Leininger used the term transcultural nursing (TCN) to describe the blending of
nursing and anthropology into an area of specialization within the discipline of nursing.
Using the concepts of culture and care, Leininger established TCN as a theory and
evidence-based formal area of study and practice within nursing that focuses on people’s
culturally based beliefs, attitudes, values, behaviors, and practices related to health,
illness, healing, and human caring.
 Transcultural Nursing is sometimes used interchangeably with cross-cultural,
intercultural, and multicultural nursing. The goal of TCN is to develop a scientific and
humanistic body of knowledge in order to provide culture-specific and culture-
universal nursing care practices for individuals, families, groups, communities, and
institutions of similar and diverse cultures.
                Transcultural Nursing as a theory and evidence-based formal area of study and
practice within nursing that focuses on people’s culturally based beliefs, attitudes,
values, behaviors, and practices related to health, illness, healing, and human caring
 
Culture-specific refers to particular values, beliefs, and patterns of behavior that tend to
be special or unique to a group and that do not tend to be shared with members of other
cultures.
 
Culture-universal refers to the commonly shared values, norms of behavior, and life
patterns that are similarly held among cultures about human behavior and lifestyles.
 
Anthropology and Culture
                To understand the history and foundations of TCN, we begin by providing a
brief overview of anthropology, an academic discipline that is concerned with the
scientific study of humans, past and present. Anthropology builds on knowledge from
the physical, biological, and social sciences as well as the humanities. A central concern
of anthropologists is the application of knowledge to the solution of human problems.
Historically, anthropologists have focused their education on one of four
areas: sociocultural anthropology, biological/physical anthropology, archaeology,
and linguistics. One of the central concepts that anthropologists study is culture.
 
Definition of Culture:
 Edward Tylor, defines culture as the complex whole that includes knowledge, beliefs, art,
morals, law, customs, and any other capabilities and habits acquired by members of a
society.
 Leininger, defines culture as the “learned, shared, and transmitted values, beliefs, norms,
and lifeways of a particular group of people that guide thinking, decisions, and actions in
a patterned way.
  Culture influences a person’s definition of health and illness, including when it is
appropriate to self-treat and when the illness is sufficiently serious to seek assistance
from one or more healers outside of the immediate family. The choice of healer and
length of time a person is allowed to recover, after the birth of a baby or following the
onset of an illness, are culturally determined.
 How a person behaves during an illness and the help rendered by others in facilitating
healing also are culturally determined.
 Culture determines who is permitted, or expected, to care for someone who is ill.
 Similarly, culture determines when a person is declared well and when they are healthy
enough to resume activities of daily living and/or return to work.
 When someone is dying, culture often determines where, how, and with whom the
person will spend his or her final hours, days, or weeks.
 Although the term culture sometimes connotes a person’s racial or ethnic background,
there are also many other examples of nonethnic cultures, such as those based
on socioeconomic status, for example, the culture of poverty or affluence and the culture
of the homeless; ability or disability, such as the culture of the deaf or hearing impaired
and the culture of the blind or visually impaired; sexual orientation, such as the lesbian,
gay, bisexual, and transgender (LGBT) cultures; age, such as the culture of adolescence
and the culture of the elderly; and occupational or professional cultures, such as nursing
and other professions in health care, business, education, and related field.
In a classic study of culture by anthropologist Edward Hall, three levels of culture are
identified: primary, secondary, and tertiary.
1. The primary level of culture refers to the implicit rules known and followed by members
of the group, but seldom stated or made explicit, to outsiders.
2. The secondary level refers to underlying rules and assumptions that are known to
members of the group but rarely shared with outsiders. The primary and secondary
levels are the most deeply rooted and most difficult to change.
3. The tertiary level refers to the explicit or public face that is visible to outsiders, including
dress, rituals, cuisine, and festivals
 
The term subculture refers to groups that have values and norms that are distinct
from those held by the majority within wider society. Members of subcultures have their
own unique shared set of customs, attitudes, and values, often accompanied by group-
specific language, jargon, and/or slang that sets them apart from others. A subculture
can be organized around a common activity, occupation, age, ethnic background, race,
religion, or any other unifying social condition. In the United States, subcultures might
include various racial and ethnic groups. For example, Hispanic is a pan-ethnic
designation that includes many subcultures consisting of people who self-identify with
Mexican, Cuban, Puerto Rican, and/or other groups that often share Spanish language
and culture.
Ethnicity is defined as the perception of oneself and a sense of belonging to a
particular ethnic group or group. It can also mean feeling that one does not belong to
any group because of multiethnicity. Ethnicity is not equivalent to race, which is a
biological identification. Rather, ethnicity includes a commitment to and involvement in
cultural customs and rituals.
In the traditional anthropological and biological systems of classification, race refers
to a group of people who share such genetically transmitted traits as skin color, hair
texture, and eye shape or color. Races are arbitrary classifications that lack definitional
clarity because all cultures have their own ways of categorizing or classifying their
members.
 
Historical and Theoretical Foundations of Transcultural Nursing
More than 60 years ago, Madeleine Leininger noted cultural differences between
patients and nurses while working with emotionally disturbed children. This clinical
nursing experience piqued her interest in cultural anthropology.
 
Leininger cites eight factors that influenced her to establish TCN as a framework for
addressing 20th-century societal and health care challenges and issues, all of which
remain relevant today:
1. A marked increase in the migration of people within and between countries worldwide.
2. A rise in multicultural identities, with people expecting their cultural beliefs, values, and
ways of life to be understood and respected by nurses and other health care providers.
3. An increase in health care providers’ and patients’ use of technologies that connect
people globally and simultaneously may become the source of conflict with the cultural
values, beliefs, and practices of some of the people receiving care
4. Global cultural conflicts, clashes, and violence that impact health care as more cultures
interact with one another
5. An increase in the number of people traveling and working in different parts of the world
6. An increase in legal actions resulting from cultural conflict, negligence, ignorance, and
the imposition of health care practices
7. A rise in awareness of gender issues, with growing demands on health care systems to
meet the gender- and age-specific needs of men, women, and children
8. An increased demand for the community- and culturally based health care services in
diverse environmental contexts
 
Leininger’s Contributions to Transcultural Nursing
 Leininger uses concepts such as worldview, social and cultural structure, language,
national history, environmental context, and popular and professional treatment
systems to provide a comprehensive and holistic view of the factors that influence
cultural care.
 Cultural congruence is at the core of Leninger's theory of culture care for diversity and
universality. One of the advantages of Leininger's theory is that it can be applied flexibly
to individuals, families, groups, communities, and institutions in different health
systems.
  Leininger's Sunrise Enabler: To help develop, test, and organize the emerging knowledge
system at TCN, Leininger recognized the need to establish a specific conceptual
framework from which to develop various theoretical statements. It describes the
components of the theory of cultural concern for diversity and universality, provides a
visual representation of these components, and illustrates the interrelationships between
these components.
 The Intercultural Nursing Association (TCNS), which generates the TCNS newsletter,
and creates the Intercultural Nursing Journal (JTN), she serves as the founding editor.
 Leininger established the first nursing master's and doctoral programs at TCN with a
focus on theory and research, and through conferences, publications and consultations,
provides TCN courses and curricula applicable to all levels of nursing education
(undergraduate and graduate).
 Leininger also created a new qualitative research method called ethnonursing research to
investigate phenomena of interest to TCN.
 
Cultural Competence
It is a combination of attitudes, abilities, behaviors, and policies that allow
organizations and their employees to operate effectively in cross-cultural environments.
It reflects the ability to acquire and apply knowledge of clients' and their families'
health-related beliefs, attitudes, practices, and communication patterns in order to
improve services, strengthen programs, increase community participation, and close
health-status gaps among diverse population groups.
 
Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model
The conceptual framework, theoretical models and theories in nursing are structured
thoughts about human beings and their health. These models allow nurses and other
members of the health team to organize and understand what is happening in practice,
critically analyze the situation of clinical decision-making, formulate care plans, propose
appropriate care interventions, predict care outcomes and evaluate the effectiveness of
care provided.
 
The goals of the Andrews/Boyle TIP Model are to:
 Provide a systematic, logical, orderly, scientific process for delivering culturally
congruent, culturally competent, safe, affordable, accessible, and quality care to people
from diverse backgrounds across the lifespan
 Facilitate the delivery of nursing and health care that is beneficial, meaningful, relevant,
culturally congruent, culturally competent, and consistent with the cultural beliefs and
practices of clients from diverse backgrounds
 Provide a conceptual framework to guide nurses in the delivery of culturally congruent
and competent care that is theoretically sound, evidence-based, and utilizes best
professional practices.
 
 These assumptions are thoughts that are formed or assumed to be true without
evidence or evidence. Hypotheses can be used to provide a basis for actions and create
"what-if" scenarios to simulate possible situations until there is evidence or evidence to
confirm or refute the hypothesis. The TIP model consists of the following interrelated
and interrelated components: values, attitudes, beliefs and practice backgrounds related to
people's health; interprofessional health teams; communication; and problem-solving
processes.
 
Interprofessional Health Care Team
The intercultural and interprofessional healthcare team takes the client as the core
and the client is the reason for the team being (the reason for its existence). In addition
to the client, the team may have one or more of the following members:
 Significant others: the client’s family and other important people in their lives, including
legally designated guardians, but may not have a genetic relationship
 Registered healthcare professionals: nurses; physics, occupation, respiratory, music, art,
dance, entertainment, and other therapists; social workers; health navigators; public and
community health workers; professionals related to formal academic preparation,
bachelor's and/or certification Imitation, and sometimes even unlicensed individuals
who learn the art and practice of healing by inheriting the ability to heal,
 Religious or spiritual therapist: a priest or lay minister who performs healing through
prayer, religious or spiritual rituals, belief therapy practices, and related actions or
interventions Lay members of religious groups, for example, priests, priestesses, elders,
rabbis, imams, monks, Christian science. And others who are believed to have healing
powers derived from faith, spiritual power, or religion.
 Other people that the client considers important to their health, well-being, or recovery,
such as culturally appropriate companion animals or pets.
 
Interprofessional Collaboration
It is defined as multiple healthcare workers from different professional backgrounds
who work with patients, families, caregivers, and the community to provide the highest
quality care.
 
Core Competencies:
 values and ethics related to interprofessional practice
 knowledge of the roles of team members
 a team approach to health care
 
Requirements:
                                Communication
                                Cooperation
                                Collaboration
 
Aspects of Communication
 Derived from the Latin verb communicare, meaning to share, communication refers to
the meaningfull exchange of information between one or more participants.
 The information exchanged may be conveyed through ideas, feelings, intentions,
attitudes, expectations, perceptions, instructions, or commands.
 Communication is an organized, patterned system of behavior that makes all nurse–
client interactions possible. It is the exchange of messages and the creation of meaning.
Language
More than 6,000 languages are spoken around the world; Most Filipinos speak
eight (8) major dialects: Tagalog, Cebuano, Ilocano, Hiligaynon or Ilonggo, Bicolano,
Waray, Pampango, and Pangasinense. With about 76 to 78 major language groups, with
more than 500 dialects.
 
