1. TRANSCULTURAL NURSING CONCEPT
Prepared by : Mrs. Namita Batra Guin
Associate Professor, Deptt. of Community Health Nursing
INTRODUCTION
From times immemorial, student nurses have been reciting Nightingale Pledge to honour their
commitment to nursing profession. The lines “I will serve mankind with love and compassion,
recognizing their dignity and rights irrespective of colour, caste, crede, relegion and
Nationality.”So it is of immense importance to discuss nursing service in terms of patient’s
safety, chiefly, from the patient’s culture.
Safety of the patient has always been paramount in the mind of a nurse, whether at
a clinical or educational setting. The person needs to feel safe, both in physical environment and
in relations. So the time has come to consider other aspects of patient’s safety i:e cultural safety ,
rather than considering safety from only from the physical point of view.
Propelled by a national concern about social justice and health disparities, the nation
of cultural competency is being incorporated into professional standards.
“Cultural competency is really nursing competence”
IMPORTANT DEFINITIONS
CULTURE
Culture represents the nonphysical traits, such as values, beliefs, attitudes and customs shared by
a group of people and passed from one denegation to next.
Culture is also the sum of beliefs, practices, habits, likes, dislikes, norms, customs and rituals
learned from family during years of socialization.
Acc. To Betancourt
“We all belong to more than one culture, which may for example, be
social, professional or religious, the concept goes beyond race, ethnic background and country of
origin.”
CULTURAL VALUES

2. The individuals desirable or preferred way of acting of knowing something that is sustained over
a period of time and which governs the actions of that individual.
ETHNICITY
Ethnicity is the sense of identification associated with a cultural group’s common social and
cultural heritage. The characteristics of an ethnic group include common language and dialect,
migratory status, race and religious faith and practice.
RELEGION
Religion is a belief in a divine or supernatural power to be obeyed and worshipped as the creator
and ruler of the universe.
THE BASIC CONCEPT OF TRANSCULTURAL NURSING
Transcultural Nursing is providing client centered, culturally competent care to clients from
various ethnic and cultural backgrounds.
- A humanistic and scientific onset of formal study in nursing, which is focused upon
differences and similarities among cultures, with respect to care, health and illness based
upon the people’s cultural values, beliefs and practices and to use this knowledge to
provide culture specific nursing care.
- Transcultural Nursing represents an effort by the nurses from all cultural backgrounds
and clinical areas to came together and defines concepts that enable them to develop the
knowledge skill needed to provide culturally sensitive care.
CULTURE AND HEALTH CARE
In the broadest sense, health may be viewed as a balance between the individual and
environment. Health practices such as eating nutritiously or subscribing to preventing health
services available in the community and are believed to have positive effect on the individual,
who in turn can positively effect the environment.
Perceptions of health and illness are shaped by cultural factors. How one experiences and
copes with the illness is very individual.
So it is important to corporate both personal and cultural reactions of the client to illness,
disease and discomfort to give culturally competent care.
Just as culture influences health related behavior, it also has profound effect on
expectations and perceptions of illness.
As a result of cultural shaping, individuals vary in health care behavior, health status and
health seeking attitude.

3. Culture influences how feelings are expressed and what verbal and non-verbal
expressions are appropriate. Communication and culture are closely related.
Cultural health practices can be categorized as beneficial, neutral or harmful.
Religion strongly affects the way people attempt to prevent illness and it plays major
role in rituals associated with health protection.
Many people believe that illness can be prevented by strictly following religious codes,
morals and practices and view illness as punishment for violating a religious code.
NURSING IN A DIVERSE HEALTH CARE SYSTEM
To work effectively in a multicultural society, nurses must be able to provide care to persons
from a vast array of cultural backgrounds.
To bridge the gap between clients of varied cultural backgrounds and the biomedical system
in which nurses’ practice, nurses should foster the inclusion of health promoters in selected
health care settings.
The new definition of Nursing as the “diagnosis and treatment of human responses to actual
or potential health problems” speaks to the importance of culture in guiding and interpreting
nursing practices.
Attention to the culture may be the factor that distinguishes nursing from medicine as the
object of nursing is “the diagnosis and treatment of human responses” and some of the
variations in human response is attributable to culture.
The American Nurses Association’s position statement and cultural diversity in health care
practices emphasizes that nurse at all levels of practice must understand how culture affects
definition of health and illness ,notions of illness causation in delivery of care .
The JHACO manual states that patients have a right that protects their personal dignity and
respect their cultural, psychosocial and spiritual values.
PURPOSE OF DEVELOPING TRANSCULTURAL PRACTICES
The purpose and a sound rationale for studying health practices is to develop a greater
understanding of human behavior and how it relates to health.
Nurses are central to the potential of developing and maintaining programs that deliver
culturally competent health care.
Combining the knowledge and patterns of transcultural advancements can result in
improved health and nursing care for persons of many cultures.
To make nursing practices culturally based, conceptualized, planned and executed.
There are marked changes in the demographic and ethnic composition of the population,
of the world in general.
With these changes, there is a growing awareness and acceptance of diversity and more
willingness to maintain and support ethnic and cultural heritage.

