Transcultural Concepts in Nursing Care PDF 7th Edition

 Transcultural Concepts in Nursing Care Seventh Edition Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Profes...

 Transcultural Concepts in Nursing Care Seventh Edition Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan Joyceen S. Boyle, PhD, RN, MPH, FAAN Adjunct Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Adjunct Professor of Nursing College of Nursing Georgia Regents University Augusta, Georgia 0002491983.INDD 1 7/10/2015 12:53:53 PM  Acquisitions Editor: Christina C. 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Printed in China Library of Congress Cataloging-in-Publication Data Transcultural concepts in nursing care / editors, Margaret M. Andrews, Joyceen S. Boyle. — Seventh edition.    p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-9397-8 I. Andrews, Margaret M., editor. II. Boyle, Joyceen S., editor. [DNLM: 1. Transcultural Nursing. 2. Culturally Competent Care. WY 107] RT86.54 362.17'3—dc23 2015015790 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. 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To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service rep- resentatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 0002491983.INDD 2 7/10/2015 12:53:53 PM  Contributors Margaret M. Andrews, PhD, RN, Patti Ludwig-Beymer, PhD, RN, CTN-A, CTN-A, FAAN NEA-BC, FAAN Director and Professor of Nursing Vice President and Chief Nursing Officer School of Health Professions and Studies Edward Hospital and Health Services University of Michigan-Flint Naperville, Illinois Flint, Michigan Margaret A. McKenna, PhD, MPH, MN Martha B. Baird, PhD, APRN/CNS-BC, CTN-A Clinical Associate Professor Assistant Professor Department of Health Services School of Nursing University of Washington University of Kansas Medical Center Seattle, Washington Kansas City, Kansas Margaret Murray-Wright, MSN, RN Joyceen S. Boyle, PhD, RN, MPH, FAAN Associate Director, Undergraduate Programs and Adjunct Professor of Nursing Clinical Assistant Professor of Nursing College of Nursing University of Michigan-Flint University of Arizona Flint, Michigan Tucson, Arizona Adjunct Professor of Nursing Dula F. Pacquiao, EdD, RN, CTN-A, TNS College of Nursing Cultural Diversity Consultant Georgia Regents University Education, Research and Practice Augusta, Georgia Lecturer, University of Hawaii Hilo School of ­Nursing Joanne T. Ehrmin, PhD, RN, CNS Hilo, Hawaii Professor Department of Health Promotion Maureen J. Reinsel, MA, MSN, APRN, College of Nursing AGPCNP-C University of Toledo Technical Writer for Patient and Program Monitoring Toledo, Ohio Improving Data for Decision-Making in Global Cervical Cancer Programs (IDCCP) Patricia A. Hanson, PhD, RN, APRN-BC, GNP Jhpiego Corporation Professor Baltimore, Maryland College of Nursing and Health Madonna University Barbara C. Woodring, EdD, CPN, RN Livonia, Michigan Professor Emerita Byrdine F. Lewis School of Nursing and Health Jana Lauderdale, PhD, RN, FAAN Professions Assistant Dean for Cultural Diversity Georgia State University School of Nursing Atlanta, Georgia Vanderbilt University Nashville, Tennessee iii Andrews7e9781451193978-FM.indd 3 3/16/2016 12:16:43 PM  Foreword I am pleased for the opportunity to write the e­ ducation, ­research, administration, and practice Foreword to Drs. Margaret Andrews and Joyceen and were the foundation for the development of Boyle’s seventh edition of their book, which illu- standards of practice for culturally competent minates the historical and theoretical foundations care for individuals, groups, local and global and evolution of transcultural nursing emerging communities, and organizations. Dr. Andrews from the disciplines of nursing and anthropology. teamed up early in her scholarly career with her I have been asked to “fill the shoes” of our men- mentor, Dr. Joyceen Boyle and they, with other tor and colleague, the late Dr. Madeleine Leini- major contributors, wrote one of the earliest text- nger, who wrote the previous Forewords to their books, Transcultural Concepts in Nursing Care book. Dr. Leininger, the first nurse anthropologist published first in 1989 who also was influenced and the “mother” of transcultural nursing, passed by Dr. Leininger. away in 2012 leaving us a legacy of transcultural Because of their long history of knowledge nursing scholarship and a body of knowledge generation in transcultural nursing, this work of that has accelerated exponentially from its earli- Andrews and Boyle is very comprehensive and est beginnings in Cincinnati, Ohio, in the 1950s shows the depth of their scholarship in terms of to its adoption in most nations of the world. Le- culture, theory development and application, ininger addressed the human condition through research, and their commitment to the delivery knowledge of what it means to be human, caring, of culturally competent care in practice. Rapid understanding, and open to all cultural traditions changes in science, technology, genetics, health by creating the discipline of transcultural nurs- care, economics, geopolitics, transportation, ing. At the outset of the programmatic develop- demographics, migration and immigration, reli- ment of the discipline of Transcultural Nursing, gious ideologies, unrelenting wars, and global Joyceen Boyle and I were asked by Dr. Leininger issues including human rights and social justice to become her first two doctoral students in 1977 have challenged nurses to understand new ways at the University of Utah, College of Nursing, Salt of engaging with clients and families, and also Lake City, Utah. Both of us had backgrounds in professional colleagues in terms of transcultural public health or anthropology and a great inter- nursing. By means of the new sciences of com- est in the study of diverse cultures. As friends plexity and the generation of enormous quanti- and students, Joyceen and I felt privileged to be ties of research of every affiliation, and diverse pioneers as Dr. Leininger put into motion her be- philosophical, political, and religious perceptions, liefs, and values of transcultural nursing, focusing we can see the interconnectedness of everything on nursing and human science, caring science, in the universe and the necessity for discernment theory development, anthropology, culture, and and evaluation of what is really happening in the transcultural nursing. Leininger advanced her world. Theoretical and experiential knowledge theoretical understanding developing The World- about our responsibilities to one another thus is wide Nursing Theory of Culture Care Diversity growing and impacts the need for intense com- and Universality and her Ethnonursing method- munication to examine and solve problems both ology. Her transcultural beliefs and values have locally and globally. Continuing to identify rel- been infused into nursing program o ­ bjectives for evant issues to promote health, human safety, and iv 0002491983.INDD 4 7/10/2015 12:53:56 PM  Foreword v improve the quality of life of all people is a major Model. The key concepts identified in the TIP goal of thoughtful national and international model are context, interprofessional health care health care professionals. For example, we can team, communication, and problem-solving pro- explore, within the United Nations Millennium cess. The cultural context (health-related beliefs Development Goals for 2015 and beyond, the and practices that weave together environmental, framework for the world community. These devel- economic, social, religious, moral, legal, political, opments are now shaping Andrews’ and Boyle’s educational, biophysical, genetic, and technologi- paradigmatic thinking in the seventh edition and cal factors), the interprofessional health care team their interest in addressing the challenges of the (nurses, physicians, social workers, therapists, interconnectedness of all by their Transcultural pharmacists, and others), cross-cultural commu- Interprofessional Practice (TIP) Model with a nication among client, family, and significant oth- theoretical foundation. Their model illuminates ers, and members of the interprofessional health the necessity for increased collaboration and care team including folk and traditional healers, communication with clients and multiple health and religious and spiritual healers facilitate the care and folk participants to address complex foundation of the problem-solving process that approaches to transcultural issues in the provision has five steps. These five steps include compre- of culturally congruent, safe, and competent care. hensive holistic client assessment, mutual goal The beginning chapters in their book highlight setting, planning, implementation of the plan of foundational and evolutionary knowledge of the action and interventions, and evaluation of the concepts of culture, subculture, race, ethnicity, plan for effectiveness to achieve the stated goals, context, communication including digital com- and desired outcomes; provide culturally