge and the Evaluation of Transcultural Nursing Competency (ETNC) was applied via role-play to evaluate the cultural competency of 120 of the 305 participants from three general hospitals in the PuDong New District, Shanghai, China. Individual transcultural nursing courses that focused on case study, traditional didactic or self-directed methods persisted for four months in three hospitals.

Statistical analyses of the cognitive scores of the participants in the transcultural nursing courses revealed a significant difference(P＜0. 01)between scores collected before and after the teaching with the three methods. Comparisons of the three hospitals revealed that the scores for transcultural nursing cognition and simulating service assessment were significantly different(P＜0. 01) for the case study nursing students. The scores of the students who were taught with the traditional didactic and self-directed methods were not significantly different across the three hospitals(P＞0. 05).Transcultural Nursing Research Paper

The results revealed that the case study, traditional didactic and self-directed method effectively improved the transcultural nursing cognitive levels of the nursing students. The case study method appeared to be the most effective approach based upon the TNQ pre-and post-tests and the ETNC cultural competency scores.

Cultural diversity is an issue that faces all health-care workers today. The immigrant population in the United States is increasing, which suggests that education is needed in transcultural nursing to allow nurses to provide culturally competent care. The nation’s minority population has reached approximately 101 million, and it is estimated that one in three United States residents is a person belonging to a minority group [1–3]. It is expected by the year 2050 that the Black, Hispanic, and Asian ethnic group percentages within the population will rise dramatically, and the Caucasian population will drop significantly [4], with the USCB (2013) projecting that the United States will become a majority-minority nation, no single group making up the majority, by 2043. Yet, according to the Department of Health and Human Services (DHHS) Office of Minority Health [5], it is estimated that only 10% of registered nurses in the United States claim minority group status. The lack of diversity in the nursing profession mandates a need for cultural competence education in order to provide culturally competent care to an ethnically diverse patient population that is increasing   Transcultural Nursing Research Paper

Currently, there are no education requirements from the Texas Board of Nursing for transcultural nursing [8]. Cultural competence education concepts remain an option for professional nursing education programs. The American Association of Colleges of Nursing (AACN) believes that diversity and equality of opportunity are core values of all educational systems, and one goal is to create a community of culturally competent scholars, including faculty, students, staff, and practitioners [9]. Decreasing inequities in the health-care system will require culturally competent nurses and other health care providers to meet the needs of disenfranchised groups [10]. The Joint Commission on Accreditation of Health-care Organizations [11] emphasizes the importance of cultural competence in terms of safety and outcomes and believes that it is now essential for nurses to examine their practices related to cultural elements.

The challenge is growing for professional nurses to care for a culturally diverse population. The American Nurses Association (ANA) believes that nurses and health care providers have a responsibility to provide an environment that recognizes differences and is free from discrimination, including discrimination based on racial and ethnic differences [12]. It is difficult to remain aware of the myriad of cultural groups that reside in the United States. However, health-care professionals should be aware of the dominant cultures within their local area. For example, there are approximately 43 different languages spoken in a city with a population of 183,021 people, which is located in the southwestern United States. Increasing awareness of these different groups will allow nurses to gain additional insight regarding the care of these individuals.Transcultural Nursing Research Paper

According to the ANA, nurses should provide care with respect for human dignity as well as considering the uniqueness of the individual client [12]. Unrealized or unacknowledged biases may prevent nurses from providing optimal quality care. Acknowledging the practices of diverse cultures will allow professional nurses to provide a range of alternatives in services, for example, in providing the patient’s dietary preferences or health care beliefs [11, 13].

Communication barriers between nurses and their patients and families may arise because of cultural differences. It is important for nurses to recognize that caregiving within the family context may differ from their own interpretation and knowing how to integrate the family’s health practices into the overall health care regimen will benefit both patient and family [14].

Nursing curricula must provide a foundation for the development of cultural competence that allows for acquisition of knowledge, skills, and attitudes. In addition, an examination of culturally diverse concepts stimulates commitment to moral and ethical values, while developing an appreciation for diverse cultural heritages. Acquisition of culturally competent concepts promotes an awareness of contemporary world issues and can be learned through multiple teaching strategies, including didactic and experiential methods [15–18].Transcultural Nursing Research Paper

In studies of cultural competence education in nursing, findings support that the addition of culturally competent content increases scores on culturally competence measures, as students gain experience during progression through the curricula [19–23]. A more recent review of the literature supports the findings of these studies [24]. Similarly, qualitative studies that examined cultural competence discovered emerging models for increasing cultural competence through education based on the patients’ perspective, as well as that of nurse, and student nurses [25–29].

2. Purpose, Rationale, and Research Question of the Study
The purpose of this study was to determine if the self-perception of cultural competence in baccalaureate nursing students as a result of their education and experiences increased during the nursing program. As the curriculum committee members were examining the existing nursing curriculum and planning a major revision, this study was instrumental in informing the faculty of the perceived cultural competence of beginning and graduating nursing students. Data generated by this study allowed nurse educators a better understanding of student perceptions of cultural competence and informed the curriculum committee of the cultural competence gained throughout the nursing program. The research question which framed this study was as follows: is there a higher perception of cultural competence among graduating nursing students as compared to beginning nursing students?Transcultural Nursing Research Paper

For the purpose of this study, culture was defined as beliefs and values of a particular group that are learned and shared and are generally transmitted between generations and influence thinking, decisions, and actions [30]. Cultural competence was theoretically defined as a process by which nurses strive to achieve the ability and availability to work within a cultural context of a patient, family, or community [31]. Cultural competence was operationally defined by a total score on the Cultural Competence Assessment (CCA) tool [20]. A beginning nursing student was defined as a baccalaureate nursing student in the first clinical semester of the nursing curriculum. A graduating nursing student was defined as a baccalaureate nursing student in the last clinical semester of the nursing curriculum.