B. Interpreters
When nurses and clients speak different languages, one of the greatest challenges of
cross-cultural communication for nurses arises. After assessing the language skills of a
client who speaks a different language with the nurse, the nurse may find herself in one
of two situations: either it is difficult to communicate effectively through an interpreter,
or she can communicate effectively without an interpreter.
Even people from other cultures or countries have basically mastered the language
spoken by most nurses and other health professionals, but they may also face being
admitted to the hospital, encountering unfamiliar symptoms, or discussing anxiety
situations. An interpreter is required. Sensitive topics, such as birth control or
gynecological or urological problems. A trained medical interpreter understands
interpreting skills, understands medical terminology, and understands the rights of
patients. Well-trained interpreters can also understand cultural beliefs and healthy
practices. This person can help bridge the cultural gap and can advise on the cultural
suitability of medical and nursing advice.
Although the nurse is responsible for the focus and process of the interview, the
interpreter should be regarded as an important member of the medical team. It can be
tempting to ask relatives, friends, or even other clients to interpret because this person
is always available and may be willing to help. However, this violates the confidentiality
of customers, and customers may not want to share personal information. In addition,
although friends or family members can speak a common language fluently, they may
not be familiar with medical terminology, hospital or clinical procedures, and healthcare
ethics. Ideally, ask the interpreter to meet with the client in advance to establish a
relationship and obtain basic descriptive information about the visitor, such as age,
occupation, education level, and attitude toward healthcare. This makes the relationship
between interpreters and clients easier and allows clients to talk about relatively non-
threatening aspects of their lives.
C. Greetings
Some cultures value formal greetings at the beginning of the day or at the first
meeting of the day, and this practice even exists among close family members. When
communicating with people from more formal cultures, it is important to address
someone by title, such as Mr., Mrs., Mrs., Ph.D, Pastor, and related titles to show
respect. Until the individual allows these issues to be addressed in a less formal way.
When a nurse first meets with a client or new member of the medical team, the
recommended best practice is to say their name, and then ask the client or team
member how they prefer to be called.
D. Silence
There are wide cultural differences in the interpretation of silence. Some people find
silence very uncomfortable and do their best to use words to fill in the delay in the
conversation. On the contrary, many Native Americans believe that silence is essential
to understanding and respecting others. A pause after a question means that the
question asked is important enough to require careful consideration.
In traditional Chinese and Japanese cultures, silence may mean that the speaker wants
the listener to consider what has been said before proceeding. Other cultural meanings
of silence can be discovered. Arabs may use silence out of respect for the privacy of
others, while people of French, Spanish and Russian descent may interpret silence as a
sign of consent. Asian culture often uses silence to show respect for the elderly. In some
African Americans, silence is used to answer questions that are considered
inappropriate.
E. Eye Contact and Facial Expression
Eye contact and facial expressions are the most prominent forms of non-verbal
communication. Eye contact is a key factor in determining the tone of communication
between two people, and there are great differences between different cultures and
countries.
 In most of the United States, Canada, Western Europe, and Australia, the interpretation
of eye contact are similar: expressing interest, active contact with one another, openness,
and honesty.
 People who avoid eye contact when speaking is seen as negative people and can be seen
as withholding information and/or lack of confidence.
 In certain regions of Asia, Africa, and the Middle East, as well as in certain Native
American countries, direct eye contact can be seen as a sign of disrespect, aggression, or
defiance of the authority of others.
 In some cultures, staring at someone for a long time indicates that the person looking
has a sexual interest in the other person.
 People who make eye contact, but only briefly, are considered respectful and polite. In
some Native American cultures, when a person in authority speaks, the person may look
at the ground to show respect and concern.
  In some African American and white cultures, the occult (rolling eyes) occurs when
someone speaks or acts in a way that is considered inappropriate.
F. Gestures
Types of Gestures
 EMBLEMS - gestures that serve the same function as words.
Examples of emblems  include signals that mean okay, the “thumbs up”  gesture, the
“come here” hand movement, or the  hand gesture used when hitchhiking.
 ILLUSTRATORS - gestures that accompany words to illustrate a verbal message. It
mimics the spoken word, such as pointing to the right or left while verbally saying the
words right or left.
 REGULATORS - include head nodding and short sounds such as “uh huh” or
“Hmmmm” and other expressions of interest or boredom.
 ADAPTORS - are non-verbal behaviors that can satisfy certain physical needs, such as
scratching or adjusting glasses, and can also represent psychological needs, such as
biting nails when nervous, yawning when bored, or clenching fists when angry.
G. Posture
Posture reflects people's emotions, attitudes, and intentions. The posture can be
open or closed and is believed to convey personal confidence, status, or acceptance to
another person.
H. Chronemics
Chronemic is the study of the use of time in nonverbal communication. The way a
person perceives and values time, constructs time, and responds to time contributes to
the context of communication. Social scientists have discovered that individuals are
divided into two broad categories in the way they approach time: monochronic or
polychronic.
In monochronic cultures, such as many groups in the United States, Northern
Europe, Israel, and most parts of Australia, time is considered a commodity, and people
tend to use things such as "waste time" or "lose time" or "time is money", as a way of
expression.
People in polychronic cultures, such as some groups in Southern Europe, Latin
America, Africa, and the Middle East, have very different views on time. People in these
cultures often think that time is uncontrollable and time is flexible. Dates are planned
based on events rather than clocks. For many people in these cultures, when one event
ends, it is time to start the next, no matter what time it is.
I. Proxemics
The study of space and how differences in space make people feel more relaxed or
anxious is called proxemics, a term coined by anthropologist and intercultural
researcher Edward T. Hall in the 1950s.
Different kinds of Proxemics:
(1) Intimate space (touching to 1 foot) is typically reserved for whispering and
embracing; nurses and other health care providers, however, sometimes need to enter
this intimate space when providing care for clients.
(2) Personal space (ranges from 2 to 4 feet) is used among family and friends or to
separate people waiting in line at the drug store or ATM machine.
(3) Social space (4 to 10 feet) is used for communication among business or work
associates and to separate strangers, such as those taking a course on natural child birth.
(4) Public space (12 to 25 feet) is the distance maintained between a speaker and the
audience
J. Modesty
Modesty is a mixed form of verbal and nonverbal communication, which refers to
reservation or decentness in speech, dress or behavior. The message is intended to avoid
attracting sexual attention or attraction from others (except one’s spouse).
K. Technology-Assisted Communication
From a cross-cultural perspective, one of the biggest challenges facing technology is
the gap between regions and countries that have more resources than other countries.
Although some progress is being made, it will take many years to mobilize technological
capabilities in a way that benefits people all over the world by improving safety, quality,
accessibility, affordability, evidence-based medicine and care, cultural consistency, and
cultural capabilities.
L. Literature, Art, Music, and Dance
The literature, art, music, and dance of various cultural groups convey to the
world the values, beliefs, history, traditions, and contributions that people in countries,
tribes, and population groups cherish. Creative products in the form of books, poems,
works of art, music and dance describe the social atmosphere of the time; they represent
religion, race, gender, politics, class, and other points of view; and they serve as unique
historical documents and cultural relics to better help people. See, hear, recognize,
understand and appreciate the richness of global multiculturalism, because they are
communicated through literary works, artistic and musical creations, and dances of
people from all over the world. Cultures from around the world.
 
Problem Solving Process
The TIP Model is intended to guide members of the interprofessional health care
team in determining what decisions, actions, and interventions the client needs to
achieve an optimal state of well-being and health.
Scientific five-step process:
1. A comprehensive cultural assessment. The cultural assessment includes a self-
assessment and a holistic assessment of the client that includes a health history and
physical examination.
 2. Mutual goal-setting that takes into account the perspectives of each member of the
health care team—the client, the client’s family, and significant others, and all those who
are co-participants with the client in the decision making and goal-setting processes
including credentialed health professionals and folk, traditional, indigenous, religious,
and/or spiritual healers.
3. Planning care that includes input from and dialogue with members of the
interprofessional health care team.
4. Implementation of the care plan through a wide range of actions and interventions.
5. Evaluation of the care plan from multiple, diverse perspectives to determine the degree
to which the plan
(a) is effective in achieving the intended goal(s);
(b) provides care that is culturally congruent with and fits the client’s culturally based
beliefs and practices related to wellness, health, illness, disease, healing, dying, and
death;
(c) reflects the delivery of culturally competent care by nurses and other members of the
interprofessional team;
(d) provides quality care that is safe, affordable, and accessible; and
(e) integrates research, evidence-based, and best practices into the care.

Multiple factors are converging at this time in history to heighten societal

awareness of cultural similarities and differences among people. In many parts of the
world, there is growing awareness of social injustice for people from diverse
backgrounds and the moral imperative to safeguard the civil and health care rights of
vulnerable population.
Vulnerable populations are groups that are poorly integrated into the health care
system because of ethnic, cultural, economic, geographic (rural and urban settings), or
health characteristics, such as disabilities or multiple chronic conditions.
            Immigration and migration result in growing numbers of immigrants, people
who move from one country or region to another for economic, political, religious,
social, and personal reasons. The verb emigrate means to leave one country or region to
settle in another; immigrate means to enter another country or region for the purpose of
living there. People emigrate from one country or region and immigrate to a different
nation or region.
 Nurses respond to global health care needs such as infectious disease epidemics and the
growing trends in health tourism, in which patients travel to other countries for medical
and surgical health care needs. By traveling to another nation, clients often obtain more
affordable care services or receive specialized care that is unavailable in their own
country.
 Nurses also respond to natural and human-made disasters around the world and provide
care for refugees (people who flee their country of origin for fear of persecution based on
ethnicity, race, religion, political opinion, or related reasons) and other casualties of civil
unrest or war in politically unstable parts of the world.
 
Guidelines for the Practice of Culturally Competent Nursing Care:

Guideline Description

Nurses shall gain an understanding of the perspectives, traditions, value

1. Knowledge of Cultures culturally diverse individuals, families, communities, and populations they c
complex variables that affect the achievement of health and well-being.

Nurses shall be educationally prepared to provide culturally congruent health

2. Education and Training in
for assuring that nursing care is culturally congruent shall be included in glo
Culturally Competent Care
formal education and clinical training as well as required ongoing, continuing

Nurses shall engage in critical reflection of their own values, beliefs, and
3. Critical Reflection
awareness of how these qualities and issues can impact culturally congruent n

4. Cross-Cultural Nurses shall utilize cross-cultural knowledge and culturally sensitive skills
Communication nursing care.

5. Culturally Competent Nurses shall utilize cross-cultural knowledge and culturally sensitive skills
Practice nursing care.

6. Cultural Competence in
Health care organizations should provide the structure and resources necess
Health Care Systems and
and language needs of their diverse clients.
Organizations

Nurses shall recognize the effect of health care policies, delivery syste
7. Patient Advocacy and
populations and shall empower and advocate for their patients as indicated. N
Empowerment
of their patient's cultural beliefs and practices in all dimensions of their health

Nurses shall actively engage in the effort to ensure a multicultural workforce

8. Multicultural Workforce to achieve a multicultural workforce is through strengthening of recruitment
clinics, and academic settings.

Nurses shall have the ability to influence individuals, groups, and system
competent care for diverse populations. Nurses shall have the knowledge
9. Cross-Cultural Leadership
private organizations, professional associations, and communities to es
comprehensive implementation and evaluation of culturally competent care.

10 . Evidence-Based Practice Nurses shall base their practice on interventions that have been systematica
and Research effective for the culturally diverse populations that they serve. In areas w
efficacy, nurse researchers shall investigate and test interventions that may
 disparities in health outcomes.

Definitions and Categories of Cultural Competence

Two major categories:
(1) individual cultural competence, which refers to the care provided for an individual
client by one or more nurses, physicians, social workers, and/or other health care,
education, or social services professionals, and
(2) organizational cultural competence, which focuses on the collective competencies of
the members of an organization and their effectiveness in meeting the diverse needs of
their clients, patients, staff, and community.

A. Cultural Self-Assessment
 to critically reflect on their own culturally-based attitudes, values, beliefs, and
practices and gain insight into, and awareness of, the ways in which their
background and lived experiences have shaped and informed the person the
nurse has become today.
 is a personal and professional journey that emphasizes strengths as well as areas
for continued growth, thereby enabling nurses to set goals for overcoming
barriers to the delivery of culturally congruent and competent nursing care.
 nurses’ awareness of their human tendencies toward bias, ethnocentrism,
cultural imposition, cultural stereotyping, prejudice, and discrimination.
 
Bias
 refers to the tendency, outlook, or inclination that results in an unreasoned
judgment, positive or negative, about a person, place, or object.
Ethnocentrism
 refers to the human tendency to view one’s own group as the center of and
superior to all other groups.
Racism
 the belief that one’s own race is superior and has the right to dominate others,
has a profound impact on the body’s stress management system.
Cultural imposition
 is the tendency of a person or group to impose their values, beliefs, and practices
onto others.
Cultural stereotype
 refers to a preconceived, fixed perception or impression of someone from a
particular cultural group without meeting the person.
Prejudice
 refers to inaccurate perceptions of others or preconceived judgments about
people based on ethnicity, race, national origin, gender, sexual orientation, social
class, size, disability, religion, language, political opinion, or related personal
characteristics.
Discrimination
 refers to the act or behavior of setting one individual or group apart from
another, thereby treating one person or group differently from other people or
groups.
 

B. Cultural Assessment of Clients

 cultural assessment, a term that refers to the collection of data about the client’s
health state.
Two major categories of data:
1. subjective data (i.e., what clients say about themselves during the admission or
intake interview)
2. objective data (i.e., what health professionals observe about clients during the
physical examination through observation, percussion, palpation, and
auscultation)
When conducting a comprehensive cultural assessment of clients, nurses need to
be able to successfully form, foster, and sustain relationships with people who may
frequently come from a cultural background that is different from the nurse’s, thus
making it necessary to quickly establish rapport with the client. The ability to see the
situation from the client’s point of view is known as an emic or insider’s perspective;
looking at the situation from an outsider’s vantage point is known as an etic perspective.
The ability to successfully form, foster, and sustain relationships with members of a
culture that differs from one’s own requires effective cross-cultural communication.
 Knowledge about a client’s family and kinship structure helps nurses to ascertain
the values, decision-making patterns, and overall communication within the household.
It is necessary to identify the significant others whom clients perceive to be important in
their care and who may be responsible for decision making that affects their health care.
The family is the basic social unit in which children are raised and where they
learn culturally based values, beliefs, and practices about health and illnesses. The
essence of family consists of living together as a unit. Relationships that may seem
obvious sometimes warrant further exploration when the nurse interacts with clients
from culturally diverse backgrounds.
C. Individual Cultural Competence
          Individual cultural competence is a complex integration of knowledge, attitudes,
values, beliefs, behaviors, skills, practices, and cross-cultural nurse–client interactions
that include effective communication and the provision of safe, affordable, accessible,
research, evidence-based, and best practices, acceptable, quality, and efficacious nursing
care for clients from diverse backgrounds.
 Cultural competence is not an endpoint, but a dynamic, ongoing, lifelong,
developmental process that requires self-reflection, intrinsic motivation, and
commitment by the nurse to value, respect, and refrain from judging the beliefs,
language, interpersonal styles, behaviors, and culturally based, health-related practices
of individuals and families receiving services as well as the professional and auxiliary
staff who are providing such services.
 Culturally competent nursing care requires effective cross-cultural
communication, a diverse workforce, and is provided in a variety of social, cultural,
economic, environmental, and other contexts across the life span.
 