congru- munication—the Internet and social media— ent and competent care; deliver quality care that evidence-based practice and problem solving, is safe and affordable; and ensure that the care is culture-specific nursing care, interprofessional evidence based with best practices. collaboration and best practices, transcultural As I reflect on the work of my colleagues, nursing, genetics, and theory development. The Andrews and Boyle, not only within the pages of chapters focus on culturally competent nursing this book but also what each of them has accom- care by highlighting transcultural nursing across plished over many years as leaders, teachers, the life span, multicultural health care settings researchers, online educators, and as Presidents including the culture of organizations, the deliv- of the Transcultural Nursing Society, what comes ery of mental health care, a focus on family and to mind is their deep dedication and devotion to community, a spotlight on the cultural diversity the discipline and profession of Transcultural of the workforce, and the challenges in trans- Nursing. Through their intellectual astuteness cultural nursing (religion, ethics, and interna- and creative actions, they have been and are role tional nursing). Each chapter follows with a set of models and mentors to students and other lead- review questions and learning activities that illu- ers who have spread and broadened transcultural minate what students, faculty, and clinical practi- care knowledge worldwide. They are commit- tioners will have integrated into their plan of care ted to the primary goal of transcultural nursing to meet mutual goals presented in the chapter to facilitate culturally congruent knowledge and case studies. The seventh edition reflects many of care so that people of the world are understood the changes in the concept of the culture-at-large, and their health care needs can be met within the especially genetics. While giving attention to dynamics of their cultures and cultural under- Leininger’s theory in Chapter 1, what is significant standing. A seventh edition of a book attests to in this seventh edition, as stated, is the develop- the fact that students, faculty, and other practi- ment of their own theory, the Andrews and Boyle tioners find within its pages relevant and chal- Transcultural Interprofessional Practice (TIP) lenging information to learn about cultures and 0002491983.INDD 5 7/10/2015 12:53:56 PM  vi Foreword ethnic groups, know how to relate and serve of every health care and anthropological disci- them, conduct research, facilitate the solving pline will be stimulated by the theory and the of problems, and “making things work.” Today content expressed by the authors and the many collaboration and communication are the key. contributors in this new edition to improve the Margaret Andrews and Joyceen Boyle have cap- health of and help people of diverse cultures tured that essence in their Transcultural Inter- worldwide. professional Practice (TIP) theory and model, which is presented in this work. I wholeheart- Marilyn A. Ray, RN, PhD, CTN-A, edly endorse this new edition. I am most proud FSfAA, FAAN to call these authors not only my colleagues but Colonel (Retired), United States Air Force, also my friends as they move forward in the evo- Nurse Corps lution of what can be termed authentic trans- Professor Emeritus cultural nursing by means of collaboration and The Christine E. Lynn College of Nursing interprofessionalism. Nursing students, faculty, Florida Atlantic University other health care ­professionals, and practitioners Boca Raton, Florida 0002491983.INDD 6 7/10/2015 12:53:56 PM  Preface Given the large number of cultures and subcultures other accrediting and certification bodies require in the world, it’s impossible for nurses to know or strongly encourage the inclusion of cultural everything about them all; however, it is possible aspects of care in nursing curricula. This, of course, for nurses to develop excellent cultural assessment underscores the importance of the purpose, goal, and cross-cultural communication skills and to and objectives for Transcultural Concepts in Nurs- follow a systematic, orderly process for the delivery ing Care, Seventh Edition. of culturally competent care. Purpose: To contribute to the development of The Andrews/Boyle Transcultural Interprofes- theoretically based transcultural nursing knowl- sional Practice (TIP) Model, which we are intro- edge and the advancement of transcultural nurs- ducing in this seventh edition of Transcultural ing practice. Concepts in Nursing Care and describe in more Goal: To increase the delivery of culturally detail in Chapters 1 and 2, emphasizes the need competent care to individuals, families, groups, for effective communication, efficient, client- and communities, and institutions. patient-centered teamwork, and collaboration Objectives: among members of the interprofessional health 1. To apply a transcultural nursing framework to care team. guide nursing practice in diverse health care The TIP Model has a theoretical foundation in settings across the lifespan. transcultural nursing that fosters communication 2. To analyze major concerns and issues encoun- and collaboration between and among all mem- tered by nurses in providing transcultural bers of the team and enables multiple team mem- nursing care to individuals, families, groups, bers to manage complex, frequently multifaceted communities, and institutions. transcultural care issues, moral and ethical dilem- 3. To expand the theoretical bases for using con- mas, challenges, and care-related problems in a cepts from the natural and behavioral sciences collegial, respectful, synergistic manner. and from the humanities to provide culturally The process used in the TIP Model is an adap- competent nursing care. tation and application of the classic scientific 4. Provide a contemporary approach to trans- problem-solving method used to deliver nursing cultural nursing that includes effective cross- and health care to people from different national cultural communication, team work, and origins, ethnicities, races, socioeconomic back- interprofessional collaborative practice. grounds, religions, genders, marital statuses, sex- ual orientations, ages, abilities/disabilities, sizes, We believe that cultural assessment skills, veteran status, and other characteristics used to combined with the nurses’ critical thinking compare one group of people to another. abilities, will provide the necessary knowledge The Commission on Collegiate Nursing Edu- on which to base transcultural nursing care. cation, the American Association of Colleges of Using this approach, nurses have the ability to Nursing’s Essentials of Baccalaureate Education for provide culturally competent and contextually Professional Nursing Practice, the National League ­meaningful care for clients—individuals, groups, for Nursing, most state boards of nursing, and families, communities, and institutions. vii 0002491983.INDD 7 7/10/2015 12:53:56 PM  viii Preface The editors and chapter authors share a com- according to race, ethnicity, religion, or a combi- mitment to: nation, such as ethnoreligion, but we make every effort to avoid using any label in a pejorative man- Foster the development and maintenance of a ner. We do believe, however, that the concepts or disciplinary knowledge base and expertise in terms minority or ethnicity are limiting, not only culturally competent care. for those to whom the label perhaps applies but Synthesize existing theoretical and research also for nursing theory and practice. We believe knowledge regarding nursing care of different that concept of culture is richer and has more the- ethnic/minority/marginalized and other disen- oretical usefulness. In addition, we all have cultural franchised populations. attributes while not all are from a minority group Identify and describe evidence-based practice or claim a particular ethnicity. and best practices in the care of diverse indi- viduals, families, groups, communities, and institutions. Critical Thinking Linked to Delivering Create an interdisciplinary and interprofes- Culturally Competent Care sional knowledge base that reflects hetero- geneous health care practices within various We believe that cultural assessment skills, com- cultural groups. bined with the nurse’s critical thinking ability, will Identify, describe, and examine methods, theo- provide the necessary knowledge on which to base ries, and frameworks appropriate for developing transcultural nursing care. Using this approach, we knowledge that will improve health and nursing are convinced that nurses will be able to provide care to minority, underserved, underrepresented, culturally competent and contextually meaning- disenfranchised, and marginalized populations. ful care for clients from a wide variety of cultural backgrounds, rather than simply memorizing the Recognizing Individual Differences esoteric health beliefs and practices of any spe- cific cultural group. We believe that nurses must and Acculturation acquire the skills needed to assess clients from We believe that it is tremendously important to virtually any and all groups that they encounter recognize the myriad of health-related beliefs and throughout their professional life. practices that exist within the population catego- Many educational programs in nursing are ries. For example, the differences are rarely rec- now teaching transcultural nursing content ognized among people who identify themselves across the curriculum. We suggest that Transcul- as Hispanic/Latino: this group includes people tural Concepts in Nursing Care can be used by fac- from along the U.S.