3. Theoretical Frameworks
The major focus of transcultural nursing is to focus on the humanistic and scientific study of individuals from different cultures with consideration to ways in which nurses can assist those individuals meet their health and living needs [32]. Leininger’s Transcultural Nursing Theory posits that caring serves to improve human conditions through behaviors, techniques, processes, and patterns. In addition, caring behaviors such as comfort, compassion, concern, interest, tenderness, touching, and trust are illuminated as key concepts to providing quality care through the lens of culture. Culture is determined by one’s personal life and worldviews. Caring and culture are linked to one another, and nursing care should be aimed at preserving, maintaining, accommodating, negotiating, and restructuring care patterns as these relate to the individual’s cultural perspectives [33].Transcultural Nursing Research Paper

The 3-Dimensional Puzzle Model of Culturally Congruent Care was also chosen to guide this study. The four basic components of the cultural competence puzzle at the health care provider level include cultural diversity, cultural awareness, cultural sensitivity, and cultural competence [34]. The model is specifically operationalized using the CCA. This study tested quantitatively the fourth puzzle piece, cultural competence, using the CCA, as it measures perception to the actions taken in response to cultural diversity, cultural awareness, and cultural sensitivity.

4. Methods and Procedures
The Institutional Review Board (IRB) approved the research study. Guidelines set forth by the Family Educational Rights and Privacy Act (FERPA) were followed to protect the privacy of student education records, and there was no identifying information collected. The design of this study was a comparative, descriptive design, testing for differences between beginning nursing students () in the first clinical course and the last clinical course () in a baccalaureate nursing program. Students were recruited during the first class meeting of the semester, and data were collected during the first week of classes using the CCA. The rationale for using a comparative design with data collection between two groups at one time instead of a longitudinal time frame allowed faculty to assess this concept in the current curriculum prior to a planned revision.

The CCA is a 43- item Likert scale and was administered to gather data about individual self-perceptions regarding culture competence. The CCA had demonstrated in a previously reported study test-retest reliability (, ; [20]). The CCA is made up of three different subscales, including the Cultural Awareness and Sensitivity Subscale (CAS) consisting of an 11-question Likert scale; the Cultural Competence Behavior Subscale (CCB) consisting of a 14-question Likert scale; and the Marlowe-Crown Social Desirability Scale consisting of 13 questions that were answered with either true or false by the student participants. The CAS is scored using a range of 1 to 7, with a higher score indicating a greater cultural awareness and sensitivity. The CCB is also scored using a range of 1 to 7, with a higher score indicative of more cultural competence behaviors being demonstrated. The Marlowe-Crown Social Desirability Scale was added to the instrument as a check/balance for honesty on the CCB subscale. This scale is scored using a range of 0 to 13, with a higher score indicating more need for approval, which indicates that respondents answered the questions according to what they believed to be socially acceptable [20].Transcultural Nursing Research Paper

The data collected were analyzed using the independent t-test. This study measured perceived cultural competence as a total score upon which each groups’ mean score was determined and subjected to independent t testing to determine differences between groups. The level of significance was set at . The data were analyzed using the Statistical Package for the Social Sciences (SPSS) 17.0 software.

5. Findings
There were a total of 99 nursing students, with an age range for the beginning nursing student participants of 19–35 years () and an age range of the graduating nursing student participants of 21–65 years (). The average age of the graduating nursing students was statistically higher compared to the average age of the beginning nursing students (, ). The racial/ethnic self-identification of the beginning nursing students included 24% Hispanic/Latino, 61% White/Caucasian, 4% Black/African American, and 11% Asian. The racial/ethnic self-identification of the graduating nursing students included 4% Hispanic/Latino, 72% White/Caucasian, 19% Black/African American, and 4% Asian.Transcultural Nursing Research Paper

The mean scores for the beginning and graduating nursing students are reported in Table 1. The graduating nursing students demonstrated a higher mean score for the CAS and the CCB (e.g., 6.018 and 4.590, resp.) as compared to the beginning nursing students (e.g., 5.695 and 3.453, resp.), indicating that the graduating nursing students have greater perceived cultural awareness and sensitivity and perceive that they demonstrate more culturally competent behaviors. However, it was noted that the beginning nursing students demonstrated a lower score on the Marlowe-Crown Social Desirability Scale as compared to the graduating nursing students (e.g., 7.00 and 7.75, resp.). This indicates that the beginning nursing students have a slightly less need for approval than do the graduating nursing students. Independent t-test findings demonstrated that perceptions of cultural diversity were significantly higher in the graduating nursing student group as compared with beginning nursing students

Internationally employed nursing staff are required to deliver care to highly diverse populations of patients with culture-specific needs. Nurses must develop cultural competence to accurately assess their patient and develop appropriate interventions in thier plans of care to optimize outcomes. Culturally competent care cannot be provided unless nurses recognize how cultural values, attitudes, and beliefs impact on the patient and family’s response to care. Competence may be manifested explicitly as sensitivity, knowledge, and skill; with culture in focus, and the domains of culture may be presented specifically as cultural values, religion, and health beliefs, among others. There are many theories, models and views related to cultural competence, and healthcare leaders are challenged to ensure that culturally appropriate scope of care is delivered. This challenge has escalated as international accreditation standards focus on the patient experience (satisfaction with care) and awareness of how the patient and family values, attitudes, and beliefs impact care and outcomes. In the international setting, it is important to employ experienced and knowledgeable staff from diverse backgrounds when producing cultural competency-focused learning assessments, outcomes, and exercises. Adult learning is a dynamic process that must incorporate interactive experiences to break through administrative limitations to inform clinical practical skills. Educators related to this subject matter must be empowering and engaging. Healthcare institutions must help develop cultural competence education and standards to ensure that nursing staff accurately access, develop, and implement effective nursing interventions.Transcultural Nursing Research Paper

Palliative care has an identity crisis – patients, families, and even healthcare professionals often have difficulty understanding exactly what it is and how it works. The result is that many who could benefit from palliative care never receive it.