Diverse or diversity
 refers to the client’s uniqueness in the dimensions of race; ethnicity; national
origin; socioeconomic background; age; gender; sexual orientation; philosophical
and religious ideology; lifestyle; level of education; literacy; marital status;
physical, emotional, and psychological ability; political ideology; size; and other
characteristics used to compare or categorize people.
Five-step problem-solving process for delivering culturally congruent and competent
nursing care for individual clients:
Step one of the process is Assessment
 of both the nurse and the client. This begins with nurses’ self-assessment of their
attitudes, values, and beliefs about people from backgrounds that differ from
their own; their knowledge of their own self-location (cultural, gender, class, and
other social self-identities) compared to those of clients and other team
members; and the psychomotor skills needed for the delivery of culturally
congruent and competent care.
Step two, Mutual goals
 are set, and objectives are established to meet the goals and desired health
outcomes.
Step three, Care Planning
 is developed using approaches that are client centered and culturally congruent
with the client’s socioeconomic, philosophical, and religious beliefs, resources,
and practices. Members of the health care team assume roles and responsibilities
according to their educational background, clinical knowledge, and skills.
Step four, Implementation
 decisions, actions, treatments, and interventions that are congruent with the
patient’s health-related cultural beliefs and practices are implemented by those
team members who are best prepared to assist the client. In some instances,
there is overlapping of scope of practice, roles, and responsibilities between and
among team members.
Step five, Evaluation of care plan and objectives by client and team
 the client and members of the health care team collaboratively evaluate the care
plan and its objectives to determine if the care is safe; culturally acceptable,
congruent, and competent; affordable; accessible; of high quality; and based on
research, scientific evidence, and/or best practices.
 
If modifications or changes are needed, the nurse should return to previous steps and
repeat the process. Throughout the five steps of the process for the delivery of culturally
congruent and competent nursing care, the nurse behaves in an empathetic,
compassionate, caring manner that matches, “fits,” and is consistent with the client’s
cultural beliefs and practices.
D. Organizational Cultural Competence
According to the National Center for Cultural Competence (National Center for Cultural
Competence, n.d.), cultural competence requires that organizations have the following
characteristics:
 A defined set of values and principles and demonstration of behaviors, attitudes,
policies, and structures that enable them to work effectively cross-culturally.
 The capacity to:
(1) value diversity,
(2) conduct self-assessments,
(3) manage the dynamics of difference,
(4) acquire and institutionalize cultural knowledge, and
(5) adapt to diversity and the cultural contexts of the communities they serve.
  Incorporation of the previously mentioned items in all aspects of policy making,
administration, practice, and service delivery and systematic involvement of
consumers, key stakeholders, and communities.
 
Clients with Special Needs
A. Health Disparities
- health disparities as population specific differences in the presence of disease, health
outcomes, or access to health care.
 Racial and ethnic minorities
 Residents of rural areas
 Women, children, and the elderly
 Persons with disabilities
 Other special populations such as the deaf
B. Culture of the Deaf
Disabling hearing loss is defined as the loss of greater than 40 decibels in the better ear in
adults and the loss of greater than 30 decibels in the better ear in children
 Disabling hearing loss means that a client has very little or no hearing, which has
consequences for interpersonal communication, psychosocial well-being, quality
of life, and economic independence.
 Hearing loss may affect one or both ears, can be congenital or acquired, and
occurs on a continuum from mild to severe.
 Hearing loss leads to difficulty in hearing conversational speech or loud sounds.
 Clients who are hard of hearing usually communicate through spoken language
and can benefit from hearing aids, captioning, and assistive listening devices.
 From an emic perspective, many deaf people see their bodies as well, whole, and
nonimpaired, and they self-identify as members of a linguistic minority, not with
the culture of disability
 From an etic (outsider’s) perspective, some physicians and other members of the
hearing society embrace concepts about deaf peoples’ bodies that emphasize their
differences from the bodies of people in the hearing society, thereby placing
unwanted, unwarranted, and unnecessary limitations on deaf people’s lives and
capabilities.
Communication and Language Assistance
With growing concerns about racial, ethnic, and language disparities in health
and health care and the need for health care systems to accommodate increasingly
diverse patient populations, language access services (LAS) have become a matter of
increasing national importance. Diversity is even greater when dimensions such as
geography, socioeconomic status, disability status, sexual orientation, and gender
identity are considered. Attention to these trends is critical for ensuring that health
disparities narrow, rather than widen, in the future.
 
National Standards for Culturally and Linguistically Appropriate Services in Health and
Health Care
Principal Standard
1. Provide effective, equitable, understandable, and respectful quality care and
services that are responsive to diverse cultural health beliefs and practices,
preferred languages, health literacy, and other communication needs.
Governance, Leadership, and Workforce
2. Advance and sustain organizational governance and leadership that promotes
CLAS and health equity through policy, practices, and allocated resources.
3. Recruit, promote, and support a culturally and linguistically diverse governance,
leadership, and workforce that are responsive to the population in the service
area.
4. Educate and train governance, leadership, and workforce in culturally and
linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance
5. Offer language assistance to individuals who have limited English proficiency
and/or other communication needs, at no cost to them, to facilitate timely access
to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly
and their preferred language, verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing
that the use of untrained individuals and/or minors as interpreters should be
avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the
languages commonly used by the populations in the service area.
Engagement, Continuous Improvement, and Accountability
9. Establish culturally and linguistically appropriate goals, policies, and
management accountability, and infuse them throughout the organizations’
planning and operations.
10. Conduct ongoing assessments of the organization’s CLAS-related activities and
integrate CLAS-related measures into assessment measurement and continuous
quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and
evaluate the impact of CLAS on health equity and outcomes and to inform service
delivery.
 12. Conduct regular assessments of community health assets and needs and use the
results to plan and implement services that respond to the cultural and linguistic
diversity of populations in the service area.
13. Partner with the community to design, implement, and evaluate policies,
practices, and services to ensure cultural and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and
linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
15. Communicate the organization’s progress in implementing and sustaining CLAS
to all stakeholders, constituents, and the general public.
Cultural Assessment
 or culturologic assessment, refers to a systematic, comprehensive examination of
individuals, families, groups, and communities regarding their health-related cultural beliefs,
values, and practices.
 the goal of the cultural assessment is to determine the nursing and health care needs of
people from diverse cultures and intervene in ways that are culturally acceptable, congruent,
competent, safe, affordable, accessible, high quality, and based on current research, evidence,
and best practices.
Process
 refers to how to approach to the client, consideration of verbal and nonverbal
communication, and the sequence and order in which data are gathered.
Content
 consists of the actual data categories in which information about clients is gathered.
 
Transcultural Perspective on the Health History
Subjective data
 a term that refers to things that people say or relate about themselves.
Objective data
 physical examination and the laboratory results to form a diagnosis about the health status of a
person.
 
The health history enables the nurse to assess health strengths, including cultural beliefs and
practices that might influence the nurse’s ability to provide culturally competent nursing care.
In many health care settings, the client is expected to fill out a printed history form or checklist.
From a transcultural perspective, this approach has both positive and negative aspects.
 On the positive side, this approach provides the client with ample time to recall details
such as relevant family history and the dates of health-related events such as surgical
 procedures and illnesses. It is expedient for nurses because it takes less time to review a
form or a checklist than to elicit the information in a face-to-face or telephone interview.
 On the negative side, this approach has limitations.
1. First, the form is likely to be in English. Those whose primary language is not English
might find the form difficult or impossible to complete accurately.
2. Second, , the symptom or disease is not recognized in the culture with which the client
identifies.
 
Health History Formats, categories:
A. Biographic Data
Although the biographic information (name, address, phone, age, gender, preferred
language, and so forth) might seem straightforward, several cultural variations in recording age
are important to note.
One of the first areas that nurses should assess is the client’s self-reported cultural
affiliation.
 With what cultural group(s) does the client report affiliation?
 Where was the client born?
 What is the ancestry or ethnohistory of the client?
 
B. Genetic Data
Genetics
 is a branch of biology that studies heredity and the variations of inherited characteristics
Genome
 is an organism’s complete set of DNA, including all of its genes.
 each genome contains all of the information needed to build and maintain that organism.
 in humans, a copy of the entire genome—more than 3 billion DNA base pairs—is
contained in all cells that have a nucleus. Genetic mapping is continuing at a rapid rate, and these
numbers and discoveries are constantly being updated.
Epigenetics
 is the study of how genes are influenced by forces such as the environment, obesity, or
medication.
 
Nurses should consider how the client will use genetic and genomic information and be
prepared to provide support if clients experience moral or ethical issues. Most hospitals have
ethics committees, chaplains, pastoral teams, and other resources to assist clients facing moral
and ethical dilemmas.
 The addition of genetics and genomics to the traditional nursing assessment will inform and
engage clients to make key decisions in their personal health care plan. By virtue of their race or
ethnicity, clients are sometimes said to be “at risk” for certain diseases.
 
The following genetic screenings may be useful to clients, nurses, and other members of the
health care team:
 Drug efficacy or sensitivity: Pharmacogenomics, the study of the role of inherited and
acquired genetic variation in drug response, is an evolving field that facilitates the
identification of biomarkers that can help health providers optimize drug selection, dose,
and treatment duration as well as eliminate adverse drug reactions.
 Carrier screening: Genetic tests can identify heterozygous carriers for many recessive
diseases such as cystic fibrosis, sickle cell disease, and Tay–Sachs disease. A couple may
wish to undergo carrier screening to help make reproductive decisions, especially in
populations where specific diseases are relatively common, for example, Tay–Sachs
disease in Ashkenazi Jewish populations and β-thalassemia in Mediterranean populations.
 Prenatal diagnosis: Amniocentesis is usually performed at 16 weeks’ gestation; chorionic
villus sampling (CVS) is carried out at 10 to 12 weeks’ gestation; preimplantation genetic
diagnosis (PGD) is carried out on early embryos (8 to 12 cells) prior to implantation; and
fetal DNA analysis in maternal circulation is done at 6 to 8 weeks’ gestation.
D. Review of Medications and Allergies
The review of medications includes all current prescription, over the counter, and home
remedies, including herbs that a client might purchase or grow in a home garden. During the
health history, note the name, dose, route of administration, schedule, frequency, purpose, and
length of time that each medicine that has been taken. Because of cultural differences in clients’
perceptions of what substances are considered medicines, it is important to ask about specific
items by name. Inquire about vitamins, birth control pills, aspirin, antacids, herbs, teas, inhalants,
poultices, vaginal and rectal suppositories, ointments, and any other items taken by the client for
therapeutic purposes. The nurse also gathers data on the client’s allergies to medicines and foods
warnings, such as contraindications (e.g., pregnancy, childhood, people with compromised
immune systems) and interactions with prescription drugs.
The client’s genetic makeup results in distinctive patterns of drug absorption,
metabolism, excretion, and effectiveness. Knowledge of clients’ individual genotypes guides
pharmacologic treatment and allows customization of choice of drug and dosage to ensure a
therapeutic response and avoid toxicity.
D. Reason for Seeking Care
The reason or reasons for seeking care refers to a brief statement in the client’s own
words describing why he/she is visiting a health care provider. This part of the health history
previously was called the chief complaint, a term that is now avoided because it focuses on
illness rather than wellness and tends to label the person as a complainer
Symptoms
 are defined as phenomena experienced by individuals that signify a departure from
normal function, sensation, or appearance.
Signs
 are objective abnormalities that the examiner can detect on physical examination or
through laboratory testing.
Assess the symptoms within the client’s sociocultural and ethnohistorical context. It is
important to use the same terms for symptoms that the client uses. For example, if the client
prefers to “swelling” of the leg, nurses should refrain from medicalizing that to “edema.”
Knowledge of the cultural expression of symptoms influences the decisions nurses make and will
facilitate their ability to provide culturally congruent and culturally competent nursing care.
E. Present Health and History of Present Illness
Although all illnesses are defined and conceptualized through the lens of culture, the
term culture-bound syndromes refer to more than 200 disorders created by personal, social,
and cultural reactions to malfunctioning biological or psychological processes and can be
understood only within defined contexts of meaning and social relationships
         When assessing clients with a culture-bound syndrome, it is important for the nurse to find
out what the client, family, and other concerned individuals believe is happening; what prior
efforts for help or cure have been tried; and what the results or outcomes from the treatment
were.
F. Past Health
 past illnesses may have residual effects on the current state of health or have sequelae
that appear many months or years later. For example, the varicella-zoster virus responsible for
chickenpox may remain latent until a person notices the characteristic rash or blisters of shingles;
chickenpox and shingles are caused by the same herpes zoster virus.
 the assessment of past illnesses includes other childhood conditions with known sequelae
such as rheumatic fever, scarlet fever, and poliomyelitis. The nurse also gathers information
about the date and nature of accidents, serious and chronic illnesses, hospitalizations, surgeries,
obstetric history, and the last examination.
G. Family and Social History
When conducting the family history, the nurse can refer to the table for conditions that
tend to be more prevalent among certain groups. If clients are aware that they are at increased
risk for a certain condition, they may seek early screening and periodic surveillance and may
choose to adopt a healthier life style, for example, stop smoking, exercise regularly, and/or lose
weight.
The health history should include in-depth data pertaining to the client’s family and/or
close social friends, including identification of key decision makers.
H. Review of Systems
The purpose of the review of systems is threefold:
(1) to evaluate the past and present health state of each body system,
(2) to provide an opportunity for the client to report symptoms not previously stated, and
(3) to evaluate health promotion practices.
 