4. There is increasing awareness among the consumers of what constitutes competent and
sensitive health care.
The nursing profession continues to value holistic and comprehensive approach to
provide care. So the knowledge and use of cultural factors cannot be ignored since
culture is integral part of client care.
ASSESSMENT MEASURES
The assessment step of nursing process is extremely important in interpreting relationships
between patients and nurses. To gather data about a patient of different culture from the nurse’s,
the nurse needs to view in the context he exists.
GIGER AND DOUDHIZER proposed six cultural phenomenons that the nurse
needs to understand to provide effective care to all patients (communication, space, social
organization, time, environmental control, biological variations.)
1) COMMUNICATION
Miscommunication is a frequent problem in hospitals and that to
when the patient and hospital staff donot speak the same language. And more subtle
problems result from cultural differences in the non-verbal communication eg many
Asians consider it disrespectful to look into someone’s eyes.
2) SPACE
This includes the comfort level related to personal space eg. Comfort in
conversation, perceptions of space and touch practices differ from cultures to cultures.
3) SOCIAL ORGANISATONS
Patterns of cultural behaviours learned through encounter
with social organisatons.The nurse should recognize that individual’s diverse background
may show varying degree of acculturation into the dominant culture. Culture is
determined not only by ethnicity but by other factors such as religion, gender and socio
economic status. The age and life cycle factors must be considered in interaction with
individuals and families.
4) TIME
Concept of passage of time, duration of time and points in reference to time needs
to be considered.eg person of England and China seems to be past oriented. They prefer
to do the things they have been doing in the past.
People from present oriented cultures tend to focus on the here and now. They are
relatively unconcerned with the future; they will deal with it when it comes eg
Americans.
5) ENVIRONMENTAL CONTROLS

5. These are abilities of the person to control nature.
Health procedures, values, definition of health and illness.
6) BIOLOGICAL VARIATIONS
Biological variations are those diverse manifestations of
normal that express people with respect to body structure, enzymatic and genetic
variations, nutritional preferences and deficiencies and psychological characteristics eg
sickle cell anemia is more common in black or African descent population.
Consistent with the above mentioned cultural phenomenon,
BOYLE AND ANDREWS purposes that nurses needs to assess eight areas reflecting
cultural variations and the nurse needs to gather the following information:
I. History of the origin of patient’s culture
II. Value orientation , including view of the world, ethics and norms and
attitude about time, work, money and education
III. Interpersonal relationships, including family patterns and role relationships.
IV. Communication patterns and norms.
V. Religion and Magic
VI. Social systems, including economic values, political system and education
VII. Diet and food habits
VIII. Health and illness belief systems including behavior and decision making.
STEPS IN CULTURAL ASSESSMENT
The variety of Assessment tools or guides has been devised. Cultural assessment does not require
information on every element of the culture. Nurses needs to identify the major values, beliefs
and behavior as they influence and relate to a particular setting or health problem.
PHASE 1 – DATA COLLECTION
IT is a three staged phase:
STAGE 1
The nurse performs a general assessment that gives an overview of the characteristics of the
client and identifies areas of potential need for more in depth assessment. Data is collected about
client’s background, ethnicity, religion and pattern of decision making, language, styles of verbal
and non-verbal communication.
STAGE 2
The nurse elicits problem specific cultural information. The nurse is interested in problem
associated with particular health area eg preschool immunization, health beliefs.

6. STAGE 3
Stage three takes place after nursing diagnosis have been made and is directed at cultural factors
that may influence intervention strategies.
PHASE 2 – DATA ORGANISATION
In this phase, the cultural content material is placed in context, it is process of data
organisation.The phase 2 is more complex than biological or psychosocial assessments. The
nurse is interested in the extent to which the client’s beliefs, values and customs are relevant to
client’s health.
The areas of incongruence are identified; the nurse needs to find out if the
client system is adaptive neutral or maladaptive in relation to possible interventions.
Cultural assessment is both process and content. They begin with awareness of
cultural richness and diversity and lead to culturally relevant nursing diagnosis that gives
direction to nursing interventions.
THE PROCESS OF CULTURAL COMPETANCE IN
DELIVERY OF HEALTH CARE SERICES
The Volcano Model
"The Process of Cultural Competence in the Delivery of Healthcare Services," is a model of
cultural competence that defines cultural competence as "the process in which the healthcare
professional continually strives to achieve the ability and availability to effectively work within
the cultural context of a client" (family, individual or community). It is a process of becoming
culturally competent, not being culturally competent,. This model of cultural competence views
cultural awareness, cultural knowledge, cultural skill, cultural encounters and cultural desire as
the five constructs of cultural competence.
Cultural awareness is defined as the process of conducting a self-examination of one’s own
biases towards other cultures and the in-depth exploration of one’s cultural and professional
background. Cultural awareness also involves being aware of the existence of documented
racism and other "isms" in healthcare delivery.
Cultural knowledge is defined as the process in which the healthcare professional seeks and
obtains a sound information base regarding the worldviews of different cultural and ethnic
groups as well as biological variations, diseases and health conditions and variations in drug
metabolism found among ethnic groups (biocultural ecology).