This eBook introduces the Whole Person Plan, a new clinical tool APRNs can use to clearly describe palliative care to patients and families who need it, and to aid in ongoing assessment, discussion, and palliation of suffering in the face of serious illness.

The Whole Person Plan highlights the physical, social, emotional, and spiritual domains essential to effective whole person care, and the importance of future planning, which helps patients articulate and document healthcare decisions that align with their goals and values.

This tool was created by Kendra Deja, MSN, GNP-BC, ACPHN, LCSW, in collaboration with the CSU Institute for Palliative Care. The eBook includes a downloadable version of the Whole Person Plan, as well as a plethora of evidence-based resources that palliative care APRNs can use to assess and address suffering in each domain that comprises the whole person.Transcultural Nursing Research Paper

How to use the Whole Person Plan to clearly and easily describe palliative care to patients and families who could benefit from it
How to guide patients and families through the domains of whole person care – physical, emotional, social, and spiritual
Evidence-based tools that can help further assess and explore potential suffering
Talking points within each whole person domain that help patients and families articulate areas of suffering, and strategies APRNs can use to help palliate that suffering
Download this eBook if you are a:

Any member of a palliative care team
Check out these courses that provide powerful strategies for APRNs working with seriously ill patients!
Advanced Practice RN Certificate in Palliative Care
This intensive online course delivers the latest evidence-based strategies in pain and symptom management, communication, care at the end of life, and more. Learn alongside an online community of your peers as you explore challenging areas of practice, and strengthen your clinical expertise. Instructor-led. 175 CEs.

Primary Palliative Care Skills
This is a comprehensive series of courses designed to provide foundational palliative care skills to any MD, PA, NP or other practitioner. Self-paced. 34 CEs or CMEs (full series); also available as individual courses.

RN Certificate in Palliative Care
This is a comprehensive series of courses designed to provide foundational palliative care skills to any MD, PA, NP or other practitioner. Self-paced. 34 CEs or CMEs (full series); also available as individual courses.Transcultural Nursing Research Paper

Post-MSW Certificate in Palliative Care
This course provides master’s prepared social workers with the knowledge and skills to be successful working in a transdisciplinary palliative care team. It provides strategies for getting out of the ‘subconscious,” giving intention to critical thinking, utilizing teaching and coaching to demonstrate leadership. Instructor-led. 144 CEs

Multiculturalism is an important topic in today’s society. However, not everyone understands terms like “multicultural” and “transcultural.” More specifically, how do these concepts apply to nursing?

In the online RN to BSN program at UTPB, you will learn the intricacies of transcultural and multicultural nursing that will prepare you for real-world experiences. As a nurse, you will work with a diverse population, and UTPB’s online RN to BSN program will set you up for success.

What Is Transcultural or Multicultural Nursing?
Nurses connect with countless patients throughout their careers, and no two patients are alike. Transcultural nursing is the ability to connect with people from different cultures and to bring those cultures together to improve their health. By developing your transcultural nursing skills, you can educate, care for and support people of different cultures, even in the face of language barriers.

The term “multicultural” relates to the presence of multiple cultural groups within a single society; multicultural nursing involves an awareness of the different cultural groups that make up our society in a healthcare setting.Transcultural Nursing Research Paper

Together, transcultural (connecting different cultures) and multicultural (awareness of different cultures) skills allow you to grow as a person and as a professional. Patients’ cultural views often influence their decisions about healthcare. Being able to recognize these cultural concerns can help you overcome obstacles with patients and deliver the best care possible.

Why Is It Relevant for Nurses?
Cultural perspectives play a big role in shaping patients’ beliefs about their health and healthcare. As a nurse, your job is to provide the very best care for each patient. That means taking patients’ cultural backgrounds into consideration when helping them make decisions about their care.

By developing multicultural skills, you will learn about the sensitivities, risk factors and concerns of different cultures. You will form a better understanding of potential barriers to care and how to overcome them. Becoming a culturally competent nurse is one of the best things you can do for yourself, your patients and your career.

How Can I Learn About Transcultural and Multicultural Nursing?
Honing your multicultural nursing skills allows you to reach a wider population. The best way to learn how to work with people of different cultures is to talk to them. If you do not know very much about a particular culture, ask people you know who belong to that culture to tell you a little bit about themselves and their customs.Transcultural Nursing Research Paper

You can also conduct research online or talk to a multicultural expert. The Transcultural Nursing Society provides a wealth of information about how to adopt a multicultural perspective and improve your multicultural nursing skills. The online RN to BSN program at the University of Texas Permian Basin can also prepare you to deal with multicultural issues in your nursing career.

The UTPB Online RN to BSN Program
At UTPB, you will take classes with people from many different cultures living all across the country. Ask your classmates questions and learn from one another. UTPB’s online RN to BSN program will boost your cultural competence with three transcultural or multicultural nursing courses in the core curriculum.