For example, when reviewing the gastrointestinal system with clients from Native American,
Asian, African, and South American descent, the nurse should inquire about symptoms of lactose
intolerance, such diarrhea, nausea, vomiting, abdominal cramps, bloating, and flatus, usually
beginning 30 minutes to 2 hours after eating or drinking foods that contain lactose (e.g., milk,
cheese, and ice cream).
 
Lactose intolerance
 means that the body cannot easily digest lactose, a type of natural sugar found in milk
and dairy products. Some people who have lactose intolerance cannot digest any milk products.
 
Transcultural Perspectives on the Physical Examination
 
There are a number of biocultural variations that nurses may encounter when conducting the
physical examination of clients from different cultural backgrounds. Accurate assessment and
evaluation of clients requires knowledge of normal biocultural variations among healthy
members of selected populations, as well as variations that occur in illness. The data about
biocultural variations presented here are evidence based and reflect the findings of classic studies
that have been conducted over a period of years.

Learning Content
At the end of this module, students will be able to:
 Explore the process and content needed for a comprehensive cultural assessment of
clients from diverse cultures.
 Identify biocultural variations in health and illness for individuals from diverse cultures.
 Integrate concepts from the fields of genetics and genomics into the cultural assessment
of clients from diverse cultural backgrounds.
 Discuss biocultural variations in common laboratory tests.
 Critically review transcultural perspectives in the health history and physical
examination.
The last meeting, you were introduced to individual and organizational cultural
competence and provided with the knowledge and skills needed to deliver culturally congruent
and competent nursing care to individual clients from diverse cultures. Nurses are encouraged to
think about out the delivery of care as a five-step process consisting of
(1) a constructively critical self-assessment of the nurse’s own attitudes, knowledge, and skills
and a cultural assessment of clients from diverse backgrounds by gathering subjective and
objective data using the health history and physical examination;
(2) mutual goal setting in collaboration with the client and other members of the
interprofessional health care team (family, significant others, credentialed, licensed, folk,
traditional, religious, and/or spiritual healers);
(3) development of the plan of care;
(4) implementation of the care plan; and
(5) evaluation of the plan for client acceptance, cultural congruence, cultural competence,
affordability, accessibility, and use of research, evidence, and best practices.
   
        For this week, we shall learn about cultural prompts or cues that enable nurses to customize
or tailor their cultural assessment according to the client’s genetic background, biographic
makeup, and his/her self-identified cultural affiliation(s). We shall define and describe the
cultural assessment and then discuss transcultural perspectives on the health history, the physical
examination, and clinical decision making and actions.

Cultural Assessment
 or culturologic assessment, refers to a systematic, comprehensive examination of
individuals, families, groups, and communities regarding their health-related cultural beliefs,
values, and practices.
 the goal of the cultural assessment is to determine the nursing and health care needs of
people from diverse cultures and intervene in ways that are culturally acceptable, congruent,
competent, safe, affordable, accessible, high quality, and based on current research, evidence,
and best practices.
Process
 refers to how to approach to the client, consideration of verbal and nonverbal
communication, and the sequence and order in which data are gathered.
Content
 consists of the actual data categories in which information about clients is gathered.
 
Transcultural Perspective on the Health History
Subjective data
 a term that refers to things that people say or relate about themselves.
Objective data
  physical examination and the laboratory results to form a diagnosis about the health status of a
person.
 
The health history enables the nurse to assess health strengths, including cultural beliefs and
practices that might influence the nurse’s ability to provide culturally competent nursing care.
In many health care settings, the client is expected to fill out a printed history form or checklist.
From a transcultural perspective, this approach has both positive and negative aspects.
 On the positive side, this approach provides the client with ample time to recall details
such as relevant family history and the dates of health-related events such as surgical
procedures and illnesses. It is expedient for nurses because it takes less time to review a
form or a checklist than to elicit the information in a face-to-face or telephone interview.
 On the negative side, this approach has limitations.
1. First, the form is likely to be in English. Those whose primary language is not English
might find the form difficult or impossible to complete accurately.
2. Second, , the symptom or disease is not recognized in the culture with which the client
identifies.
 
Health History Formats, categories:
A. Biographic Data
Although the biographic information (name, address, phone, age, gender, preferred
language, and so forth) might seem straightforward, several cultural variations in recording age
are important to note.
One of the first areas that nurses should assess is the client’s self-reported cultural
affiliation.
 With what cultural group(s) does the client report affiliation?
 Where was the client born?
 What is the ancestry or ethnohistory of the client?
 
B. Genetic Data
Genetics
 is a branch of biology that studies heredity and the variations of inherited characteristics
Genome
 is an organism’s complete set of DNA, including all of its genes.
 each genome contains all of the information needed to build and maintain that organism.
 in humans, a copy of the entire genome—more than 3 billion DNA base pairs—is
contained in all cells that have a nucleus. Genetic mapping is continuing at a rapid rate, and these
numbers and discoveries are constantly being updated.
Epigenetics
 is the study of how genes are influenced by forces such as the environment, obesity, or
medication.
 
Nurses should consider how the client will use genetic and genomic information and be
prepared to provide support if clients experience moral or ethical issues. Most hospitals have
ethics committees, chaplains, pastoral teams, and other resources to assist clients facing moral
and ethical dilemmas.
The addition of genetics and genomics to the traditional nursing assessment will inform and
engage clients to make key decisions in their personal health care plan. By virtue of their race or
ethnicity, clients are sometimes said to be “at risk” for certain diseases.
 
The following genetic screenings may be useful to clients, nurses, and other members of the
health care team:
 Drug efficacy or sensitivity: Pharmacogenomics, the study of the role of inherited and
acquired genetic variation in drug response, is an evolving field that facilitates the
identification of biomarkers that can help health providers optimize drug selection, dose,
and treatment duration as well as eliminate adverse drug reactions.
 Carrier screening: Genetic tests can identify heterozygous carriers for many recessive
diseases such as cystic fibrosis, sickle cell disease, and Tay–Sachs disease. A couple may
wish to undergo carrier screening to help make reproductive decisions, especially in
populations where specific diseases are relatively common, for example, Tay–Sachs
disease in Ashkenazi Jewish populations and β-thalassemia in Mediterranean populations.
 Prenatal diagnosis: Amniocentesis is usually performed at 16 weeks’ gestation; chorionic
villus sampling (CVS) is carried out at 10 to 12 weeks’ gestation; preimplantation genetic
diagnosis (PGD) is carried out on early embryos (8 to 12 cells) prior to implantation; and
fetal DNA analysis in maternal circulation is done at 6 to 8 weeks’ gestation.
D. Review of Medications and Allergies
The review of medications includes all current prescription, over the counter, and home
remedies, including herbs that a client might purchase or grow in a home garden. During the
health history, note the name, dose, route of administration, schedule, frequency, purpose, and
length of time that each medicine that has been taken. Because of cultural differences in clients’
perceptions of what substances are considered medicines, it is important to ask about specific
items by name. Inquire about vitamins, birth control pills, aspirin, antacids, herbs, teas, inhalants,
poultices, vaginal and rectal suppositories, ointments, and any other items taken by the client for
therapeutic purposes. The nurse also gathers data on the client’s allergies to medicines and foods
warnings, such as contraindications (e.g., pregnancy, childhood, people with compromised
immune systems) and interactions with prescription drugs.
The client’s genetic makeup results in distinctive patterns of drug absorption,
metabolism, excretion, and effectiveness. Knowledge of clients’ individual genotypes guides
pharmacologic treatment and allows customization of choice of drug and dosage to ensure a
therapeutic response and avoid toxicity.
D. Reason for Seeking Care
The reason or reasons for seeking care refers to a brief statement in the client’s own
words describing why he/she is visiting a health care provider. This part of the health history
previously was called the chief complaint, a term that is now avoided because it focuses on
illness rather than wellness and tends to label the person as a complainer
Symptoms
 are defined as phenomena experienced by individuals that signify a departure from
normal function, sensation, or appearance.
Signs
 are objective abnormalities that the examiner can detect on physical examination or
through laboratory testing.
Assess the symptoms within the client’s sociocultural and ethnohistorical context. It is
important to use the same terms for symptoms that the client uses. For example, if the client
prefers to “swelling” of the leg, nurses should refrain from medicalizing that to “edema.”
Knowledge of the cultural expression of symptoms influences the decisions nurses make and will
facilitate their ability to provide culturally congruent and culturally competent nursing care.
E. Present Health and History of Present Illness
Although all illnesses are defined and conceptualized through the lens of culture, the
term culture-bound syndromes refer to more than 200 disorders created by personal, social,
and cultural reactions to malfunctioning biological or psychological processes and can be
understood only within defined contexts of meaning and social relationships
         When assessing clients with a culture-bound syndrome, it is important for the nurse to find
out what the client, family, and other concerned individuals believe is happening; what prior
efforts for help or cure have been tried; and what the results or outcomes from the treatment
were.
F. Past Health
 past illnesses may have residual effects on the current state of health or have sequelae
that appear many months or years later. For example, the varicella-zoster virus responsible for
chickenpox may remain latent until a person notices the characteristic rash or blisters of shingles;
chickenpox and shingles are caused by the same herpes zoster virus.
 the assessment of past illnesses includes other childhood conditions with known sequelae
such as rheumatic fever, scarlet fever, and poliomyelitis. The nurse also gathers information
about the date and nature of accidents, serious and chronic illnesses, hospitalizations, surgeries,
obstetric history, and the last examination.
G. Family and Social History
When conducting the family history, the nurse can refer to the table for conditions that
tend to be more prevalent among certain groups. If clients are aware that they are at increased
risk for a certain condition, they may seek early screening and periodic surveillance and may
choose to adopt a healthier life style, for example, stop smoking, exercise regularly, and/or lose
weight.
The health history should include in-depth data pertaining to the client’s family and/or
close social friends, including identification of key decision makers.
H. Review of Systems
The purpose of the review of systems is threefold:
(1) to evaluate the past and present health state of each body system,
(2) to provide an opportunity for the client to report symptoms not previously stated, and
(3) to evaluate health promotion practices.
 
For example, when reviewing the gastrointestinal system with clients from Native American,
Asian, African, and South American descent, the nurse should inquire about symptoms of lactose
intolerance, such diarrhea, nausea, vomiting, abdominal cramps, bloating, and flatus, usually
beginning 30 minutes to 2 hours after eating or drinking foods that contain lactose (e.g., milk,
cheese, and ice cream).
 
Lactose intolerance
 means that the body cannot easily digest lactose, a type of natural sugar found in milk
and dairy products. Some people who have lactose intolerance cannot digest any milk products.
 
Transcultural Perspectives on the Physical Examination
 
There are a number of biocultural variations that nurses may encounter when conducting the
physical examination of clients from different cultural backgrounds. Accurate assessment and
evaluation of clients requires knowledge of normal biocultural variations among healthy
members of selected populations, as well as variations that occur in illness. The data about
biocultural variations presented here are evidence based and reflect the findings of classic studies
that have been conducted over a period of years.
 
Biocultural Variations in Measurements
A. Height
In all groups, height increases up to 1.5 inches as socioeconomic status improves. First-
generation immigrants might be up to 1.5 inches taller than their counterparts in the country of
origin, due to better nutrition and decreased interference with growth by infectious diseases.