7. Cultural skill is the ability to conduct a cultural assessment to collect relevant cultural data
regarding the client’s presenting problem as well as accurately conducting a culturally-based
physical assessment.
Cultural encounter is the process which encourages the healthcare professional to directly
engage in face-to-face cultural interactions and other types of encounters with clients from
culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to
prevent possible stereotyping.
Cultural desire is the motivation of the healthcare professional to “want to” engage in the
process of becoming culturally aware, culturally knowledgeable, culturally skillful and seeking
cultural encounters; not the “have to.” Cultural desire is the spiritual and pivotal construct of
cultural competence that provides the energy source and foundation for one’s journey towards
cultural competence. Therefore, cultural competence can be depicted as a volcano, which
symbolically represents that it is cultural desire which stimulates the process of cultural
competence When cultural desire erupts, it gives forth the desire to enter into the process of
becoming culturally competent by genuinely seeking cultural encounters, obtaining cultural
knowledge, conducting culturally-sensitive assessments and being humble to the process of
cultural awareness.
Cultural Competency in Healthcare Delivery:
Have I 'ASKED' Myself The Right Questions?"
(Campinha-Bacote, 2002)
Awareness: Am I aware of my biases and prejudices towards other cultural groups, as well as
racism and other "isms" in healthcare?
Skill: Do I have the skill of conducting a cultural assessment in a sensitive manner?
Knowledge: Am I knowledgeable about the worldviews of different cultural and ethnic groups,
as well as knowledge in the field of biocultural ecology?

8. Encounters: Do I seek out face-to-face and other types of interactions with individuals who are
different from myself?
Desire: Do I really "want to" become culturally competent?
CULTURE CARE THEORY
(Madeleine Leininger’s)
A major contribution to Advanced Transcultural Nursing Knowledge and practices.
Leininger underlines the meaning and importance of culture in explaining an individual’s
health needs and caring behavior and CULTURE CARE THEORY IS THE ONLY
THEORY THAT FOCUSES ON CULTURE.
Leininger discovered that the patients from diverse cultures valued care
more than the nurses did.Leininger became convicted about the need for a theoretical
framework to discover, explain and predict dimensions of care developed culture care
theory as the outcomes of the studies performed in numerous western and non-western
cultures.
SOME UNIQUE FEATURES OF THE THEORY
Some major unique, contributing features of the theory are:
a. The theory remains one of the oldest theories of nursing developed in mid 1950s.
b. It is the only theory that focused on the close inter-relationships of culture and care on
well being, health, illness and death.
c. It the most holistic and multidimensional theory to discover specific and multifaceted
curiosity based care meaning and practices.
d. It is the first theory with specifically designed research method (ethno nursing) to fit the
theory.
e. It is the first theory focused on the GENERIC (EMIC) and PROFESSIONAL (ETIC)
culture care, data related to world-view, social structure factors and ethno history in
diverse environmental contexts.
LEININGER DEFINITION OF THEORY
Leininger defines theory differently from other nursing theorists. According to her:
Theory is a systematic and creative way to discover knowledge about something or to
account for some vaguely known phenomenon.