Transcultural Nursing (NURS 3302)
This three-credit-hour class concentrates on communication with people from different cultures, especially Spanish-speaking patients and families. In particular, you will learn how to discuss medical terminology with patients who are unfamiliar with English jargon. This course will also teach you how to gather patient history, discuss medication and discharge planning, and explain procedures and treatments with people of various cultural backgrounds.

Multicultural Public Health Nursing (NURS 4313)
With an emphasis on public health resources, this three-credit-hour course will train you to handle the cultural influences on the health of patients, families and communities. This course introduces you to the importance of community partnerships and helping families modify their lifestyles to promote health. You will also learn about emergency management in the community from a multicultural perspective.Transcultural Nursing Research Paper

Multicultural Public Health Nursing: Clinical (NURS 4213)
In this two-credit-hour course, you will examine evidence-based nursing skills and how you can apply them to helping at-risk families and vulnerable populations. You will learn how to handle community assessment and planning strategies, as well as multicultural nursing advocacy within the healthcare system.

Being able to understand and connect with people of different cultures is an important part of nursing. You will be working with people at their most vulnerable, so understanding their cultural concerns and perspectives is crucial. By educating yourself about different cultures through communication with diverse people, online research, and completing your required transcultural or multicultural classes in your nursing program, you will be well-prepared to work with any population as a professional nurse.

The Transcultural Nursing track in the Master of Arts in Nursing program was designed to prepare nurses for advanced practice across care settings in culturally diverse communities. The curriculum is grounded in nursing science, theory guided practice, and provides students with a solid baseline of transcultural nursing theory.

Emphasis is on reaching out to persons and populations that are underserved by traditional care systems and who exist outside of the social mainstream. As such, the track provides rich alternative learning opportunities for graduate students locally and internationally.Transcultural Nursing Research Paper

The Transcultural Nursing track prepares nurses to apply for advanced certification in Transcultural Nursing through the International Transcultural Nursing Society and/or certification in Holistic Nursing through the American Holistic Nurses Credentialing Corporation (AHNCC), which is a separate entity from American Holistic Nurses Association.

Students will take a total of 33 semester credit hours — eight 3-semester credit hour courses + 9 semester credits of practica equal to 405 ‘clock’ hours of practice. Four courses and the related practica make up the Advanced Nursing Core that all Master of Arts in Nursing students must take, with the remaining four courses and practica focused on transcultural nursing content and skill development.

The cultural face of the America’s population is changing. According to the US Census Bureau,1 one of every three persons in the US comes from an ethnicity other than non-Hispanic white. In Kaiser Permanente (KP), Santa Clara County, CA, we care for an especially diverse population. The most recent census,2 which was in 2006, showed that of the 1.7 million people in Santa Clara County, CA, 63% are white, 30.5% are Asian, 2.8% are black, 0.8% are American Indian or Alaska Native, 0.4% are native Hawaiian or other Pacific Islander, and 2.5% are persons who identified with two or more races.Transcultural Nursing Research Paper

Despite this growing diversity in the US and in our service area, diversity among nurses has not kept up with that of the population. In many health care settings, nursing does not reflect the demographics of the general population. Even when nurses are well educated and culturally sensitive, the lack of ethnic diversity among them creates a challenge for those who are attempting to provide holistic care to an increasingly diverse group of patients. Holistic care is a term often used in nursing that means to care for patients in their entirety: body, emotions, mind, and social and cultural, environmental, and spiritual aspects.

To develop an effective and therapeutic relationship with a patient, a nurse must establish trust and respect with the patient. Acknowledging a patient’s individual cultural perspective is an important part in establishing this trust.4,5 Misunderstanding cultural differences can be a barrier to effective health care intervention and can even cause harm. This is especially true when a health care professional misinterprets or overlooks a patient’s perspectives that are different from those of the health care professional.

Cultural Encounter as Workplace Stressor
Workplace stress has been defined as “the physical and emotional outcomes that occur when there is disparity between the demands of the job and the amount of control the individual has in meeting those demands.”6 Stress may occur when nurses are unable to provide the kind of care that is expected of them. If nurses are unprepared to deal with cultural differences in the workplace, a stressful situation can result.Transcultural Nursing Research Paper

The presence of workplace stressors not only affects the delivery and quality of care but also creates unnecessary costs for the institution. When nurses are constantly exposed to stress, absenteeism increases and employee turnover may result, both of which can have a significant financial impact on the organization.

Family and Cultural Sensitivity
Family support during illness has unique meanings across cultures that help maintain integrity within the extended family, especially in an unfamiliar environment with norms and values that differ from those of the family. In caring for patients and interacting with families, nurses must demonstrate cultural sensitivity, respect diverse practices and beliefs, and understand how cultural differences might alter the way care is provided.

In some cultures, it is considered a moral responsibility for a family member to be by a patient’s side and to provide care.7–11 Family members may find it difficult to arrange transportation to and from distant medical facilities, to locate someone to stay with the patient, or to take care of children during a parent’s hospitalization; in such a situation, they often rely on other members of their widely extended family. In some cultures, the family stays with the patient to ensure that if the patient dies, a family member is there to hear the patient’s last words.