B. Body Proportions
Biocultural variations are found in the body proportions of individuals, largely because of
differences in bone length. In comparing sitting/standing height ratios, Blacks of both genders
have longer arms and legs and shorter trunks than Whites, Native Americans, or Asians. Because
proportionately most of the body’s weight is in the trunk, white men appear more obese than
their black counterparts. The reverse is true of women. Clients of Asian heritage are markedly
shorter, weigh less, and have smaller body frames than their White counterparts and/or the
overall population.
C. Weight
Biocultural differences exist in the amount of body fat and the distribution of fat
throughout the body. Generally, people from the lower socioeconomic class are more obese than
those from the middle class, who are more obese than members of the upper class. On average,
black men weigh less than their white counterparts throughout adulthood (166.1 pounds vs.
170.6 pounds).
The opposite is true of women. Black women are consistently heavier than white women
of every age (149.6 pounds vs. 137 pounds). Between the ages of 35 and 64 years, black women
weigh on average 20 pounds more than white women.
D. Vital Signs
Although the average pulse rate is comparable across cultures, there are racial and gender
differences in blood pressure. Black men have lower systolic blood pressures than their white
counterparts from ages 18 to 34, but between the ages of 35 and 64, it reverses: Blacks have an
average systolic blood pressure 5 mm Hg higher between 35 and 64 years of age. After age 65,
there is no difference between the two races. Black women have a higher average systolic blood
pressure than their white counterparts at every age. After age 45, the average blood pressure of
black women might be as much as 16 mm Hg higher than that of white women in the same age
group.
 
Biocultural Variations in the Assessment of Pain
Pain is the most frequent and compelling reason that people seek health care and is
sometimes referred to as the fifth vital sign.
Pain
 is defined as an unpleasant sensory and emotional experience conveyed by the brain
through sensory neurons arising from actual or potential tissue damage to the body.
 derived from the Greek word for penalty, pain is often associated with punishment in
Judeo–Christian thought.
a. acute pain
 a direct, one-to-one relationship exists between an injury and pain, and the pain is
frequently short-lived and self-limiting.
 cute pain, however, can become persistent and intractable if the underlying cause
continues for a prolonged period.
b. Chronic pain
 is described as pain that persists greater than 3 months. Chronic pain is now considered
the most frequent cause of disability in industrialized nations globally
 
Sensation threshold
 refers to the lowest stimulus that results in tingling or warmth.
Pain threshold
 refers to the point at which the individual reports that a stimulus is painful.
 
Pain assessment is influenced by three factors:
(1) characteristics of the client, such as race and ethnicity;
(2) the environmental context; and
(3) the nurse’s background and experience.
 
Nurses and other health care providers are challenged to avoid bias when assessing pain and to
take appropriate action commensurate with the level of self-reported pain.
 
Biocultural Variations in General Appearance
In assessing general appearance, survey the person’s entire body. Note the general health
state and any obvious physical characteristics and readily apparent biologic features unique to
the individual. In assessing the client’s general appearance, consider four areas: physical
appearance, body structure, mobility, and behavior.
 
Physical appearance
 includes age, gender, level of consciousness, facial features, and skin color (evenness of
color tone, pigmentation, intactness, and presence of lesions or other abnormalities).
Body structure
 includes stature, nutrition, symmetry, posture, position, and overall body build or
contour.
Mobility
 includes gait and range of motion.
Behavior
 includes such variables as facial expression, mood and affect, fluency of speech, ability to
communicate ideas, appropriateness of word choice, grooming, and attire or dress.
 
During the assessment, the nurse should:
 Note the nature of breath odor—sweet may suggest diabetic ketoacidosis (sickly sweet
smell), alcoholism (distinctive), liver failure (a sweet smell), or maple syrup urine
disease; unpleasant or foul may suggest renal failure (urine or fishlike breath due to
ammonia) and infections of the mouth, nose, pharynx, or chest (putrid odor).
 Examine state of teeth and teeth hygiene and note whether the teeth are real or false—
loose-fitting teeth may be responsible for mouth ulcers or decayed teeth, which may
cause halitosis (bad breath odor).
 Check the following tests results for indications of abnormalities:
- Blood tests such as full blood count and the erythrocyte sedimentation rate will be helpful in
determining the presence of infection.
- Renal function tests may suggest renal failure as cause of breath odor.
- Liver function tests may suggest hepatic coma as cause of breath odor.
- Blood sugar may suggest diabetic ketoacidosis as a cause of breath odor.
- Blood alcohol level to establish if alcoholism may be the cause of the breath odor.
 Urine analysis
- Glucose and ketones present may suggest diabetic ketoacidosis as cause of breath odor.
- Urine microscopy and culture may detect urinary tract infection.
 Culture of the mouth, gums, and nasopharynx may be necessary to diagnose anaerobic
infections that may be the cause of breath odor.
 Sputum microscopy and culture
 Vaginal or penile discharge swab for culture, if appropriate
 Stool tests
- Stool microscopy for ova, parasites, and culture for bacteria
- Giardia antigen
- Twenty-four-hour stool analysis of fecal fat—if steatorrhea is present (i.e., fatty, pale colored,
extremely smelly stools that float in the toilet and are difficult to flush away due to excess fat in
the stool)
 Radiological investigations
- X-ray or CT scan of chest or sinuses—if suspect respiratory infection as a cause of breath odor
- Esophagogram will help detect a diverticulum (a pouch opening from the esophagus) that may
cause bad breath odor
 
Biocultural Variations in Skin
An accurate and comprehensive examination of the skin of clients from culturally diverse
backgrounds requires knowledge of biocultural variations and skill in recognizing color changes,
some of which might be subtle. Awareness of normal biocultural differences and the ability to
recognize the unique clinical manifestations of disease are developed over time as the nurse
gains experience with clients with various skin color.

Mongolian spots

are irregular areas of deep blue pigmentation usually located in the sacral and gluteal areas but
sometimes occurring on the abdomen, thighs, shoulders, or arms.

during embryonic development, the melanocytes originate near the embryonic nervous system in the
neural crest. They then migrate into the fetal epidermis. Mongolian spots are embryonic pigment that
has been left behind in the epidermal layer during fetal development. The result looks like a bluish
discoloration of the skin.

are a normal variation in children of African, Asian, or Latin descent.

Vitiligo

a condition in which the melanocytes become nonfunctional in some areas of the skin, is characterized
by unpigmented, patchy, milky white skin patches that are often symmetric bilaterally.

affects an estimated 2 to 5 million Americans

Hyperpigmentation
other areas of the skin affected by hormones and, in some cases, differing for people from certain ethnic
backgrounds are the sexual skin areas, such as the nipples, areola, scrotum, and labia majora.

these areas are darker than other parts of the skin in both adults and children, especially among African
American and Asian clients.

when assessing these skin surfaces on dark-skinned clients, observe carefully for erythema, rashes, and
other abnormalities because the darker color might mask their presence.

Cyanosis

a severe condition indicating a lack of oxygen in the blood, cyanosis is the most difficult clinical sign to
observe in darkly pigmented persons.

because peripheral vasoconstriction can prevent cyanosis, be attentive to environmental conditions

such as air conditioning, mist tents, and other factors that might lower the room temperature and thus
cause vasoconstriction. For the client to manifest clinical evidence of cyanosis, the blood must contain 5
g of reduced hemoglobin in 1.5 g of methemoglobin per 100 mL of blood.

Jaundice

in both light- and dark-skinned clients, jaundice is best observed in the sclera. When examining culturally
diverse individuals, exercise caution to avoid confusing other forms of pigmentation with jaundice.

many darkly pigmented people, for example, African Americans, Filipinos, and others, have heavy
deposits of subconjunctival fat that contain high levels of carotene in sufficient quantities to mimic
jaundice. The fatty deposits become denser as the distance from the cornea increases. The portion of
the sclera that is revealed naturally by the palpebral fissure is the best place to accurately assess color. If
the palate does not have heavy melanin pigmentation, jaundice can be detected there in the early
stages (i.e., when the serum bilirubin level is 2 to 4 mg/100 mL).

Pallor
assessing for pallor in darkly pigmented clients can be difficult because the underlying red tones are
absent. This is significant because these red tones are responsible for giving brown or black skin its
luster. The brown-skinned individual will manifest pallor with a more yellowish brown color, and the
black-skinned person will appear ashen or gray.

generalized pallor can be observed in the mucous membranes, lips, and nail beds. The palpebrae,
conjunctivae, and nail beds are preferred sites for assessing the pallor of anemia. When inspecting the
conjunctiva, lower the lid sufficiently to see the conjunctiva near the inner and outer canthi. The
coloration is often lighter near the inner canthus.

Erythema, Petechiae, and Ecchymoses

Erythema (redness)

can also be difficult to assess in darkly pigmented clients because the contrast between white and red is
more pronounced than it is when the skin color is darker.

Erythema is frequently associated with localized inflammation and is characterized by increased skin
temperature.

Petechiae

are best visualized in the areas of lighter melanization, such as the abdomen, buttocks, and volar surface
of the forearm. When the skin is black or very dark brown, petechiae cannot be seen in the skin. Most of
the diseases that cause bleeding and the formation of microscopic emboli, such as thrombocytopenia,
subacute bacterial endocarditis, and other septicemias, are characterized by petechiae in the mucous
membranes and skin.

Petechiae are most easily seen in the mouth, particularly the buccal mucosa, and in the conjunctiva of
the eye

Ecchymoses
caused by systemic disorders are found in the same locations as petechiae, although their larger size
makes them more apparent on dark-skinned individuals.

when differentiating petechiae and ecchymoses from erythema in the mucous membrane, pressure on
the tissue will momentarily blanch erythema but not petechiae or ecchymoses.

Addison’s Disease

the cortisol deficiency characteristic of Addison’s disease causes an increase in melanin production,
which turns the skin a bronze color that resembles sun tan. The nipples, areola, genitalia, perineum, and
pressure points such as the axillae, elbow, inner thighs, and buttocks look bronze.

Addison’s disease is very difficult to recognize in people with darkly pigmented skin; therefore,
laboratory tests and other clinical manifestations of the disease should be used to corroborate the skin
changes.

Uremia
 is the illness accompanying kidney failure characterized by unexplained changes in
extracellular volume, inorganic ion concentrations, or lack of known renal synthetic
products.
 Uremic illness is due largely to the accumulation of organic waste products, not all
identified, that are normally cleared by the kidneys.
Albinism
 the term albinism refers to a group of inherited conditions. People with albinism have
little or no pigment in their eyes, skin, or hair. They have inherited altered genes that do
not make the usual amounts of the pigment melanin.
 Vision problems are associated with all forms of albinism. People with albinism always
have impaired vision (not correctable with eye glasses) and many have low vision.

 
Biocultural Variations in Sweat Glands
The apocrine and eccrine sweat glands are important for fluid balance and
thermoregulation. Approximately 2 to 3 million glands open onto the skin surface through pores
and are responsible for the presence of sweat. When glands are contaminated by normal skin
flora, odor results. Most Asians and Native Americans have a mild to absent body odor, whereas
Whites and African Americans tend to have strong body odor.
 
Biocultural Variation in the Head
 Nurses will notice marked, biocultural variations when examining the hair, eyes, ears,
and mouths of clients from diverse racial and ethnic backgrounds. The ability to distinguish
normal variations from abnormal ones could have serious implications as some variations are
associated with systemic sometimes life-threatening conditions.
A. Hair
Perhaps one of the most obvious and widely variable cultural differences occurs with
assessment of the hair. African American hair varies widely in texture. It is very fragile and
ranges from long and straight to short, spiraled, thick, and kinky. The hair and scalp have a
natural tendency to be dry and require daily combing, gentle brushing, and the application of oil.
By comparison, clients of Asian backgrounds generally have straight, silky hair.
B. Eyes
Biocultural differences in both the structure and the color of the eyes are readily apparent
among clients from various cultural backgrounds. Racial differences are evident in the palpebral
fissures. Persons of Asian background are often identified by their characteristic epicanthal eye
folds, whereas the presence of narrowed palpebral fissures in non-Asian individuals might be
diagnostic of a serious congenital anomaly known as Down syndrome or trisomy 21.
C. Ears
Asians and Native Americans (including Eskimos) have an 84% frequency of dry
cerumen. Wet cerum is found in 99% of African Americans and 97% of Whites. The clinical
significance of this occurs when examining or irrigating the ears; the presence and composition
of cerumen are not related to poor hygiene, and flaky, dry cerumen should not be mistaken for
the dry lesions of eczema.
D. Mouth
Oral hyperpigmentation also shows variation by race. Usually absent at birth,
hyperpigmentation increases with age. By age 50, 10% of Whites and 50% to 90% of African
Americans will show oral hyperpigmentation, a condition believed to be caused by a lifetime of
accumulation of post inflammatory oral changes.
 
Cleft uvula
 a condition in which the uvula is split either completely or partially, occurs in 18% of
some Native American groups and 10% of Asians.
Leukoedema
 a grayish-white benign lesion occurring on the buccal mucosa, is present in 68% to 90%
of blacks and 43% of whites.
 
E. Teeth
Teeth are often used as indicators of developmental, hygienic, and nutritional adequacy,
and there are important biocultural differences. It is rare for a White baby to be born with teeth
(1 in 3,000), but the incidence is 1 in 11 among Tlingit Indian infants and 1 or 2 in 100 among
Canadian Aboriginal infants. Although congenital teeth are usually not problematic, extraction is
necessary for some breast-fed infants.
                The size of teeth varies widely, with the teeth of Whites being the smallest, followed
by Blacks and then Asians and Native Americans. The largest teeth are found among Native
Alaskans and Australian Aborigines. Larger teeth cause some groups to have prognathic
(protruding) jaws, a condition that is seen more frequently in African and Asian Americans. The
condition is normal and does not reflect a serious orthodontic problem.
Agenesis (absence of teeth) varies by race, with missing third molars occurring in 18%
to 35% of Asians, 9% to 25% of Whites, and 1% to 11% of Blacks. Throughout life, whites have
more tooth decay than blacks, which might be related to a combination of socioeconomic factors
and biocultural variation.
 