–Mexico border, Puerto Rico, ulty members to integrate transcultural content Mexico, Spain, Guatemala, or “little Havana” across the curriculum in the following manner: in Miami, as well as other Central and South Chapters 1 to 4 in the first clinical courses when American countries, who may share some similari- students are learning how to conduct health his- ties (speaking Spanish, for example) but who may tories, health assessments, and physical examina- also have distinct cultural differences. tions; Chapters 10 and 11, mental health nursing We would like to comment briefly on the terms and family and community nursing, in the appro- minority and ethnic minorities. These terms are priate specialty nursing courses; Chapters 5 to 8, perceived by some to be offensive because they which include nursing care across the lifespan, connote inferiority and marginalization. Although in courses that focus on the nursing care of the we have used these terms occasionally, we prefer to childbearing family, children, adults, and older make reference to a specific subculture or culture adults; Chapters 9, 12, and 14, which concern cul- whenever possible. We refer to categorizations turally competent organizations, diversity in the 0002491983.INDD 8 7/10/2015 12:53:57 PM  Preface ix multicultural health care workforce, and compe- ­ ichigan-Flint School of Health Professions M tence in ethical decision making, in courses that and Studies. Margaret (Margie) Murray-Wright, focus on nursing leadership and management; Associate Director of Undergraduate Programs Chapter 13, which examines religion, culture, and and Clinical Assistant Professor of Nursing, nursing, an excellent resource throughout the infused state-of-the art content on genetics and curriculum; and Chapter 15 in courses that focus genomics and coauthored Chapter 3, Cultural on global health/community health nursing. Competence in the Health History and Physical Examination. An Adult-Gerontology Nurse Prac- New to the Seventh Edition titioner, Maureen J. Reinsel has extensive expe- rience in global public health and international All content in this edition was reviewed and development in Asia, Africa, and Europe. In addi- updated to capture the nature of the changing tion to her nursing background, Maureen earned health care delivery system, new research studies, her MA degree in International Affairs from the and theoretical advances, emphasis on effective Johns Hopkins University School of Advanced communication, team work, and collaboration, International Studies. She wrote Chapter 15, and to explain how nurses and other health care Nursing and Global Health, which is available providers can use culturally competent skills online. to improve the care of clients, families, groups, and communities. In writing the seventh edition, we have been impressed with the developments Chapter Pedagogy in the field of transcultural nursing. The Trans- Learning Activities cultural Nursing Society and the American Acad- emy of Nursing (AAN) have moved ahead with All of the chapters include review questions as developing Standards of Practice for Culturally well as learning activities to promote critical Competent Care that nurses around the world thinking. When relevant web-based information are using as a guide in clinical practice, research, is available to supplement the chapter content, education, and administration. In addition, a references are provided on. In addition, special task force from the Transcultural Nurs- each chapter includes chapter objectives and key ing Society has developed a Core Curriculum terms to help readers understand the purpose for Transcultural Nursing that is being used as a and intent of the content. basis for certification in transcultural nursing and for instructional purposes by faculty and students Evidence-Based Practice in educational programs. The recognition of the Current research studies related to the content Standards of Practice and Core Curriculum for of the chapter are presented as Evidence-Based transcultural nursing enhances the development Practice boxes. We have included a section in of cultural competence in nursing, thus improv- each box describing clinical implications of the ing the care of clients. Lastly, the Andrews/Boyle research. Transcultural Interprofessional Practice Model is introduced in recognition of the need to put the Case Studies client or patient first and of the changing com- Case Studies based on the authors’ actual clinical plexion of the health care workforce. experiences and research findings are presented to make conceptual linkages and to illustrate how New Chapter Contributors concepts are applied in health care settings. Case We welcome two new colleagues in the sev- studies are oriented to assist the reader to begin to enth edition, both from the University of develop cultural competence with selected cultures. 0002491983.INDD 9 7/10/2015 12:53:58 PM  x Preface Text Organization c­ ultural competence in mental health and in fam- ily and community health care settings. We also Part One: Foundations of Transcultural examine cultural competence in health care orga- Nursing nizations and cultural diversity in the health care This first section focuses on the foundational workforce, two very critical and current topics aspects of transcultural nursing. The develop- of concern. The clinical application of concepts ment of transcultural nursing frameworks that throughout this section uses situations c­ ommonly include concepts from the natural and behavioral encountered by nurses and describes how ­ sciences are described as they apply to nursing ­transcultural nursing principles can be applied in practice. Because nursing perspectives are used diverse settings. The chapters in this section are to organize the content in Transcultural Con- intended to illustrate the application of transcul- cepts in Nursing Care, the reader will not find a tural nursing knowledge to nursing practice. chapter purporting to describe the nursing care of a specific cultural group. Instead, the nursing Part Four: Contemporary Challenges needs of culturally diverse groups are used to in Transcultural Nursing illustrate ­cultural concepts used in nursing prac- tice. ­Chapter 1 provides an overview of the theo- In the fourth section of the text, Chapters 13 to 15, retical foundations of transcultural nursing, and we examine selected contemporary issues and chal- Chapter 2 introduces key concepts associated ­ lenges that face nursing and health care. In Chapter with cultural competence using the Andrews/ 13, we review major religious traditions of the United Boyle Transcultural Interprofessional Practice States and the interrelationships among religion, cul- Model as the organizing framework. In Chapter 3, ture, and nursing. Recognizing the numerous moral we discuss the domains of cultural knowledge that and ethical challenges in contemporary health care as are important in cultural assessment and describe well as within the transcultural nursing, Chapter 14, how this cultural information can be incorpo- available on , discusses cultural competence rated into all aspects of care. Chapter 4 provides in ethical and moral dilemmas from a transcultural a summary of the major cultural belief systems perspective. Chapter 15, available on , embraced by people of the world with special provides a global perspective of what is occurring emphasis on their health-related and culturally in the international areas to promote human and based values, attitudes, beliefs, and practices. health. This chapter is slightly different from the rest of the chapters as it highlights the field of inter- Part Two: Transcultural Nursing: Across national nursing and the ways in which nurses can the Lifespan contribute to the global efforts to improve the health status of people across the world. Chapters 5 through 8 use a developmental frame- work to discuss transcultural concepts across the lifespan. The care of childbearing women and their Instructor Resources families, children, adolescents, middle-aged adults, The following tools to assist you with teaching your and the elderly is examined, and information about course are available upon adoption of this text on cultural groups is used to illustrate common trans- : cultural nursing issues, trends, and concerns. The Test Generator lets