Communication Across Cultures
Sensitivity to cultural needs, beliefs, and values, including in communication, is essential for nursing interventions to be effective.12 Communication is the central factor in providing transcultural care.13 One of the most obvious challenges occurs when a nurse and a patient do not speak the same language. Non-native English-speaking patients or nurses may have to process English conversation in their native tongue—interpreting word for word, thinking in their native tongue, and then trying to make sense of their thoughts before expressing them.14 In the meantime, there may be an uncomfortable silence and a delay in response, which the patient may misinterpret.Transcultural Nursing Research Paper

It is difficult to give timely care when the nurse has to look for a certified interpreter at the hospital. Nailon15 studied the experiences of Emergency Department (ED) nurses when dealing with non-English-speaking Latino patients. She found that there was often a delay in care because nurses had to interrupt their nursing assessment to look for a translator who was not always available. Sometimes the nurses checked vital signs and reviewed the test results, choosing to secure a translator later when a physician would be ready to assess the patient. The nurses expressed their concern that care was delayed because of a lack of interpreters, especially in a setting with a great many patients requiring acute care. It was also a concern that nurses were using family members as interpreters, because patients might have withheld some information because they knew that it could affect their relationship to the family. Other times, nurses did not use telephone translators, even when such aid was readily available; instead, they tried to communicate using their limited Spanish vocabulary. Sometimes nurses would ask a staff member who was not formally trained to interpret. Using an interpreter who is not formally trained may result in inaccurately interpreted messages; if nurses cannot verify patient responses, there is no assurance that the message was accurate.

Another way of communicating cultural needs among staff is through a patient’s medical record (charting). Such documentation can help promote cultural sensitivity and foster continuity of care.16

Theoretic Perspective
Generally, the provider’s attitudes and personal biases are the primary barrier to culturally competent care. Several conceptual frameworks have been proposed to support the development of greater cultural sensitivity in delivery of health care.12,17–19 The common denominators among these models and frameworks include gaining self awareness, checking for personal biases, avoiding the tendency to stereotype, and refraining from discrimination. An introspective examination of this kind is, of course, challenging, especially for health care professionals who have limited transcultural experience or have not been trained in dealing with cultures different from their own.Transcultural Nursing Research Paper

In developing the ACCESS (assessment, communication, cultural negotiations and compromise, establishing respect, sensitivity, and safety) model for providing health care, Narayanasamy20 explored nurses’ responses to the cultural needs of their patients. Nurses were asked to give an example of a nursing situation in which cultural care was given. On the basis of the data, Narayanasamy reported that the nurses tended to associate cultural needs with food or religion. Even though the study suggested that nurses recognize cultural needs and that they actively practiced culturally sensitive care, such care was interpreted within a more narrow understanding.20

Research Question
Our study built on the work of Narayanasamy20 in 2003, in that we wanted to gain a greater understanding of nurses’ cultural awareness by asking nurses to describe their own experiences with diverse patients and families. Specifically, the aim of our study was to explore how nurses know how to care for patients from cultures different from their own. Given the growing diversity of our patient population, we sought to clarify what nurses draw on in taking care of patents from multiple cultures. We hypothesized that many of the ways they do so are drawn from personal or professional experience and exposure to other cultures, as well as from formal education.Transcultural Nursing Research Paper

In 2004, the Kaiser Family Foundation published the Sullivan Commission Report,3 recommending the following three goals related to racial and ethnic diversity: First, all racial and ethnic groups in a community should be represented among health care professionals. Second, talents, skills, and ideas from ethnically different groups should be incorporated systemwide. Third, health care institutions should change the health care culture by promoting diversity through creating professional development opportunities. Overall, the commission emphasized the importance of increasing the representation of minorities in the workforce.

Community health clients belong to a variety of cultural groups. A culture is a design for living; it provides a set of norms and values that offer stability and security for members of a society and plays a major role in motivating behaviors. The increase in and great variety of cultural groups reinforce the need for community health nurses to understand and appreciate cultural diversity. Ethnocentrism is the bias that a person’s own culture is best and others are wrong or inferior. It can create serious barriers to effective nursing care. Understanding cultural diversity and being sensitive to the values and behaviors of cultural groups often is the key to effective community health intervention. Culture has five characteristics: it is learned from others; it is an integrated system of customs and traits; it is shared; it is tacit; and it is dynamic. Every culture preserves its integrity by deleting nonfunctional practices and acquiring new components that better serve the group. To gain acceptance, nurses must strive to introduce improved health practices that are presented in a manner consistent with clients’ cultural values. Five transcultural nursing principles, drawn from an understanding of the concept of culture, can guide community health nursing practice: 1. Develop cultural self-awareness. 2. Cultivate cultural sensitivity. 3. Assess the client group’s culture. 4. Show respect and patience while learning other cultures. 5. Examine culturally derived health practices. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. All rights reserved.Transcultural Nursing Research Paper

It is useful to define the culture before discussing the term. According to the definition made by Turkish Language Institution Culture, the culture is described as the sum of all the material and spiritual values ​​created in the process of social development and the tools that are used to create and hand these values down to next generations and show the extent of the man’s authority and control over their natural and social environment [1].

According to another definition, the culture is the general total of beliefs, attitudes and behaviors, customs and traditions, learned and shared values, and sustains its existence through learning and teaching of attitudes, actions and role models [2].

As it can be understood from these definitions, culture is a non-written link from the past to the present day, bridging the individuals in society. As a phenomenon, The term “culture,” which diversifies in each community and so is experienced differently, also affects the way individuals perceive the phenomena such as health, illness, happiness, sadness and the manner these emotions are experienced [3].

Culture is a relative concept that varies according to health cultures as well as affecting the perception of health [4].

Health is determined by biological and environmental factors as well as by cultural practices [5].

Culture affects many aspects of human life, such as parental attitudes, child rearing patterns, how to speak, what language to speak, how to dress, believe, treat patients, what to do with and how to feed them and to deal with funerals [6, 7].Transcultural Nursing Research Paper

Individuals’ health behaviors and health perceptions are regarded inseparable from each other. Communities having endeavored to maintain their cultural characteristics for centuries have passed down this on their health behaviors and strived for finding cures to their health problems in their cultural lives. Types of food, cooking methods, sleeping habits, dressing patterns, forms of treatment of diseases, housing and residence, perception of diseases, modes of acceptance of innovations are characteristics varying from culture to culture and intertwined with culture. It is known that people cannot act independently of the culture they live in [8].