Biocultural Variations in the Mammary Venous Plexus
Regardless of gender, the superficial veins of the chest form a network over the entire
chest that flows in either a transverse or a longitudinal pattern.
1. In the transverse pattern, the veins radiate laterally and toward the axillae.
2. In the longitudinal pattern, the veins radiate downward and laterally like a fan.
Biocultural Variations in the Musculoskeletal System
Many normal biocultural variations are found in clients’ musculoskeletal systems. The
long bones of blacks are significantly longer, narrower, and denser than those of whites. Bone
density measured by race and gender shows that black males have the densest bones, accounting
for the relatively lower incidence of osteoporosis and hip fractures in this population. Similarly,
Black women have lower incidence of these two conditions when compared with Hispanic and
White women.
As the largest component of adipose tissue-free body mass in humans, skeletal muscle is
central to the body’s nutritional, physiologic, and metabolic processes. Between the ages of 18
and 80 years, Blacks have more skeletal muscle than White, Hispanic, and Asian counterparts
across the entire age range, even when adjusting for weight and height. Body composition should
be interpreted according to ethnicity and gender. Different standards for skeletal muscle should
be applicable for multiethnic populations.
 
Biocultural Variations in Illness
Researchers have abundant evidence that there is a relationship between ethnicity and the
incidence of certain diseases across the lifespan, from infancy to old age. Knowledge of normal
biocultural variations and those occurring during illness helps nurses to conduct more accurate,
comprehensive, and thorough physical examinations of clients from diverse cultures.
 
Biocultural Variations in Laboratory Tests
 Biocultural variations occur with some laboratory tests, such as measurement of
hemoglobin, hematocrit, cholesterol, serum transferrin, blood glucose, creatinine, and estimated
glomerular filtration rate. There are also biocultural differences in the results of tests conducted
during pregnancy. For example, the multiple marker screening test and two tests of amniotic
fluid constituents are routinely used to screen pregnant women for potential fetal problems.
 
Transcultural Perspectives in Clinical Decision Making and Actions
1. Cultural care preservation or maintenance refers to those professional actions and
decisions that help people of a particular culture to retain and/or preserve relevant care
values so that they can maintain their well-being, recover from illness, or face handicaps
and/or death.
2. Cultural care accommodation or negotiation refers to professional actions and
decisions that help people of a designated culture to adapt to or to negotiate with others
for beneficial or satisfying health outcomes with professional care professional.
3. Cultural care repatterning or restructuring refers to professional actions and decisions
that help clients reorder, change, or greatly modify their lifeways for new, different, and
beneficial health care patterns while respecting the clients’ cultural values and beliefs and
yet providing more beneficial or healthier lifeways than before the changes were co-
established with the clients.
 
Once the plan has been implemented, it should be evaluated in collaboration with the client,
the client’s family and significant others, and with other credentialed, licensed, folk, traditional,
religious, and spiritual healers who are members of the team. The evaluation includes a
comprehensive analysis of the plan’s effectiveness in meeting mutually established goals and
desired outcomes.

Culture Belief System

Cultural meanings and cultural belief systems develop from the shared
experiences of a social group and are expressed symbolically. The use of symbols to
define, describe, and relate to the world around us is one of the basic characteristics of
being human
 
Health Belief System
Generally, theories of health and disease or illness causation are based on a
group’s prevailing worldview. These worldviews include a group’s health-related
attitudes, beliefs, and practices, frequently referred to as health belief systems. People
embrace three major health belief systems or worldviews: magico-religious, scientific (or
biomedical), and holistic, each with its own corresponding system of health beliefs. In two
of these worldviews (magico-religious and holistic), disease is thought of as an entity
separate from self, caused by an agent external to the body but capable of “getting in”
and causing damage.
Three Major Health Belief System:
A. Magico-Religious Health Paradigm
 the world is an arena dominated by supernatural forces.
 humans, depends on the actions of God, the gods, or other supernatural forces for
good or evil.
 the human individual is at the mercy of such forces regardless of behavior.
 the gods punish humans for their transgressions.
 
Many Latino, African American, and Middle Eastern cultures are grounded in the
magico-religious paradigm. Magic involves the calling forth and control of supernatural
forces for and against others.
Some African and Caribbean cultures, such as Voodoo, have aspects of magic in their
belief systems.
Western cultures, there are examples of this paradigm in which metaphysical reality
interrelates with human society. For instance, Christian Scientists believe that physical
healing can be effected through prayer alone.
 
Magic and religion are logical in their own way, but not based on empiric premises;
that is, they defy the demands of the physical world and the use of one’s senses,
particularly observation. In the magico-religious paradigm, disease is viewed as the
action and result of supernatural forces that cause the intrusion of a disease-producing
foreign body or health-damaging spirit.
In the magico-religious paradigm, illness is initiated by a supernatural agent with or
without justification, or by another person who practices sorcery or engages the services
of sorcerers. The cause-and-effect relationship is not organic; rather, the cause of health
or illness is mystical. Health is seen as a reward given as a sign of God’s blessing and
goodwill. Illness may be seen as a sign of God’s special favor insofar as it gives the
affected person the opportunity to become resigned to God’s will, or it may be seen as a
sign of God’s possession or as a punishment. For example, in many Christian religions,
the faithful gather communally to pray to God to heal those who are ill or to practice
healing rituals such as laying on of hands or anointing the sick with oil.
In addition, in this paradigm, health and illness are viewed as belonging first to the
community and then to the individual. Therefore, one person’s actions may directly or
indirectly influence the health or illness of another person. This sense of community is
virtually absent from the other paradigms.

B. Scientific or Biomedical Health Paradigm

  life is controlled by a series of physical and biochemical processes that can
be studied and manipulated by humans.
 
Specific forms of symbolic:
1. Determinism
- which states that a cause-and-effect relationship exists for all natural phenomena
2. Mechanism
- assumes that it is possible to control life processes through mechanical, genetic, and
other engineered interventions.
3. Reductionism
- according to which all life can be reduced or divided into smaller parts; study of the
unique characteristics of these isolated parts is thought to reveal aspects or properties of
the whole, for example, the human genome and its component parts.
4. Objective materialism
- which states that what is real can be observed and measured. There is a further
distinction between subjective and objective realities in this paradigm.
Biomedical model
- refers to when the scientific paradigm is applied to matters of health.
- all aspects of human health can be understood through the natural sciences, biology,
chemistry, physics, and mathematics.
 disease is viewed metaphorically as the breakdown of the human machine
because of wear and tear (stress), external trauma (injury, accident), external
invasion (pathogens), or internal damages (fluid and chemical imbalances,
genetic or other structural changes).

C. Holistic Health Paradigm

 the forces of nature itself must be kept in natural balance or harmony.
 health is viewed as a positive process that encompasses more than the
absence of signs and symptoms of disease.
 seeks to maintain a sense of balance between humans and the larger
universe. Explanations for health and disease are based on imbalance or
disharmony among the human, geophysical, and metaphysical forces of the
universe.
Holistic
- coined in 1926 by Jan Christian Smuts
- an attitude or mode of perception in which the whole person is viewed in the context of
the total environment
- Indo-European root word, kailo, means “whole, intact, or uninjured.” From this root
have come the words hale, hail, hallow, holy, whole, heal, and health.
 
Metaphors used in this paradigm:
1. healing power of nature, health foods, and Mother Earth
2. yin and yang
Yin - force in the universe represents the female aspect of nature
      - is characterized as the negative pole, encompassing darkness, cold, and emptiness.
Yang - or male force
         - is characterized by fullness, light, and warmth. It represents the positive pole.
3. hot/cold theory of disease.
- is founded on the ancient Greek concept of the four body humors: yellow bile, black
bile, phlegm, and blood

Health and Illness Behavior

The series of behaviors typifying the health-seeking process have been labeled
health and illness behaviors. These behaviors are expressed in the roles people assume
after identifying a symptom. Related to these behaviors are the roles individuals assign
to others and the status given to the role players.
 
Health behavior
- is any activity undertaken by a person who believes himself or herself to be healthy for
the purpose of preventing disease or detecting disease in an asymptomatic stage.
Illness behavior
- is any activity undertaken by a person who feels ill to define the state of his or her
health and discover a suitable remedy.
Sick role behavior
- is any activity undertaken by a person who considers himself ill to get well or to deal
with the illness.
 
Three sets of factors influence the course of behaviors and practices carried out to
maintain health and prevent disease:
(1) one’s beliefs about health and illness;
(2) personal factors such as age, education, knowledge, or experience with a given
disease condition; and
(3) cues to action, such as advertisements in the media, the illness of a relative, or the
advice of friends.
 
Mechanic’s Determinants of Illness Behavior

Types of Healing System

The term healing system refers to the accumulated sciences, arts, and techniques of
restoring and preserving health that are used by any cultural group.
1. Professional Care Systems
- also referred to as scientific or biomedical systems, are formally taught, learned, and
transmitted professional care, health, illness, wellness, and related knowledge and
practice skills that prevail in professional institutions, usually with multidisciplinary
personnel to serve consumers.
2. Folk Healing System
 - is a set of beliefs that has a shared social dimension and reflects what people actually
do when they are ill versus what society says they ought to do according to a set of social
standards.
3. Complementary, Integrative, and Alternative Health System
- is an umbrella term for hundreds of therapies based on health care systems of people
from around the world.
- Allopathic or biomedicine is the reference point, with all other therapies being
considered complementary (in addition to), integrative (combined with selected magico-
religious or holistic therapies whose efficacy has been scientifically documented), or
alternative to (instead of).
a. Integrative health care
- is defined as a comprehensive, often interdisciplinary approach to treatment,
prevention, and health promotion that brings together complementary and conventional
therapies.
b. Complementary Health Approaches
 Alternative medical systems are built on complete systems of theory and
practice. Examples of alternative medical systems that have developed in
 Western cultures include homeopathic medicine and naturopathic medicine.
Examples of systems that have developed in Eastern cultures include traditional
Chinese medicine and Ayurveda, which originated in India.
 Natural Products include herbs (also known as botanicals), vitamins, minerals,
and probiotics. They are often marketed to the public as dietary supplements.
 Mind and body practices include a diverse group of techniques administered by a
trained practitioner or teacher that are designed to enhance the mind’s capacity
to affect bodily functions and symptoms.
 Manipulative and body-based methods are based on manipulation and/or
movement of one or more parts of the body. Some examples include chiropractic
or osteopathic manipulation and massage therapy
 Energy therapies involve the use of energy fields in two ways:
 Biofield therapies are intended to affect energy fields that surround
and penetrate the human body. (The existence of such fields has not yet
been scientifically proven.) Some forms of energy therapy manipulate
biofields by applying pressure and/ or manipulating the body by placing
the hands in, or through, these fields. Examples include qigong, Reiki,
and Therapeutic Touch.
 Bioelectromagnetic-based therapies involve the unconventional
use of electromagnetic fields, such as pulsed fields, magnetic fields, or
alternating-current or direct-current fields.
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PRELIM WEEK 5
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Learning Content
At the end of this module, students will be able to:
 Analyze how culture influences the beliefs and behaviors of the childbearing
woman and her family during pregnancy.
 Recognize the childbearing beliefs and practices of diverse cultures.
 Examine the needs of women making alternative lifestyle choices regarding
childbirth and child rearing.
 Explore how cultural ideologies of childbearing populations can impact
pregnancy outcomes.

Overview of Cultural Belief Systems and Practices to

Childbearing
 In light of global population shifts that are likely to continue for years to come,
cultural beliefs regarding childbearing and childrearing need to be examined to enable
nurses to offer our patients culturally congruent care throughout their pregnancy, birth,
and the early postpartum.
The dominant cultural practices or rituals include formal prenatal care (including
childbirth classes), ultrasonography to view the fetus, and hospital delivery. Hospital
deliveries routinely involve a highly specialized group of nurses, obstetricians,
perinatologists, and pediatricians who actively monitor the mother’s physiologic status
and the fetal status, deliver the infant, and provide postpartum and newborn care.
Routine hospital care can also include inducing labor, providing anesthesia for labor
and delivery, and performing a cesarean section.
 
Fertility Control and Culture
A. Unintended Pregnancy
Among women aged 19 years and younger, more than four out of five pregnancies
were unintended. The proportion of pregnancies that were unintended was highest
among teens younger than age 15 years, at 98%. Among women aged 19 years and
younger, more than four out of five pregnancies were unintended. The proportion of
pregnancies that were unintended was highest among teens younger than age 15 years,
at 98%.
                Women more likely to experience unintended births included unmarried
women, black women, women who are socioeconomically disadvantaged, and those with
less education.
Unintended pregnancy can have numerous negative effects on the mother and
the fetus, including a delay in prenatal care, continued or increased tobacco and other
drug use, as well as increased physical abuse during pregnancy; any of these factors can
lead to preterm labor or low-birth-weight (LBW) infants.
 