9. Nursing theory must take into account the cultural beliefs, caring behaviors and values of
individuals, families and groups to provide effective, satisfying and culturally congruent
nursing care.
THEORY OVERVIEW
Leininger theory is based on a holistic view of nursing, incorporating
anthropological concepts. It is a new kind of nursing focused on human beings in
a multicultural world.
Leininger envisioned transcultural nursing was different from anthropology in
that “its focus was on comparative health care, health and well being in different
environmental contexts and cultures.
Leininger theory focused on the cultural beliefs, values and lifestyles of people
that allow them to maintain and for restoring their health throughout the lifespan.
The profession must understand, embrace and respect these culturally based
beliefs and practices to provide culturally congruent care.
BASIC ASSUMPTIONS
The basic assumptions behind transcultural nursing concept are:
Nursing is a transcultural phenomenon because nursing practices involves at least two
persons, generally having different cultural orientation and life styles.
Caring is a universal phenomenon, however the forms and manifestations of caring vary
among cultures.
What constitutes therapeutic nursing is largely culturally determined, culturally based and
culturally validated.
Members of a given culture have their own caring practices, which are frequently
unfamiliar to nurses from other cultures.
Transcultural nursing care practices will vary according to their system and social
structure of each culture.
KEY CONCEPTS OF THE THEORY
The major key concepts of the theory are:
A. CULTURAL DIVERSITY: This is the difference or variations among and between
different cultures. Recognition of these differences is crucial because this helps the nurse
avoid stereotyping patients.( assuming that all members of a particular culture subscribe
to the same philosophies and therefore will respond to nursing care in same manner)
B. CULTURAL UNIVERSALITY: (The commonalities or similarities in different cultures)

10. Together these two concepts “lead to an important goal of the theory ,that nurse is
to discover similarities and differences about care and its impact on health and well being
of the group.
C. GENERIC CARE (FOLK CARE) which refers to the remedies passed down from one
generation to another within a particular culture. Typically people rely on these
traditional practices long before seeking professional care.
While these alternative practices play an important role in many cultures, they are
frequently looked down upon by health care professional as cold tales, or based on
superstitions and are often disregarded as unscientific or ignorant. As a result patients are
often reluctant to report these practices to health care practitioners and result in gap
building.
Leninger goal is to interface generic and professional care into creative and
meaningful nursing.
To accomplish this important goal, Leininger outlines three elements that nurse needs to
consider in order to provide culturally congruent care:
1. Culture care preservation and maintenance
2. Culture care accommodation and negotiation
3. Culture care reconstructing
These key concepts (cultural diversity and cultural universality along with
generic and professional care) formed the basis of Leiningers theory.
CULTURE SPECIFIC CARE: The care that results from the identification and abstraction of
care in a particular culture that will lead to the planning and application of nursing care that
would fit the specific care needs of the patient and life ways of a client from that culture.
CULTURALLY CONGRUENT CARE: The central idea and goal of Leininger’s theory is-
Nursing care tha is based on the cultural values ,beliefs and practices of an individual or groups
,the acts or decisions which support ,facilitate or enable the nurse in providing “meaningful
,beneficial and satisfying care that leads to health and well being”
THE SUNRISE MODEL
The sunrise model is a visual map designed to help guide one’s exploration of a culture.

11. THEORY STRENGTHS
 The individual cultural value priorities are respected and patient care is provided
harmoniously within the context on their cultural heritage.
 Incorporating culture care is preservation ,accommodation and separating into the nursing
plan of care allows for meaningful quality of care.

12.  Culturally competant care is accoompalished through the inclusion of important cultural
values while asssissting in patient to modify practices in ways to attain their optimal level
of wellness and quality of life.
 Providing culturally congruent care shows respect for the patients culture and their
values,which facilitates the nurse patient ralationship fostering trust and ultimately can
lead to patient compliance with health care.
THEORY WEAKNESSES
Even today ,in multicultural society ,cultural diversity education is lacking.
 The fact that cultures are dynamic and ever changing requires ongoing research and
continuous updates in order to provide quality and relevant training.
 There are multiple variations within cultures,so there is not a inclusive and authoritative
way to define or explain a particular culture.
 In the most emergent situations or other common situations when time constraints are an
issue,the additional time required plan appropriate culture care is often not possible.
APPLICATION OF THE THEORY
The key elements of a method of application in practice methodology identified by Dr.
Leininger are:
 Goals of nursing
 Cultural Assessment
 Nurisng Judgements,decisions and actions
Four major tenants were formulated to systematically examine the theory .These are:
 Culturally based care has diversities and some universal features.
 Worldwide cultures and social structure factors and others in sunrise model influence
care outcomes related to culturally congruent care.
 Generic emic(folk,lay or indigenous) practices and professional etic nursing practices
influence care practices outcome.
 The three predicted theoretical models for transcultural care actions and decisions are
namely culture care perservation,culture care accomodation and culture care
repatterning or reconstructing to provide culturally competant care.
CONCLUSION
If nurses profess to work in caring in non-discriminating manner ,they must accept the patient
patient for what he or she is,not what the nurse feels the patient should be.We often use our own
cultures and backgrounds to determine what is normal and acceptable even though we are aware
that everyone is different.

13. So a nurse should be consious of the dynamic inherent when cultures interact and should
exercise cultural awareness.Being culturally competant is essential to being an efficient nurse.
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10. www.careassociates.com
11. www.journal of transcultural nursing.com