Culture is influential at many levels in health, ranging from the formation of new diagnostic groups, to the diagnosis of disease to the determination of what is called a disease or not symptoms and disease cues [6, 7].

However, in almost all regions of the world, wars, ethnic conflicts, repressive regimes, environmental and economic crises along with globalization have forced many people to abandon their country and migrate in their country or to immigrate other countries as refugees. As a result, multicultural populations comprised of individuals, families and groups from different cultures and subcultures are rapidly emerging all around the world [9, 10, 11].

2. Cultural factors affecting health and disease
In order to improve the health behaviors of the community, cultural factors affecting health behavior and health care services need to be clearly recognized [12, 13].Transcultural Nursing Research Paper

The individuals’ beliefs about health, attitudes and behaviors, past experiences, treatment practices, in short their culture, play a vital role in improving health, preventing and treating diseases [14].

Cultural variables can be motivational factors in health-disease relationships, [8].

2.1. Cultural factors/variables can be listed as in the following list
Socioeconomic status

Family pattern

Gender roles and responsibilities

Marriage patterns

Sexual behavior

Preventive patterns

Population policy

Pregnancy and birth practices

Body

Nutrition

Dressing/wearing

Personal hygiene

Housing arrangements

General health regulations

Professions

Religion

Habits

Culture-induced stress

Status of immigrants

Substance use

Leisure time habits of

Pets and birds

Self-healing strategies and therapies [8].

3. Health culture
Today, health-related cultural traits are under the influence of a medical approach that may be considered as highly conservative almost all around the world. There is an increasing tendency to perceive and evaluate health and disease-related processes explained in medical terms. The rigid medical approach, engaged in extending human life with costly inventions, with a narrow level of knowledge and practices, makes it impossible for individuals to use the potential for qualified living. Modern medicine overwhelms the will of people to experience their own facts and solve their problems. On the other hand, the concept of health should be regarded as a dynamic phenomenon in life and be removed from some patterns of thought. Hence, healthcare should be assessed with a comprehensive understanding of culture in order to promote the art of living healthily among people [15].Transcultural Nursing Research Paper

Individuals who embrace contemporary public health, evaluate health with a holistic approach, give the other individuals an opportunity to participate in their health care issues, and have the potential to solve problems with appropriate preferences can only be the output of cultural constructs supporting health, values, knowledge, attitudes, behaviors and norms. Health culture is concerned with every individual’s or the society’s patterns of living, celebrating, being happy in life, suffering and dying. It is not enough for the individual to acquire only health-related information, but basic skills such as comprehending health-related values, developing a healthy lifestyle and self-evaluation must be developed. The main purpose of developing health culture is to raise the level of health in the country scale. This can only be ensured by the fact that health education standards be established by well-trained and conscious individuals into practice with the help of their knowledge and skills [15].

4. Transcultural healthcare
It is vital that health services are also appropriate for the target cultures to the extent that they are compatible with contemporary medical understanding. People’s beliefs and practices are part of the culture of the society in which they live. Cultural characteristics should be seen as a dynamic factor of health and disease. In order to be able to provide better health care, it is necessary to at least understand how the group receiving care perceives and responds to disease and health, and what cultural factors lie behind their behaviors [7, 13, 16, 17, 18, 19, 20].

Unless health care initiatives are based on cultural values, it will be impossible to achieve the goal and the care provided will be incomplete and fail [2, 21].

For this reason, healthcare providers should try to understand the cultural structure of a society. Health workers must collect cultural data to understand the attitudes of towards coping with illness, health promotion and protection [2, 21].Transcultural Nursing Research Paper

Cultural differences and health beliefs have been recognized for many years as prior knowledge in practice. Despite that, cultural health care is unfortunately not part of a routine or common health practice. Knowing cultural beliefs related to health can enable us to build a framework for data collection in health care [2, 22].

Today, health policies focus primarily on the prevention of health-related inequalities and discrimination, especially ethnic characteristics. In order for the societies to regulate health care that will meet the needs of different groups in terms of culture, all health team members must be equipped with the necessary knowledge and skills [23, 24].

5. Understanding transcultural nursing
The term health, with its changing nature and meanings from one culture to another, requires care, including cultural recognition, value and practice. The main element in the transcultural approach in which every health professional has an active role is the individual. The transcultural approach can be applied at all levels of health care institutions; but nurses are in a privileged position in this approach. According to Leininger’s model, only nurses can provide transcultural health services. Because the main aim of nursing is to provide a caring service that respects people’s cultural values and lifestyles. Nurses should offer acceptable, affordable and culturally suitable care to individuals under the conditions of the day [2].

Knowing what cultural practices are applied in the societies receiving healthcare services and identifying the cultural barriers to accessing health care services positively affects the caring process [25].

The nursing profession, which plays an important role in the health team, is a cultural phenomenon. The patient’s cultural values, beliefs and practices are an integral part of holistic nursing care [26, 27].Transcultural Nursing Research Paper

The nurses should explore new ways of providing cultural care in multicultural societies, understand how cultures affect health-disease definitions, and bridge the gap between care for individuals in different cultures [13, 28, 29].

Transcultural nursing provides effective nursing care to meet the cultural needs of individuals, families and groups [30].

The concept of “Transcultural Nursing” derived from the need to care for individuals in different cultures in nursing was first used by Madeleine Leininger in 1979 [30, 31, 32].