Consideration must also be given to what is influencing unintended pregnancy:
- changes in social mores sanctioning motherhood outside of marriage
- contraception availability including abortion
- earlier sexual activity, and multiple partners

B. Contraceptive Methods
 Commonly used methods of contraception include hormonal methods,
intrauterine devices (IUDs), permanent sterilization, and, to a lesser degree,
barrier and “natural” methods.
  Natural methods of family planning are based on the recognition of fertility
through signs and symptoms and abstinence during periods of fertility.
 The religious beliefs of some cultural groups might affect their use of fertility
controls such as abortion or artificial regulation of conception; for example,
Roman Catholics might follow church edicts against artificial control of
conception, and Mormon families might follow their church’s teaching regarding
the spiritual responsibility to have large families and promote church growth.
The ability to control fertility successfully also requires an understanding of the
menstrual cycle and the times and conditions under which pregnancy is more or less
likely to occur—in essence, an understanding of bodily functions. When these functions
change, the woman might perceive the changes as abnormal or unhealthy. Because the
use of artificial methods of fertility control might alter the body’s usual cycles, women
who use them might become anxious, consider themselves ill, and discontinue the
method.

C. Refugees and Reproductive Health

Rwandan crisis in 1994
- an estimated 26 million individuals have been displaced across international borders
(as of mid-2013) as part of a mass exodus from their homes due to war, ethnic and civil
unrest, and political instability.
CDC Refugee Reproductive Health Activities Goals:
1. Initiate epidemiologic studies to evaluate the reproductive health status of women in
refugee and IDP settings to better provide information to improve service, quality, and
accessibility.
2. Design, implement, and evaluate reproductive health rapid assessment tools and
behavioral and epidemiologic surveillance systems appropriate to refugee settings.
3. Design, recommend, and evaluate interventions and “best practices” identified
through epidemiologic research, rapid assessment, and surveillance.
4. Strengthen the capacity of the refugee/IDP community, as well as the agencies
providing health services, to collect and use data to improve reproductive health status
and services.
5. Translate and communicate study findings and best practices to refugees and
supporting agencies.
 
D. Religion and Fertility Control
The influence of religious beliefs on birth control choices varies within and
between groups, and adherence to these beliefs may change over time. Cultural practices
tend to arise from religious beliefs, which can influence birth control choices. For
example, the Hindu religion teaches that the right hand is clean and the left is dirty. The
right hand is for holding religious books and eating utensils, and the left hand is used for
dirty things, such as touching the genitals. This belief complicates the use of
contraceptives requiring the use of both hands, such as a diaphragm.

E. Cultural Influences on Fertility Control

It is common for health professionals to have misconceptions about contraception and
the prevention of pregnancy in cultures different from their own.
Nurses providing family planning services must take care to be culturally sensitive so
that women can be assisted in examining their own attitudes, beliefs, and sense of gynecologic
well-being regarding fertility control.
 

Pregnancy and Culture

All cultures recognize pregnancy as a special transition period, and many have particular
customs and beliefs that dictate activity and behavior during pregnancy.
A. Biologic Variations
Knowledge of certain biologic variations resulting from genetic and environmental
backgrounds is important for nurses who care for childbearing families.
Example:
Pregnant women who have:
- the sickle cell trait and are heterozygous for the sickle cell gene are at increased risk for
asymptomatic bacterial and urinary tract infections such as pyelonephritis.
- diabetes mellitus
 
B. Cultural Variations Influencing Pregnancy
Nurses must be able to differentiate among beliefs and practices that are harmful and
those that are benign. Few cultural customs related to pregnancy are dangerous and many are
health promoting.
1. Alternative Lifestyle Choices
Many of today’s women are career oriented, and they may delay childbirth until after
they have finished college and established their career. Some women are making choices
regarding childbearing that might not involve the conventional method of conception and
childrearing.
Lesbian childbearing couples are a distinct subculture of pregnant women with special
needs. The most common fear reported by lesbian mothers is the fear of unsafe and inadequate
care from the practitioner once the mother’s sexual orientation is revealed. Reluctance to
disclose sexual orientation to one’s health care provider can act as a barrier to a woman
receiving appropriate services and referrals.
Four areas that are significant in regard to lesbians considering parenting:
(a) sexual orientation disclosure to providers and finding sensitive caregivers,
(b) conception options,
(c) assurance of partner involvement, and
(d) how to legally protect both the parents and the child.
2. Maternal Role Attainment
Maternal role attainment is often taken for granted in Western culture. If you give birth
and become a mother, the assumption is that you automatically become “maternal” and
successfully care for and nurture your infant. However, many factors can affect maternal role
attainment, including separation of mother and infant in cases such as illness, incarceration, or
adoption, to name only a few.
Six internal and external factors used to assist in attainment:
(a) setting a purpose of raising their babies;
(b) keeping their chronic illness status secret;
(c) maintaining feelings of autonomy and optimism by living as if nothing were wrong, that is,
normalization;
(d) belief of quality versus quantity of support from husbands, mothers, or sisters;
(e) hope for a cure; and
(f) belief that their secret is safe with their health care providers.

Learning Content
At the end of this module, students will be able to:
 Analyze how culture influences the beliefs and behaviors of the childbearing woman and
her family during pregnancy.
 Recognize the childbearing beliefs and practices of diverse cultures.
 Examine the needs of women making alternative lifestyle choices regarding childbirth
and child rearing.
 Explore how cultural ideologies of childbearing populations can impact pregnancy
outcomes.

Overview of Cultural Belief Systems and Practices to

Childbearing
 In light of global population shifts that are likely to continue for years to come, cultural
beliefs regarding childbearing and childrearing need to be examined to enable nurses to offer
our patients culturally congruent care throughout their pregnancy, birth, and the early
postpartum.
The dominant cultural practices or rituals include formal prenatal care (including
childbirth classes), ultrasonography to view the fetus, and hospital delivery. Hospital deliveries
routinely involve a highly specialized group of nurses, obstetricians, perinatologists, and
pediatricians who actively monitor the mother’s physiologic status and the fetal status, deliver
the infant, and provide postpartum and newborn care. Routine hospital care can also include
inducing labor, providing anesthesia for labor and delivery, and performing a cesarean section.
 

Fertility Control and Culture

A. Unintended Pregnancy
Among women aged 19 years and younger, more than four out of five pregnancies were
unintended. The proportion of pregnancies that were unintended was highest among teens
younger than age 15 years, at 98%. Among women aged 19 years and younger, more than four
out of five pregnancies were unintended. The proportion of pregnancies that were unintended
was highest among teens younger than age 15 years, at 98%.
                Women more likely to experience unintended births included unmarried women, black
women, women who are socioeconomically disadvantaged, and those with less education.
 Unintended pregnancy can have numerous negative effects on the mother and the fetus,
including a delay in prenatal care, continued or increased tobacco and other drug use, as well as
increased physical abuse during pregnancy; any of these factors can lead to preterm labor or
low-birth-weight (LBW) infants.
 
Consideration must also be given to what is influencing unintended pregnancy:
- changes in social mores sanctioning motherhood outside of marriage
- contraception availability including abortion
- earlier sexual activity, and multiple partners

B. Contraceptive Methods
 Commonly used methods of contraception include hormonal methods, intrauterine
devices (IUDs), permanent sterilization, and, to a lesser degree, barrier and “natural”
methods.
 Natural methods of family planning are based on the recognition of fertility through
signs and symptoms and abstinence during periods of fertility.
 The religious beliefs of some cultural groups might affect their use of fertility controls
such as abortion or artificial regulation of conception; for example, Roman Catholics
might follow church edicts against artificial control of conception, and Mormon families
might follow their church’s teaching regarding the spiritual responsibility to have large
families and promote church growth.
The ability to control fertility successfully also requires an understanding of the menstrual
cycle and the times and conditions under which pregnancy is more or less likely to occur—in
essence, an understanding of bodily functions. When these functions change, the woman might
perceive the changes as abnormal or unhealthy. Because the use of artificial methods of fertility
control might alter the body’s usual cycles, women who use them might become anxious,
consider themselves ill, and discontinue the method.
C. Refugees and Reproductive Health
Rwandan crisis in 1994
- an estimated 26 million individuals have been displaced across international borders (as of
mid-2013) as part of a mass exodus from their homes due to war, ethnic and civil unrest, and
political instability.
CDC Refugee Reproductive Health Activities Goals:
1. Initiate epidemiologic studies to evaluate the reproductive health status of women in refugee
and IDP settings to better provide information to improve service, quality, and accessibility.
2. Design, implement, and evaluate reproductive health rapid assessment tools and behavioral
and epidemiologic surveillance systems appropriate to refugee settings.
3. Design, recommend, and evaluate interventions and “best practices” identified through
epidemiologic research, rapid assessment, and surveillance.
4. Strengthen the capacity of the refugee/IDP community, as well as the agencies providing
health services, to collect and use data to improve reproductive health status and services.
5. Translate and communicate study findings and best practices to refugees and supporting
agencies.
 
D. Religion and Fertility Control
The influence of religious beliefs on birth control choices varies within and between
groups, and adherence to these beliefs may change over time. Cultural practices tend to arise
from religious beliefs, which can influence birth control choices. For example, the Hindu
religion teaches that the right hand is clean and the left is dirty. The right hand is for holding
religious books and eating utensils, and the left hand is used for dirty things, such as touching
the genitals. This belief complicates the use of contraceptives requiring the use of both hands,
such as a diaphragm.

E. Cultural Influences on Fertility Control

It is common for health professionals to have misconceptions about contraception and
the prevention of pregnancy in cultures different from their own.
Nurses providing family planning services must take care to be culturally sensitive so
that women can be assisted in examining their own attitudes, beliefs, and sense of gynecologic
well-being regarding fertility control.
 

Pregnancy and Culture

All cultures recognize pregnancy as a special transition period, and many have particular
customs and beliefs that dictate activity and behavior during pregnancy.
A. Biologic Variations
Knowledge of certain biologic variations resulting from genetic and environmental
backgrounds is important for nurses who care for childbearing families.
Example:
Pregnant women who have:
- the sickle cell trait and are heterozygous for the sickle cell gene are at increased risk for
asymptomatic bacterial and urinary tract infections such as pyelonephritis.
- diabetes mellitus
 