you generate new tests from a bank of NCLEX-style questions to Part Three: Nursing in Multicultural Health help you assess your students’ understanding Care Settings of the course material. In the third section of the text (Chapters 9 PowerPoint Presentations provide an easy through 12), we explore the components of way for you to integrate the textbook with your 0002491983.INDD 10 7/10/2015 12:53:58 PM  Preface xi students’ classroom experience, either via slide Theory and the best practices for e-learning shows or handouts. from the Next Generation Learning Initiative. Instructor’s Guide for Teaching Transcultural For more information, go to http://thepoint. Concepts includes activities and discussion top- lww.com/rntobsn. ics to help you engage students in the material. Acknowledgments Student Resources We are pleased to acknowledge the assistance and Students who have purchased Transcultural support of our families, friends, and colleagues in Concepts in Nursing Care, Seventh Edition have once again making this book possible. We also appre- access to the following additional resources: ciate the help of the many nursing faculty members, practitioners, and students who have offered helpful Chapter 14, Cultural Competence in Ethical comments and suggestions. We have found it very Decision Making, discusses cultural compe- gratifying to be able to call upon many of our col- tence in ethical and moral dilemmas from a leagues for help and advice in this new edition. transcultural perspective. We would like to gratefully acknowledge and Chapter 15, Nursing and Global Health, dis- thank Elizabeth Connolly, Development Editor, cusses the field of international nursing and the Wolters Kluwer Health, for her helpful recom- opportunities available for nurses who would mendations on ways to strengthen the seventh like to practice internationally. edition, her careful attention to detail, her flex- Journal Articles corresponding to book chap- ibility, her invaluable input on the Andrews/Boyle ters offer access to current research available in Transcultural Interprofessional Practice Model, Wolters Kluwer journals. her assistance in locating suitable digital images, and the long hours that she spent reviewing and Lippincott RN to BSN Online rereviewing the chapters and appendices. Lippincott RN to BSN Online, a full curriculum We gratefully acknowledge the support of our online course solution aligned with The Essen- friends, too numerous to list by name, who wrote tials of Baccalaureate Education for Profes- encouraging e-mails or phoned to express their sional N ­ ursing Practice and Quality and Safety interest and encouragement. We thank all of our col- Education for Nurses Competencies, uniquely leagues who have purchased our book in the past and features self-paced multimedia modules that the many who have expressed interest in the seventh foster experiential, active learning. Lippincott edition. We are always appreciative of their support. RN to BSN Online capitalizes on the “flipped Last of all, we would once again like to thank classroom” pedagogy trend by integrating qual- each other for what has been a lifetime of friend- ity textbook content, assessments, and reme- ship that has withstood the test of time and now diation with interactive modules. At its core is seven editions of this book! Through it all, we have its exceptional instructional design strategies— found our professional endeavors in transcultural storytelling, modeling, case-based, social, and nursing and the friends that we have made along collaborative learning. These innovative stu- the way to be both satisfying and rewarding. dent and instructor resources take RN to BSN courses to the next level by featuring a guiding Margaret M. Andrews, PhD, RN, CTN-A, FAAN framework derived from the Cognitive ­Learning Joyceen S. Boyle, PhD, RN, MPH, FAAN For a list of the reviewers of this book and the accompanying Test Generator questions, please visit at http:// thepoint.lww.com/Andrews7e. 0002491983.INDD 11 7/10/2015 12:53:59 PM  Contents Part One: Foundations of Transcultural Nursing Chapter 1 Theoretical Foundations of Transcultural Nursing 2 Margaret M. Andrews and Joyceen S. Boyle Chapter 2 Culturally Competent Nursing Care 30 Margaret M. Andrews Chapter 3 Cultural Competence in the Health History and Physical Examination 55 Margaret M. Andrews and Margaret Murray-Wright Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices 102 Margaret M. Andrews Part Two: Transcultural Nursing: Across the Lifespan Chapter 5 Transcultural Perspectives in Childbearing 120 Jana Lauderdale Chapter 6 Transcultural Perspectives in the Nursing Care of Children 153 Margaret M. Andrews and Barbara C. Woodring Chapter 7 Transcultural Perspectives in the Nursing Care of Adults 186 Joyceen S. Boyle Chapter 8 Transcultural Perspectives in the Nursing Care of Older Adults 213 Margaret A. McKenna Part Three: Nursing in Multicultural Health Care Settings Chapter 9 Creating Culturally Competent Health Care Organizations 242 Patti Ludwig-Beymer Chapter 10 Transcultural Perspectives in Mental Health Nursing 272 Joanne T. Ehrmin xii 0002491983.INDD 12 7/10/2015 12:53:59 PM  Contents xiii Chapter 11 Culture, Family, and Community 317 Joyceen S. Boyle and Martha B. Baird Chapter 12 Cultural Diversity in the Health Care Workforce 359 Margaret M. Andrews Part Four: Contemporary Challenges in Transcultural Nursing Chapter 13 Religion, Culture, and Nursing 394 Patricia A. Hanson and Margaret M. Andrews Chapter 14 Cultural Competence in Ethical Decision Making 447 Dula F. Pacquiao Chapter 15 Nursing and Global Health 465 Maureen J. Reinsel and Margaret M. Andrews Chapters 14 and 15 available on. Appendix A Andrews/Boyle Transcultural Nursing Assessment Guide for Individuals and Families A-1 Joyceen S. Boyle and Margaret M. Andrews Appendix B Andrews/Boyle Transcultural Nursing Assessment Guide for Families, Groups, and Communities B-1 Joyceen S. Boyle and Margaret M. Andrews Appendix C Andrews/Boyle Transcultural Nursing Assessment Guide for Health Care Organizations and Facilities C-1 Joyceen S. Boyle, Margaret M. Andrews, and Patti Ludwig-Beymer Appendix D Components of a Cultural Assessment: Traditional Native American Healing D-1 Joyceen S. Boyle Appendix E Boyle/Baird Transcultural Nursing Assessment Guide for Refugees E-1 Joyceen S. Boyle and Martha B. Baird Index I-1 0002491983.INDD 13 7/10/2015 12:53:59 PM 0002491983.INDD 14 7/10/2015 12:53:59 PM Part One Foundations of Transcultural Nursing  1 Theoretical Foundations of Transcultural Nursing Margaret M. Andrews and Joyceen S. Boyle Key Terms Culture Nonverbal communication Culture-specific nursing care Paralanguage Anthropology Culture-universal nursing care Personal space Assessment Ethnicity Polychronic culture Assumptions Ethnonursing research Problem-solving process Chronemics Evaluation Proxemics Communication Evidence-based practice Race Core Curriculum Hijab Subculture Cross-cultural communication Implementation Transcultural Interprofessional Cultural competence Interprofessional collaboration Practice (TIP) Model Cultural context Interprofessional health care Transcultural nursing Culturally competent care team Transcultural nursing Culturally congruent nursing Language certification care Modesty Verbal Communication Cultural-specific Monochronic culture Cultural universals Mutual goal setting Learning Objectives 1. Explore the historical and theoretical foundations of transcultural nursing. 2. Critically examine the relevance of transcultural nursing in addressing contem- porary issues and trends in nursing. 3. Analyze Leininger’s contributions to the creation and development of transcul- tural nursing as a theory and evidence-based formal area of study and practice within the nursing profession. 4. Critically examine the contributions of selected transcultural scholars to the advancement of transcultural nursing theory and practice. 5. Discuss key components of the Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model. 