In addition to Leininger, a pioneer model of transcultural nursing, many nurses worked in the field of cultural care. Giger and Davidhazar developed the “Cross-Cultural Diagnosis Model” to assess various variables related to health and illness and provide a practical diagnostic tool for nursing so that culturally competent care could be offered [33].

Campinha-Bacote described the cultural competence model [34].

Culturally competent nurses are in contact with cultural experiences and aware of their own personality traits and contribute to socio-cultural knowledge in nursing care by providing individualized care [35].

Nurses who are aware of cultural differences and the effects of these differences on the health of the individual enhance the therapeutic environment by communicating more effectively with the patients [13].

The role and significance of transcultural nursing has been increasingly recognized in the world challenged by cultural diversity. Cultural differences can be seen among ethnic groups as well as within any ethnic group [36].

It has been reported that cultural differences may exist among individuals who live in the same or different regions in Turkey [37].Transcultural Nursing Research Paper

Although studies on cross-cultural nursing care in our country are limited, several studies have examined the views of nursing and midwifery students regarding patient care [37, 38, 39].

In a study conducted, the views of nurses working in two different hospitals on the cultural problems they faced in patient care were compared [11, 36].

In recent years, it has been recognized that nurses must explore new ways of providing cultural care in culturally diverse societies, understand how culture affects disease-health definitions, and act as a bridge between the biomedical system and care for individuals in different cultures [2, 40].

The nature and importance of providing culturally sensitive nursing services is multidimensional, including individual and professional aspects. The transcultural approach allows nurses to broaden their horizons and perspectives in addition to making them competent in offering creative care to individuals. Culturally based approaches and knowledge can enhance both the nurse’s and the patient’s self-esteem [2, 41, 42].

The American Nurses Association (ANA) refers to three reciprocal interactions: the culture of the individual (patient), the culture of the nurse, and the culture of the environment in relation to the patient-nurse:

Culture of the individual: When nurses understand the specific factors affecting individual health behaviors, they will be more successful in meeting their needs [2].

Individuals’ beliefs about health, culture, past illness/health experiences form a wholistic structure and play a vital role in improving the health of individuals [43].

Culture is influential in how people think, speak the language, how to dress, believe, treat their patients and how to feed them and what to do with their funerals etc. Moreover, it plays a significant role in a variety of aspects such as new diagnostic methods, prognosis, symptomatic patterns and determination of whether there is an illness or not [7].Transcultural Nursing Research Paper

Culture of the nurse: The only factor influencing the patient-nurse relationship is not the patient himself/herself. The nurses’ own customs and traditions, beliefs and values are also important in transcultural relationships. The nurse’s self-awareness can be the starting point to understand the patient culturally.

Culture of the environment: The last element of the transcultural trio is the culture of the environment. The environment is an integral part of the culture. Individuals as physical, ecological, sociopolitical and cultural beings are continuously interacting with each other. Nurses may have to intervene in the patient and family relationship because of frequent bureaucratic arrangements and procedures. The transcultural approach should be considered in a wide range of subjects, starting from asking if there are any religious practices to be followed or done by the patient during the hospitalization, and writing the signs in the hospital in two different languages

Transcultural nursing has started from the mid 1950s [1]. Since Leininger started her conceptualization of culture and development of her transcultural nursing theory in 1960s [1], transcultural nursing has become a major field of nursing. When the literature during the past 10 years was roughly searched using the PubMed database, more than 950 articles related to transcultural nursing were retrieved. As the large number of articles indicates, transcultural nursing is now considered as an important area of nursing in research and practice.

Through many years of experiences in transcultural nursing, a dozen of concepts and theories for transcultural nursing have been suggested and used by many nursing scholars [2]. Many concepts including cultural competence, cultural knowledge, cultural sensitivity, and cultural brokerage have been developed and used [3]. Cultural competence has been suggested by many scholars as a major component of nursing 4, 5, 6. A number of articles have been published on theoretical issues and scientific rigor in transcultural nursing; specifically, many articles related to the equivalence of concepts that do not exist in other cultures have been discussed 7, 8, 9. Also, several theorists proposed their own grand or middle-range theories related to transcultural nursing Transcultural Nursing Research Paper

With drastic changes in nursing environments and subsequent advances in nursing science, theoretical thoughts in transcultural nursing have historically evolved in nursing history 15, 16. In general, at every evolutionary step, there have been prominent trends in the area of nursing theories 15, 16. Nursing once emphasized conceptual frameworks and grand theories 15, 16. Then, nursing had hot discussions on metatheoretical issues related to nursing 15, 16. With these trends and changes, theoretical works related to transcultural nursing have also evolved. Transcultural nursing started with grand theories and has moved with concept development and analysis. Now, it is up to development of the middle-range theories and situation-specific theories 13, 17. However, no specific article on the current trends of theoretical works in transcultural nursing during the past 10 years was identified in literature searches through multiple databases, including the PubMed, CINAHL, and PsycINFO.

The purpose of this article is to explore the current trends in theoretical works related to transcultural nursing through an integrated literature review. First, a brief review of the theoretical works that are being used in the field of transcultural nursing is provided. Here, trends refer to “prevailing tendencies or inclinations” [18] and transcultural nursing meant “a nursing specialty created to answer the need for developing a global perspective in the practice of nursing in a world of interdependent nations and people” [19]. Then, the methods used to retrieve and analyze the literature are concisely presented, and the themes reflecting the current trends in theoretical works related to transcultural nursing are discussed. Finally, suggestions for future development of transcultural nursing theories are proposed based on the literature review.Transcultural Nursing Research Paper

An Overview of Theoretical Works in Transcultural Nursing
From the early stage of transcultural nursing, theories have been an essential part of transcultural nursing. Under heavy influences of anthropology and psychology, theorists began to determine the theoretical basis of transcultural nursing and to define culture and nursing care, nursing environments, nursing intervention, and nurses’ roles 10, 11, 12, 13, 14. As mentioned previously, the central concepts in transcultural nursing were culture, nursing, and environment.

During the time, several theories related to culture have been adopted from other disciplines and used in nursing with some modifications and refinements of the major and subconcepts of existing theories from other disciplines. During the 1950s, 1960s, and early 1970s, several theorists have developed theories that could uniquely explain the concepts related to transcultural nursing to provide an independent conceptual framework for nursing education, practice, and research in transcultural nursing 10, 12, 20.

During the late 1960s and 1970s, when metatheoretical discussions were made by nursing theorists 11, 16, grand theories including transcultural nursing theories were criticized for their lack of explicated propositions and empirical testing [21]. Then, in the mid 1970 to the 1980s, theorists began to discuss the necessity of substantive theories in nursing and began to discuss the central concepts in nursing [16]. From the 1980s and 2000s, all concept analysis and concept development methods were suggested and used [22]. During these periods, nursing scholars in transcultural nursing also focused on their theoretical works on concept analyses and concept development of central concepts related to transcultural nursing  Transcultural Nursing Research Paper

From the 1990s, two new types of nursing theories were introduced: middle-range theories and situation-specific theories [17]. With the emerging middle-range theories in nursing in general, several middle-range theories related to transcultural nursing were proposed 16, 30. Also, a number of situation-specific theories related to transcultural nursing were proposed during the same period 31, 32, 33, 34, 35, 36, 37, 38.

In recent years, with drastic advances in nursing research, transcultural nursing scholars began to search for the theoretical bases that could be easily operationalized into research in transcultural nursing as in nursing in general [17]. At the same time, with globalization and advances in nursing practice, transcultural nursing also needs to find the theoretical bases that could be easily translated into transcultural nursing practice. In the current stage of nursing theories that is characterized as “diversity in thought” [39], an increasing number of theories are suggested in many different areas in nursing, including acute care, oncology, women’s health, pediatric, occupation health, community health, and so forth. 40, 41. However, there has been no exploration on the current trends in theoretical works related to transcultural nursing in recent years.Transcultural Nursing Research Paper

To explore the current trends in theoretical works related to transcultural nursing, an integrated literature review was conducted using multiple databases including, the PubMed, CINAHL, and Scopus databases. The databases were searched only for the articles published during the past 10 years (2007–2018) because this review aimed to explore the current trends. Initial searches using the relevant keywords were conducted. Four articles were retrieved from the databases using the keywords of “transcultural nursing” and “grand theory.” Next, 10 articles were retrieved using the keywords of “transcultural nursing,” “mid-range theory,” and “middle-range theory.” When the keywords of “transcultural nursing” and “situation specific theory” were used, seven articles were retrieved. A total of 46 articles were retrieved using the keywords of “transcultural nursing” and “grounded theory.” Finally, with the keywords “transcultural nursing” and “concept analysis,” an additional 56 articles were retrieved.

The resulting 123 articles retrieved from this initial search were screened for duplicates, and six articles were excluded via this process. Title and abstract reviews were conducted on the remaining 117 articles, which resulted in the exclusion of eight articles for which either the abstract or full text was inaccessible. The remaining 109 articles were selected for full-text reviews. However, six articles were excluded from the full-text reviews because they were written in a language other than English. Two articles were excluded because they consisted of the guidelines and standards of culturally competent care rather than theoretical works. Finally, additional 33 articles were excluded because they did not address the topics of theory, concepts, or models at all. Thus, a total of 68 articles were identified as eligible for full-text reviews.Transcultural Nursing Research Paper

First, the eligible articles were classified by study design, country where the study was conducted, and type of theory (e.g., grand theories, middle-range theories, situation-specific theories, grounded theories, and concept development/analysis). Next, individual articles were reviewed to verify that they actually presented a theory or a theoretical discourse. Those articles which actually presented a theory/model/concept were reviewed in the aspects of purpose of theorizing, types of theorizing, sources of theorizing, checking and linkages to practice or research. The review categories were selected based on the major components of the integrative approach to theory development to explore the current trends in theoretical works related to transcultural nursing 38, 39.

The characteristics of the 68 reviewed studies are shown in Table 1. Depending on the purposes of the theoretical works, various methods were used [42]. The most frequently used methods were the following: literature reviews (41.2%) and qualitative studies with interviews (33.8%). The majority were conducted in the U.S. (47.1%), followed by Canada (7.4%), Australia (5.9%), and the U.K. (4.4%). Two articles involved authors from multinations 43, 44. The majority of the articles (58.8%) did not specify the type of the theory or the level of the theory. Thirteen (19.1%) articles specified their theorizing methods as concept analyses (19.1%), and eight (11.8%) identified their methods as grounded theory methods. Although the terms of “thematic analysis” and “content analysis” were not included in the keywords for the literature searches, five (7.4%) articles specified their methods as thematic analyses, and one (1.5%) article used both thematic and content analyses. Among 68 reviewed articles, 47 (69.1%) implemented theoretical discourses using theories and models as theoretical frameworks 45, 46, conceptual frameworks 47, 48, and concepts underpinning the development of a study tool [49]. Only the remaining 21 (30.9%) articles presented theories, models, or concepts that they actually developed. Only these articles were analyzed by purpose of theorizing, types of theorizing, sources of theorizing, checking assumptions, and linkages to practice or research Transcultural Nursing Research Paper