2  Chapter 1 Theoretical Foundations of Transcultural Nursing 3 Introduction to Transcultural Given that culture is the central focus of anthropology and TCN, we begin this chapter Nursing by introducing, defining, and describing the con- cept of culture. We’ll then discus the historical In her classic, groundbreaking book titled “Nursing and theoretical foundations of TCN, including and Anthropology: Two Worlds to Blend,” Leininger its relevance in contemporary nursing practice (1970) analyzed the ways in which the fields of and the significant contributions of Leininger and anthropology and nursing are interwoven and other TCN scholars, leaders, and clinicians to interconnected (c.f., Brink, 1976; McKenna, 1985; the global advancement of TCN research, theory, Osborne, 1969). Leininger used the term transcul- education, and clinical practice. In the remain- tural nursing (TCN) to describe the blending of der of the chapter, we examine the Transcultural nursing and anthropology into an area of special- Interprofessional Practice (TIP) Model as a frame- ization within the discipline of nursing. Using the work for delivering client-centered, high-quality concepts of culture and care, Leininger established nursing and health care that are culturally congru- TCN as a theory and evidence-based formal area of ent and competent, safe, affordable, and accessible study and practice within nursing that focuses on to people from diverse backgrounds across the people’s culturally based beliefs, attitudes, values, lifespan. The term client is used throughout the behaviors, and practices related to health, illness, book because nursing concerns not only the care healing, and human caring (Leininger, 1991, 1995; of people who are ill but also those who strive for Leininger & McFarland, 2002, 2006). optimum health and wellness in their lives. TCN is sometimes used interchangeably with cross-cultural, intercultural, and multicultural nursing. The goal of TCN is to develop a scientific Anthropology and Culture and humanistic body of knowledge in order to provide culture-specific and culture-­universal To understand the history and foundations of TCN, nursing care practices for individuals, families, we begin by providing a brief overview of anthro- groups, communities, and institutions of similar pology, an academic discipline that is concerned and diverse cultures. Culture-specific refers to with the scientific study of humans, past and pres- particular values, beliefs, and patterns of behav- ent. Anthropology builds on knowledge from the ior that tend to be special or unique to a group physical, biological, and social sciences as well as and that do not tend to be shared with members the humanities. A central concern of anthropolo- of other cultures. Culture-universal refers to the gists is the application of knowledge to the solution commonly shared values, norms of behavior, and of human problems. Historically, anthropologists life patterns that are similarly held among cultures have focused their education on one of four areas: about human behavior and lifestyles (Leininger, sociocultural anthropology, biological/physi- 1978, 1991, 1995; Leininger & McFarland, 2002, cal anthropology, archaeology, and linguistics. 2006; McFarland & Wehbe-Alamah, 2015a). For Anthropologists often integrate the perspectives of example, although the need for food is a culture- several of these areas into their research, teaching, universal, there are culture-specifics that deter- and professional lives (American Anthropological mine what items are considered to be edible; Association, n.d.; Council on Nursing and acceptable methods used to prepare and eat Anthropology, n.d.). One of the central concepts meals; rules concerning who eats with whom, the that anthropologists study is culture. A compli- frequency of meals, and gender- and age-related cated, multifaceted concept, culture has numerous rules governing who eats first and last at meal definitions. The earliest recorded definition comes time; and the amount of food that individuals are from a 19th c­ entury British pioneer in the field of expected to consume. anthropology named Edward Tylor, who defines 4 Part One Foundations of Transcultural Nursing culture as the complex whole that includes knowl- rendered by others in facilitating healing also are edge, beliefs, art, morals, law, customs, and any culturally determined. Culture determines who is other capabilities and habits acquired by members permitted, or expected, to care for someone who of a society (Tylor, 1871). Influenced by her formal is ill. Similarly, culture determines when a person academic preparation in anthropology (Meade, is declared well and when they are healthy enough 1937), Leininger defines culture as the “learned, to resume activities of daily living and/or return shared, and transmitted values, beliefs, norms, and to work. When someone is dying, culture often lifeways of a particular group of people that guide determines where, how, and with whom the person thinking, decisions, and actions in a patterned will spend his or her final hours, days, or weeks. way…. Culture is the blueprint that provides the Although the term culture sometimes connotes a broadest and most comprehensive means to know, person’s racial or ethnic background, there are also explain, and predict people’s lifeways over time many other examples of nonethnic cultures, such as and in different geographic locations” (McFarland those based on socioeconomic status, for example, & Wehbe-Alamah, 2015a, p. 10). the culture of poverty or affluence and the culture Culture influences a person’s definition of of the homeless; ability or disability, such as the cul- health and illness, including when it is appropri- ture of the deaf or hearing impaired and the culture ate to self-treat and when the illness is sufficiently of the blind or visually impaired; sexual orientation, serious to seek assistance from one or more heal- such as the lesbian, gay, bisexual, and transgender ers outside of the immediate family. The choice of (LGBT) cultures; age, such as the culture of ado- healer and length of time a person is allowed to lescence and the culture of the elderly; and occu- recover, after the birth of a baby or following the pational or professional cultures, such as nursing onset of an illness, are culturally determined. How (American Nurses Association, 2013; International a person behaves during an illness and the help Council of Nurses, 2013) (see Figure 1-1), medicine, Figure 1-1. The profession of nursing is an example of a nonethnic occupational culture. The faculty member on the left is transmitting the requisite knowledge and skills from one generation to the next by mentoring the nursing student on the right.  Chapter 1 Theoretical Foundations of Transcultural Nursing 5 and other professions in health care, business, edu- nic and racial categories: White American, Native cation, and related fields. American, and Alaska Native; Asian American, In a classic study of culture by the anthropologist Black, or African American; Native Hawaiian and Edward Hall (1984), three levels of culture are iden- other Pacific Islander; and people of two or more tified: primary, secondary, and tertiary. The primary races; a race called “some other race” is also used level of culture refers to the implicit rules known in the census and other surveys but is not official. and followed by members of the group, but seldom The Census Bureau also classifies Americans as stated or made explicit, to outsiders. The second- “Hispanic or Latino” and “Not Hispanic or Latino,” ary level refers to underlying rules and assumptions which identifies Hispanic and Latino Americans as that are known to members of the group but rarely a racially diverse ethnicity. shared with outsiders. The primary and secondary In the traditional anthropological and biological levels are the most deeply rooted and most difficult systems of classification, race refers to a group of to change. The tertiary level refers to the explicit people who share such genetically transmitted traits or public face that is visible to outsiders, including as skin color, hair texture, and eye shape or color. dress, rituals, cuisine, and festivals. Races are arbitrary classifications that lack defini- The term subculture refers to groups that have tional clarity because all cultures have their own values and norms that are distinct from those held ways of categorizing or classifying their members by the majority within a wider society. Members of (Hesmondhalgh & Sala, 2013; Hunt, Truesdel, & subcultures have their own unique shared set of cus- Kreiner, 2013). Some define race as a geographically toms, attitudes, and values, often accompanied by and genetically distinct population, whereas others group-specific language, jargon, and/or slang that suggest that racial categories are socially constructed sets them apart from others. A subculture can be (Zimitri, 2013). The most current scientific data indi- organized around a common activity, occupation, cate that all humans share the same 99.1% of genes; age, ethnic background, race, religion, or any other the remaining 0.1% accounts for the differences in unifying social condition. In the United States, sub- humans (National Human Genome Institute, 2014). cultures might include the various racial and ethnic groups. For example, Hispanic is a panethnic des- ignation that includes many subcultures consisting Historical and Theoretical of people who self-identify with Mexican, Cuban, Puerto Rican, and/or other groups that often share Foundations of Transcultural Spanish language and culture (Morris, 2015). Nursing Ethnicity is defined as the perception of one- self and a sense of belonging to a particular ethnic More than 60 years ago, Madeleine Leininger group or groups. It can also mean feeling that one (1925 to 2012; see Figure 1-2) noted cultural dif- does not belong to any group because of multieth- ferences between patients and nurses while work- nicity. Ethnicity is not equivalent to race, which is a ing with emotionally disturbed children. This biological identification. Rather, ethnicity includes clinical nursing experience piqued her interest commitment to and involvement in cultural cus- in cultural anthropology. As a doctoral student toms and rituals (Douglas & Pacquiao, 2010). In in anthropology, she conducted field research on the United States, ethnicity and race are defined the care practices of people in Papua New Guinea by the federal Office of Management and Budget and subsequently studied cultural similarities and (OMB) and the U.S. Census Bureau; they provide differences in the culture care perceptions and standardized categories, which are used in the col- expressions of people around the world. lection of census information on racial and ethnic At the same time that Leininger (Leininger, populations and are also often used by biomedical 1978, 1991, 1995, 1997, 1998, 1999; Leininger & researchers. There are six officially recognized eth- McFarland, 2002, 2006) was establishing TCN, 6 Part One Foundations of Transcultural Nursing Figure 1-2. Author, Dr. Margaret Andrews (left), and Transcultural Nursing Foundress, Dr. Madeleine Leininger (right), at a meeting of the American Academy of Nursing. other anthropologists, nurse–anthropologists, 3. An increase in health care providers’ and and nurses who were studying, teaching, and patients’ use of technologies that connect peo- writing about ethnicity, race, diversity, and/or cul- ple globally and simultaneously may become ture in nursing used terms such as cross-­cultural the source of conflict with the cultural values, nursing, ethnic nursing care (Orque, Bloch & beliefs, and practices of some of the people Monrroy, 1983), or referred to caring for people receiving care of color (Branch & Paxton, 1976). The term trans- 4. Global cultural conflicts, clashes, and violence cultural nursing is used in this book, in recogni- that impact health care as more cultures inter- tion of the historical, research, and theoretical act with one another contributions of Leininger (1978), who used this 5. An increase in the number of people trav- term in her research and other scholarly works. eling and working in different parts of the Leininger cites eight factors that influenced her world to establish TCN as a framework for addressing 6. An increase in legal actions resulting from 20th-century societal and health care challenges cultural conflict, negligence, ignorance, and and issues, all of which remain relevant today: the imposition of health care practices 7. A rise in awareness of gender issues, with 1. A marked increase in the migration of people growing demands on health care systems to within and between countries worldwide meet the gender- and age-specific needs of 2. A rise in multicultural identities, with people men, women, and children expecting their cultural beliefs, values, and 8. An increased demand for community- and ways of life to be understood and respected by culturally based health care services in diverse nurses and other health care providers environmental contexts (Leininger, 1995)  Chapter 1 Theoretical Foundations of Transcultural Nursing 7 TCN exists today as an evidence-based, Among the strengths of Leininger’s theory is dynamic area of specialization within the ­nursing its flexibility for use with individuals, families, profession because of the visionary leadership of groups, communities, and institutions in diverse its founder, Madeleine Leininger, and many other health systems. To help develop, test, and orga- nurses committed to the provision of care that nize the emerging body of knowledge in TCN, is consistent with and “fits” the cultural beliefs Leininger recognized that it would be necessary and practices of those receiving it. This sec- to have a specific conceptual framework from tion explores the contributions of Leininger and which various theoretical statements are devel- then examines the ways in which other nursing oped. Leininger’s Sunrise Enabler (Figure 1-3) scholars contributed to the development and depicts components of the Theory of Cultural advancement of TCN theory, research, practice, Care Diversity and Universality, provides a visual education, and administration globally. representation of these components, and illus- trates the interrelationships among the compo- Leininger’s Contributions to nents. As the world of nursing and health care has become increasingly multicultural, the theory’s Transcultural Nursing relevance has increased as well. Leininger’s Theory of Culture Care Diversity While creating TCN as a respected and recog- and Universality describes, explains, and pre- nized nursing specialty and developing her theory, dicts nursing similarities and differences in care Leininger also had the foresight to establish the and caring in human cultures (Leininger, 1991). Transcultural Nursing Society (TCNS), generate Leininger uses concepts such as worldview, social the TCNS Newsletter, and create the Journal of and cultural structure, language, ethnohistory, Transcultural Nursing (JTN), for which she served environmental context, and folk and professional as the founding editor. The TCNS holds regional healing systems to provide a comprehensive and and annual conferences, disseminates the newslet- holistic view of factors that influence culture ter, and collaborates with a publishing company care. Culturally based care factors are recog- to produce a quarterly journal, all of which pro- nized as major influences on human experiences vide forums for the exchange of TCN knowledge, related to well-being, health, illness, disability, and research, and evidence-based, best practices rela- death. After conducting a comprehensive cultural tive to the provision of culturally congruent and assessment based on the preceding factors, the culturally competent nursing and health care. To three modes of nursing decisions and actions— integrate TCN into the curricula of schools of culture care preservation and/or maintenance, nursing, Leininger established the first master’s culture care accommodation and/or negotiation, and doctoral programs in nursing with a theo- and culture care repatterning and/or restructur- retical and research focus in TCN and provided ing—are used to provide culturally congruent exemplars for TCN courses and curricula suitable nursing care (Leininger, 1991, 1995; Leininger for all levels of nursing education (undergraduate & McFarland, 2002, 2006). Culturally congruent and graduate) through her lectures, publications, nursing care “refers to those cognitively based and consultations. Leininger also created a new assistive, supportive, facilitative, or enabling acts qualitative research method called ethnonursing or decisions that are mostly tailor-made to fit with research to investigate phenomena of interest in an individual’s, group’s or institution’s cultural TCN (Leininger, 1995; Leininger & McFarland, values, beliefs, and lifeways in order to provide 2002, 2006; McFarland, Mixer, Webhe-Alamah, meaningful, beneficial, satisfying care that leads & Burk, 2012; McFarland & Wehbe-Alamah, to health and well-being” (Leininger, 1991, p. 47). 2015). Hundreds of studies have been conducted Cultural congruence is central to Leininger’s using ethnonursing research, which is the first Theory of Culture Care Diversity and Universality. research methodology developed by a nurse for 8 Part One Foundations of Transcultural Nursing Leininger’s Sunrise Enabler to Discover Culture Care CULTURE CARE Worldview Cultural & Social Structure Dimensions Cultural Values, Kinship & Beliefs & Political & Social Lifeways Legal Factors Factors Environmental Context, Language & Ethnohistory Religious & Economic Philosophical Factors Factors Influences Care Expressions Patterns & Practices Technological Educational Factors Factors Holistic Health/Illness/Death Focus: Individuals, Families, Groups, Communities, or Institutions in Diverse Health Contexts of Professional Generic (Folk) Nursing Care Care–Cure Care Practices Practices Culture Care Decisions & Actions Culture Care Preservation and/or Maintenance Culture Care Accommodation and/or Negotiation Culture Care Repatterning and/or Restructuring Culturally Congruent Care for Health, Wellbeing, or Dying Code: (Influencers) Figure 1-3. Leininger’s Sunrise Enabler to discover culture care. (Reprinted by permission of McFarland, M. R., & Wehbe-Alamah, H. B. (2015). Leininger’s sunrise enabler. In M. R. McFarland & H. B. Wehbe-Alamah (Eds.), Culture care diversity and universality: A worldwide nursing theory (3rd ed., p. 25). Burlington, MA: Jones and Bartlett Learning.)  Chapter 1 Theoretical Foundations of Transcultural Nursing 9 use in studying topics relevant to nursing. Ray and The following TCN scholars and leaders have colleagues studied caring, complexity science, enhanced, expanded, and advanced the specialty and transcultural caring dynamics in nursing through their research, teaching, publications, and healthcare (Davidson & Ray, 2011; Ray, 2010; conceptual models, frameworks, and/or theories: Ray, Turkel, & Cohn, 2011). Lastly, Leininger’s Josepha Campinha-Bacote (Campinha-Bacote, contributions to TCN rapidly gained global and 2011), Geri-Ann Galanti (Gilanti, 2014), Joyce interprofessional recognition as many health care Newman Giger (Giger, 2013), Marianne Jeffreys professionals from medicine, physical therapy, (Jeffreys & Dogan, 2014), Larry Purnell (Purnell, occupational therapy, social work, and related dis- 2014), Marilyn Ray (Davidson & Ray, 2011; ciplines learned about the Theory of Cultural Care Ray, 2010; Ray, Turkel, & Cohn, 2011), Priscilla Diversity and Universality and either adopted or Sagar (Sagar, 2012, 2014, 2015), Rachel Spector adapted it to fit their respective disciplines. (Spector, 2013), and the late Ruth Davidhizar. As nursing and health care have become increas- ingly multicultural and diverse, TCN’s relevance The Core Curriculum has increased as well. There also is heightened soci- etal awareness that people of all cultures deserve In collaboration with a group of other TCN schol- to receive nursing and health care that are cultur- ars and experts globally, the editor and associate ally congruent and culturally competent. Cultural editor of the JTN published the Core Curriculum competence refers to the complex integration of in Transcultural Nursing and Health Care to knowledge, attitudes, values, beliefs, behaviors, “establish a core base of knowledge that supports skills, practices, and cross-cultural encounters that TCN practice” (Douglas & Pacquiao, 2010, p. S5). include effective communication and the provision The Core Curriculum marks the culmination of of safe, affordable, quality, accessible, evidence- many years of research and theory development in based, and efficacious nursing care for individuals, TCN and draws on knowledge and research from families, groups, and communities of diverse and the natural, social, and behavioral sciences; philos- similar cultural backgrounds. Cultural competence ophy, theology, and religious studies; history; the is discussed in detail in Chapter 2. fine arts; and applied or professional disciplines such as medicine, social work, education, and Advancements in Transcultural other fields. The Core Curriculum clearly identi- Nursing fies, delineates, and authoritatively establishes the core of knowledge that supports TCN practice. In addition to Leininger, many other TCN schol- The Core Curriculum includes the following: ars and leaders around the world have made, and continue to make, significant contributions to the Contributions by many of the foremost experts body of transcultural knowledge, research, theory, in TCN from around the world who provide and evidence-based practices that guide nurses in concrete and specific curricular outline for TCN. the delivery of culturally congruent and culturally A comprehensive compendium that contains competent care for people from similar and diverse an overview of the key knowledge, research, cultures (Clark, 2013; Courtney & Wolgamott, evidence, and general content areas that col- 2015; deRuyter, 2015; Eipperle, 2015; Larson, lectively form the foundation for TCN practice. 2015; McFarland & Wehbe-Alamah, 2015a & Content on subjects such as global health; b;McFarland, et al., 2015; Mixer, 2015; Raymond comparative systems of health care delivery; & Omeri, 2015). While the authors of this textbook cross‐cultural communication; culturally based have chosen to emphasize the research and theory health and illness beliefs and practices across generated by Leininger, there are many different the lifespan; culturally based healing and care ways to conceptualize TCN and deliver culturally modalities; cultural health assessment; educa- congruent and culturally competent nursing care. tional issues for students, organizational staff, 10 Part One Foundations of Transcultural Nursing patients, and communities; organizational cul- ­ ractice, critically analyze situations for clinical p tural competency; research methodologies for decision making, develop a plan of care, propose investigating cultural phenomena and evaluat- appropriate nursing interventions, predict the ing interventions; and professional roles and outcomes from the care, and evaluate the effec- attributes of the transcultural nurse. tiveness of the care provided (Alligood, 2014). Content that will prepare nurses to take one or both of the examinations leading to transcultural Goals, Assumptions, and Components nursing certification. of the Model Basic certification in transcultural nursing (CTN- The goals of the Andrews/Boyle TIP Model are to: B) and advanced certification in transcultural nursing (CTN-A). Both exams are offered by the Provide a systematic, logical, orderly, scientific TCNS’s Certification Commission (Transcultural process for delivering culturally congruent, Nursing Certification Commission, 2007) and culturally competent, safe, affordable, acces- appear on the list of Magnet national certifica- sible, and quality care to people from diverse tions for inclusion on the Demographic Data backgrounds across the lifespan Collection Tool. See Sagar (2015) for further Facilitate the delivery of nursing and health information about certification in TCN. care that is beneficial, meaningful, relevant, culturally congruent, culturally competent, The Core Curriculum also is used in schools and consistent with the cultural beliefs and of nursing, hospitals, health departments, and practices of clients from diverse backgrounds other health care organizations to determine the Provide a conceptual framework to guide nurses key content to be included in seminars, work- in the delivery of culturally congruent and com- shops, conferences, and credit-bearing and con- petent care that is theoretically sound, evidence tinuing professional development courses on based, and utilizes best professional practices TCN and cultural competency. Those interested in cultural competence, multiculturalism, diver- Fundamental assumptions underlying the TIP sity, and related topics from multiple disciplines Model include those related to TCN (Box 1-1), will also find valuable information in the Core humans (Box 1-2), and cross-cultural commu- Curriculum. As scientific, technological, and dis- nication between and among team members cipline-specific advances are made in TCN, the (Box 1-3). These assumptions are ideas that are Core Curriculum will be updated and refined. formed or taken for granted as having veracity The coauthors of this book contributed to the without proof or evidence. Assumptions are use- Core Curriculum, as did many of the chapter con- ful in providing a basis for action and in creating tributors; therefore, the key concepts contained in “what if…” scenarios to simulate possible situa- the Core Curriculum also are found in this book. tions until such time as there is proof or evidence available to corroborate or refute the assumption. The TIP Model consists of the following inter- Andrews/Boyle Transcultural connected and interrelated components: the Interprofessional Practice context from which people’s health-related val- ues, attitudes, beliefs, and practices emerge; the (TIP) Model interprofessional health care team; communi- cation; and the problem-solving process. Conceptual frameworks, theoretical models, and theories in nursing are structured ideas about Cultural Context human beings and their health. Models enable nurses and other health care team members Derived from the Latin contexere (con- mean- to organize and understand what happens in ing together and texere meaning to weave or  Chapter 1 Theoretical Foundations of Transcultural Nursing 11 Box 1-1 Assumptions about Transcultural Nursing Transcultural nursing is a theoretical and evi- thetic, therapeutic relationship with dence-based formal area of study and practice clients and a collaborative, colle- within professional nursing that focuses on peo- gial relationship with other members of the ple’s culturally based beliefs, attitudes, values, interprofessional health care team. behaviors, and practices related to wellness, Transcultural nursing assessment is facili- health, birth, illness, healing, dying, and death. tated when the nurse’s communications are Transcultural nursing requires that nurses client-centered and focused on establishing engage in an ongoing process of construc- and maintaining a therapeutic nurse–client tively critical, reflective self-assessment that relationship. enables them to identify their own culturally Transcultural nursing practice requires that based values, attitudes, beliefs, behaviors, nurses be aware of changes in the world that biases, stereotypes, prejudices, and practices. influence and challenge their knowledge of Transcultural nursing knowledge is intercon- the unfolding meaning of diversity and the nected with the knowledge, research, and need for the delivery of nursing and health scholarship of other disciplines in the natural care that is respectful and responsive to indi- sciences (e.g., biology, chemistry, physics), vidual needs and differences of the people social and behavioral sciences (e.g., anthro- and communities served. pology, sociology, psychology, economics, Transcultural nursing practice encompasses political science), professional disciplines (e.g., autonomous and collaborative care of indi- medicine, pharmacy, social work, education), viduals of all ages, families, groups, and and the humanities (e.g., music, art, history, communities, sick or well and in all settings. languages, philosophy, theater). Transcultural nursing practice requires that Transcultural nursing practice encompasses nurses establish and maintain a caring, autonomous and collaborative care of indi- empathetic, therapeutic relationship with cli- viduals of all ages across the lifespan whether ents; formally educated and/ or licensed cre- they are sick or well, able or disabled. dentialed healers, such as registered nurses, Transcultural nursing engages nurses the care licensed physicians, and other health profes- of families, groups, populations, and commu- sionals; and folk, traditional, religious, spiri- nities globally. tual, and other healers identified by clients Transcultural nursing includes the promotion of as significant to their health and well-being. health, prevention of disease, and the care of In transcultural nursing practice, the nurse’s sick, ill, disabled, and dying people from diverse communications are other oriented and cultures across the lifespan from birth to old age. focused on what is best for the client’s health Transcultural nursing roles include advocacy, well-being, recovery, or peaceful death. research, health policy development, health Transcultural nursing practice requires that systems leadership, management, education, nurses be respectful and responsive to indi- clinical practice, and consultation. vidual needs and differences of the people Transcultural nursing practice requires that and communities served. nurses establish and maintain a caring, empa- braid), the term context refers to the condi- the cultural context of human experiences and tions, circumstances, and/or situations that exist need to be assessed, interpreted, examined, and when and where something happens, thereby evaluated when clients interact with nurses and providing meaning to what transpired. In the other members of the interprofessional health TIP Model, the following factors contribute to care team: environmental, social, economic, 12 Part One Foundations of Transcultural Nursing Box 1-2 Assumptions about Humans Humans are complex biological, cultural, psy- pain and suffering associated with chosocial, spiritual beings who experience disease, illness, dying, and death. health and illness along a continuum through- Although humans have common culture- out the span of their lives from birth to death. universal needs, they also have culture-spe- All humans have the right to safe, accessible, cific needs that are interconnected with their and affordable nursing and health care, regard- health-related values, attitudes, beliefs, and less of national origin, race, ethnicity, gender, practices. age, socioeconomic background, religion, sex- In times of health and illness, humans seek ual orientation, size, and related characteristics. the therapeutic (beneficial) assistance of Whether rich or poor; educated or illiterate; various types of healers to promote health religious or nonbelieving; male or female; and well-being, prevent disease, and recover black, white, yellow, red, or brown, each per- from illness or injury. son deserves to be respected by nurses and Humans seek therapeutic interventions from other health members of the health care team. family and significant others; credentialed or As people from different racial, ethnic, and cul- licensed health care providers; folk, tradi- tural backgrounds travel and comingle with tional, indigenous, religious, and/or spiritual those having backgrounds that differ from their healers; and companion or therapy animals own, the likelihood of intermarriage and offspring and pets as they perceive appropriate for of mixed racial and ethnic heritage increases. their condition, situation, or problem. Regardless of their national origin or current Interventions are judged to have a therapeu- citizenship, humans around the world share tic effect when they result in a desirable and culture-universal needs for food, shelter, safety, beneficial outcome, whether the outcome and love; seek well-being and health; and was expected, unexpected, or even an unin- endeavor to avoid, alleviate, or eliminate the tended consequence of the intervention. Box 1-3 Assumptions about Effective Communication Effective communication begins with an Communication occurs verbally, assessment of the client’s ability to read, write, nonverbally, in writing, and in com- speak, and comprehend messages. bination with technology. Effective communication in contemporary Communication should be appropriate for society sometimes requires literacy in the use the client’s age, gender, health status, health of computers, smartphones, and numerous literacy, and related factors. technology-assisted medical or health devices. When nurses communicate with others from Effective communication includes the ability cultural and linguistic backgrounds different to convey sincere interest in others, patience, from their own, the probability of miscommu- and willingness to intervene or begin again nication increases significantly. when misunderstandings occur. In promoting effective cross-cultural com- To provide safe, quality, affordable, accessible, munication with clients from diverse back- efficacious, culturally congruent, and culturally grounds, nurses should avoid technical competent nursing and health care, members jargon, slang, colloquial expressions, abbre- of the interprofessional health care team must viations, and excessive use of medical communicate effectively. terminology.  Chapter 1 Theoretical Foundations of Transcultural Nursing 13 religious, philosophical, moral, legal, political, The client’s family, and others significant in his educational, biological (genetic/inherited fac- or her life, including a legally appointed guard- tors), and technological. In TCN, culture is the ian who might not be genetically related lens through which nurses see the world, their Credentialed health professionals such as clients, and other members of the team. When nurses; physicians; physical, occupational, culture is interwoven with the other factors (see respiratory, music, art, dance, recreational, and Figure 1-4), it forms the health-related cultural other therapists; social workers; health naviga- values, attitudes, beliefs, and practices of humans tors; public and community health workers; worldwide, including clients and other members and related professionals with formal academic of the team. preparation, licensure, and/or certification Folk, indigenous, or traditional healers—­ unlicensed individuals who learn healing arts Interprofessional Health Care Team and practices through study, observation, The transcultural interprofessional health care apprenticeship, imitation, and sometimes by team has at its core the client, who is the team’s inheriting healing powers, for example, herb- raison d’etre (reason for being). In addition to the alists, curanderos, medicine men/women, client, the team may have one or more of the fol- Amish brauchers, bonesetters, lay midwives, lowing members: sabadors, and healers with related names Cultural Context Environmental Social Economic Religious Philosophical Moral Legal Political Educational Biological Genetic Technological Factors Health-related values, attitudes, beliefs, and practices Humans Worldwide Interprofessional Health Care Team Figure 1-4. Influence of cultural context on health values, beliefs, and practices of the interprofessional health care team. (© Margaret M. Andrews.) 14 Part One Foundations of Transcultural Nursing Religious or spiritual healers—clergy or lay professionals must recognize their own indi- members of religious groups who heal through vidual scope of practice and skill set and have prayer, religious or spiritual rituals, faith heal- an awareness of and appreciation for other ing practices, and related actions or interven- health professionals’ capacity to contribute to tions, for example, priests, priestesses, elders, the delivery of care to clients in order to achieve rabbis, imams, monks, Christian Science prac- optimal health outcomes. Working as a mem- titioners, and others believed to have healing ber of an interprofessional team requires com- powers derived from faith, spiritual powers, or munication, cooperation, and collaboration religion. (Fulmer & Gaines, 2014; Institute of Medicine, Others identified by the client as significant to 2011; Interprofessional Education Collaborative his or her health, well-being, or healing such Expert Panel, 2011). as companion animals or pets as culturally