B. Cultural Variations Influencing Pregnancy
 Nurses must be able to differentiate among beliefs and practices that are harmful and
those that are benign. Few cultural customs related to pregnancy are dangerous and many are
health promoting.
1. Alternative Lifestyle Choices
Many of today’s women are career oriented, and they may delay childbirth until after
they have finished college and established their career. Some women are making choices
regarding childbearing that might not involve the conventional method of conception and
childrearing.
Lesbian childbearing couples are a distinct subculture of pregnant women with special
needs. The most common fear reported by lesbian mothers is the fear of unsafe and inadequate
care from the practitioner once the mother’s sexual orientation is revealed. Reluctance to
disclose sexual orientation to one’s health care provider can act as a barrier to a woman
receiving appropriate services and referrals.
Four areas that are significant in regard to lesbians considering parenting:
(a) sexual orientation disclosure to providers and finding sensitive caregivers,
(b) conception options,
(c) assurance of partner involvement, and
(d) how to legally protect both the parents and the child.
2. Maternal Role Attainment
Maternal role attainment is often taken for granted in Western culture. If you give birth
and become a mother, the assumption is that you automatically become “maternal” and
successfully care for and nurture your infant. However, many factors can affect maternal role
attainment, including separation of mother and infant in cases such as illness, incarceration, or
adoption, to name only a few.
Six internal and external factors used to assist in attainment:
(a) setting a purpose of raising their babies;
(b) keeping their chronic illness status secret;
(c) maintaining feelings of autonomy and optimism by living as if nothing were wrong, that is,
normalization;
(d) belief of quality versus quantity of support from husbands, mothers, or sisters;
(e) hope for a cure; and
(f) belief that their secret is safe with their health care providers.
3. Nontraditional support systems
A cultural variation that has important implications is a woman’s perception of the need
for formalized assistance from health care providers during the antepartum period. Western
medicine is generally perceived as having a curative rather than a preventive focus. Indeed,
many health care providers view pregnancy as a physiologic state that at any moment will
become pathologic. Because many cultural groups perceive pregnancy as a normal physiologic
process, not seeing pregnant women as ill or in need of the curative services of a doctor, women
in these diverse groups often delay seeking, or even choose not to seek, prenatal care.
4. A number of factors influence childbearing practices for Filipino women including
cultural beliefs, socioeconomic factors, and, in recent years, Western medicine.
Approximately 41% of Filipino births are supported by indigenous attendants
called hilots. The attendants act as a consultant throughout the pregnancy. During the
postpartum period, the hilot performs a ritualistic sponge bath with oils and herbs, which
is believed to have both physical and psychological benefits.
5. In Arab countries, labor and delivery is considered the business of women.
Traditionally, dayahs and midwives presided over home deliveries. The dayahs provide
support during the pregnancy and labor and are considered by traditional Arab women
to be most knowledgeable due to their experience in caring for other pregnant women.
Hospital births are on the rise in most Arab countries, with a decrease in the number of
traditional home births
4. Cultural beliefs related to parental activity during pregnancy
Cultural variations also involve beliefs about activities during pregnancy. A belief is
something held to be actual or true on the basis of a specific rationale or explanatory model.
Prescriptive beliefs
- which are phrased positively, describe what should be done to have a healthy baby; the more
common
Cultural Beliefs Regarding Activity and Pregnancy:
● Remain active during pregnancy to aid the baby’s circulation (Crow Indian)
● Keep active during pregnancy to ensure a small baby and an easy delivery (Mexican and
Cambodian)
● Remain happy to bring the baby joy and good fortune (Pueblo and Navajo Indian, Mexican,
Japanese)
● Sleep flat on your back to protect the baby (Mexican)
● Continue sexual intercourse to lubricate the birth canal and prevent a dry labor (Haitian,
Mexican)
● Continue daily baths and frequent shampoos during pregnancy to produce a clean baby
(Filipino)
Restrictive beliefs
- which are phrased negatively, limit choices and behaviors and are practices/behaviors that the
mother should not do in order to have a healthy baby.
Cultural Beliefs Regarding Activity and Pregnancy:
● Avoid cold air during pregnancy to prevent physical harm to the fetus (Mexican, Haitian,
Asian)
● Do not reach over your head or the cord will wrap around the baby’s neck (African American,
Hispanic, White, Asian)
● Avoid weddings and funerals or you will bring bad fortune to the baby (Vietnamese)
● Do not continue sexual intercourse or harm will come to you and baby (Vietnamese, Filipino,
Samoan)
● Do not tie knots or braid or allow the baby’s father to do so because it will cause difficult labor
(Navajo Indian)
● Do not sew (Pueblo Indian, Asian)
Taboos
- restrictions with serious supernatural consequences, are practices believed to harm the baby or
the mother.
Cultural Beliefs Regarding Activity and Pregnancy
● Avoid lunar eclipses and moonlight or the baby might be born with a deformity (Mexican)
● Do not walk on the streets at noon or 5 o’clock because this might make the spirits angry
(Vietnamese)
● Do not join in traditional ceremonies like Yei or Squaw dances or spirits will harm the baby
(Navajo Indian)
● Do not get involved with persons who cast spells or the baby will be eaten in the womb
(Haitian)
● Do not say the baby’s name before the naming ceremony or harm might come to the baby
(Orthodox Jewish)
● Do not have your picture taken because it might cause stillbirth (African American)
● During the postpartum period, avoid visits from widows, women who have lost children, and
people in mourning because they will bring bad fortune to the baby (South Asian Canadian)
5. Food taboos and cravings.
Many cultures traditionally believed that the mother had little control over the outcome
of pregnancy except through the avoidance of certain foods. Another traditional belief in many
cultures is that a pregnant woman must be given the food that she smells to eat; otherwise, the
fetus will move inside of her and a miscarriage will result. Spicy, cold,andsour  foods are often
believed to be foods that a pregnant woman should avoid during pregnancy.
 
C. Cultural Issues Impacting Prenatal Care
1. Cultural Interpretation of Obstetric Testing
Many women do not understand the emphasis that Western prenatal care places on
urinalysis, blood pressure readings, and abdominal measurements. For traditional Islamic
women from the Middle East, the vaginal examination can be so intrusive and embarrassing
that they avoid prenatal visits or request a female physician or midwife.
For women of other cultural groups, common discomforts of pregnancy might be
managed with folk, herbal, home, or over-the-counter remedies on the advice of a relative
(generally the maternal grandmother) or friends.
2. Cultural Preparation for Childbirth
Women from diverse cultural backgrounds often use culturally appropriate ways of
preparing for labor and delivery. These methods might include assisting with childbirth from the
time of adolescence, listening to birth and baby stories told by respected elderly women, or
following special dietary and activity prescriptions during the antepartal period. Most
commonly in American culture, pregnant women and their significant others attend childbirth
classes/or get pregnancy information from the Internet.
Preparation for childbirth can be developed through programs that allow for cultural
variations, including classes during and after the usual clinic hours in busy urban settings, teen-
only classes, single-mother classes, group classes combined with prenatal checkups at home,
classes on rural reservations, and presentations that incorporate the older “wise women” of the
community. In addition, nurses can organize classes in languages other than English and
conduct these classes in community settings that are culturally appropriate and welcoming to
women.
 
D. Birth and Culture
Beliefs and customs surrounding the experience of labor and delivery can vary, despite
the fact that the physiologic processes are basically the same in all cultures. Factors such as
cultural attitudes toward the achievement of birth, methods of dealing with the pain of labor,
recommended positions during delivery, the preferred location for the birth, the role of the
father and the family, and expectations of the health care practitioner might vary according to
the degree of acculturation to Western childbirth customs, geographic location, religious beliefs,
and individual preference.
9. Traditional Home Birth
All cultures have an approach to birth rooted in a tradition of home birth, being within
the province of women. A dependence on self-management, a belief in the normality of labor
and birth, and a tradition of delivery at home might influence some women to arrive at the
hospital in advanced labor. The need to travel a long distance to the closest hospital might also
be a factor contributing to arrival during late labor or to out-of-hospital delivery.
 Support During Childbirth
 Despite the traditional emphasis on female support and guidance during labor, women
from diverse cultures report a desire to have husbands or partners present for the birth. Spouses
or partners are now encouraged and even expected to make important contributions in
supporting pregnant women during labor. Many women also wish to have their mother or some
other female relative or friend present during labor and birth. Because many hospitals have
rules limiting the number of persons present, the mother-to-be might be forced to make a
difficult choice among the persons close to her.
Nurses must determine how much personal control and involvement are desired by a
woman and her family during the birth experience. It is always best practice for the nurse to ask
patients directly about their cultural beliefs and preferences so that hospital practices can be
aligned with individual needs.
 
Intrapartum Nursing Care for Culturally Diverse Women:
 If you are unable to speak the woman’s language, make every effort to arrange for an
interpreter.
 If your nursing agency commonly cares for culturally diverse clients, find out whether
other nurses have had experiences with similar clients. Share resources and your
expertise with staff members.
 Attempt to gain as much information as possible by completing a cultural assessment.
 Elicit the mother’s expectations about her labor and delivery experience.
 Ask if she wants a support person with her. If so, have her identify that person.
 Explore with her any cultural rituals she wants incorporated into her plan of care. If
requests are manageable, honor them.
 Be patient, draw pictures, gesture. Identify key words from family or the interpreter that
you will need to be able to express yourself to her, for example, push, blow, pant, and
stop.
 Cultural Expression of Labor Pain
Although the pain threshold is remarkably similar in all persons, regardless of gender or
social, ethnic, or cultural differences, these differences play a definite role in a person’s
perception and expression of pain. Pain is a highly personal experience, dependent on cultural
learning, the context of the situation, and other factors unique to the individual.
 Birth Positions
Numerous anecdotal reports in the literature describe “typical” birth positions for
women of diverse cultures, from the seated position in a birth chair favored by Mexican
American women to the squatting position chosen by Laotian women. The choice of positions is
influenced by many factors other than culture, and the socialization that occurs when a woman
arrives in a labor and delivery unit might prevent her from stating her preference.
 Cultural Meaning Attached to Infant Gender
 The meaning that parents attach to having a son or daughter varies from culture to
culture. Historically , families saw males as being the preferred gender of the first-born child for
reasons including male dominated inheritance patterns, carrying on the family name, and
becoming the “man” of the family should the need arise. However, modern societies report a
preference for a gender mix. Although the “structural” conditions in which son preference was
originated have eroded, the related “cultural” idea of boys providing higher utility for the family,
etc., may have survived.
 
E. Culture and the Postpartum Period
Western medicine considers pregnancy and birth the most dangerous and vulnerable
time for the childbearing woman. However, other cultures place much more emphasis on the
postpartum period. Many cultures have developed special practices during this time of
vulnerability for the mother and the infant in order to mobilize support and strengthen the new
mother for her new role.
 Postpartum Depression
Postpartum depression (PPD) is reported worldwide. However, identifying and reporting
of PPD in non-Western cultures may be delayed by culturally unacceptable labeling of the
disorder, varying symptoms, or differences in treatments from culture to culture.
In Western culture, treatment for PPD typically follows a pharmaceutical approach.
However, drug treatment may be culturally inappropriate for Muslim women experiencing such
symptoms. Culturally appropriate care may instead include support through family and
community. Clinical implications include the importance of nurses acknowledging the illness
and the feelings the woman expresses and allowing her to choose the treatment that she feels is
right for her.
 Hot/Cold Theory
Central to the belief of perceived imbalance in the mother’s physical state is adherence to the
hot/ cold theories of disease causation.
6. Pregnancy is considered a “hot” state. Because a great deal of the heat of pregnancy is
thought to be lost during the birth process, postpartum practices focus on restoring the
balance between the hot and cold, or yin and yang.
7. Common components of this theory focus on the avoidance of cold, in the form of air,
water, or food. This real fear of the detrimental effects of cold air and water in the
postpartum period can cause cultural conflict when the woman and infant are
hospitalized.
In order to avoid conflict, some women may pretend to follow the activities suggested by nurse:
10. Pretending to shower.
Nurses must assess the woman’s beliefs regarding bathing and other self-care practices
in a nonjudgmental manner. The common use of perineal ice packs and sitz baths to
promote healing can be replaced with the use of heat lamps, heat packs, and anesthetic
or astringent topical agents for those who prefer to avoid cold influences. The routine
 distribution of ice water to all postpartum women is another aspect of care that can be
modified to meet a woman’s cultural needs. Offering women a choice of water at room
temperature, warm tea or coffee, broth, or another beverage should satisfy most
women’s needs for warmth, along with the offering of additional bed blankets. It is
always appropriate to discuss cultural practices with the new mother to elicit her
concerns, needs, and preferences.
 Postpartum Dietary Prescriptions and Activity Levels
Dietary prescriptions are also common in this period. The nurse might note that a
woman eats little “hospital” food and relies on family and friends to bring food to her while she
is in the hospital. If there are no dietary restrictions for health reasons, this practice should be
respected. Fruits and vegetables and certainly cold drinks might be avoided because they are
considered “cold” foods. Indeed, the nurse should assess what types of food are being eaten by
the woman and document them as appropriate to ensure the foods are nutritious and not
harmful.
 Postpartum Rituals

Placental burial rituals are part of the traditional Hmong culture, ethnic group living chiefly in
China and Southeast Asia. The Hmong believe the placenta is the baby’s “first clothing” and must
be buried at the family’s home, in a place where the soul can find the afterlife garment once the
person is deceased. If the soul is unable to find the placental “jacket,” it will not be able to
reunite with its ancestors and will spend eternity wandering.
 
F. Cultural Influences on Breast-Feeding and Weaning Practices
Culturally, breast-feeding and weaning can be affected by a variety of values and beliefs
related to societal trends, religious beliefs, the mother’s work activities, ethnic cultural beliefs,
social support, access to information on breast-feeding, and the health care provider’s personal
beliefs and experiences regarding breast-feeding and/or weaning practices, to name a few.
For breast-feeding women from traditional backgrounds, it is important for nurses to be
aware of factors that have been shown to affect the quality and duration of the breast-feeding
experience, along with factors impacting weaning practices.

G. Cultural Issues Related to Intimate Partner Violence During Pregnancy

Domestic violence has emerged as one of the most significant health care threats for
women and their unborn children. Numerous transcultural factors influence the prevalence of
and response to domestic violence, including a history of family violence, sexual abuse
experienced as a child, alcohol and drug abuse by the mother or significant other, shame
associated with abuse, fear of retaliation by the abuser, or fear of financial implications if the
mother leaves the abuser, to cite a few. Outcomes of abuse shared by abused women of all
cultures include stress (physical and emotional), poor lifestyle health practices, delayed prenatal
care, and lack of support.
 
Intimate Partner Violence (IPV)
- is the result where homicide is a leading cause of pregnancy-associated death and health care
providers must acknowledge and understand.
- screening for both partner violence and suicidal ideation is an essential component of
comprehensive health and nursing care for women during and after pregnancy.
 

Nurses’ Roles:
 Nurses and other health practitioners in prenatal clinics are in an ideal position to
facilitate a trusting relationship with an abused woman.
 Good assessment skills are crucial, because the first sign of abuse might not be an
admission of abuse but physical findings of trauma.
 It is also helpful that the nurses have strong interpersonal skills and a genuine interest.
 The nurse in the prenatal setting is in an ideal position to gather information and initiate
a trusting relationship.
 The nurse might need to rely heavily on her assessment and history-taking skills, being
particularly alert to instances of trauma and problems with past pregnancies.
 Patient education must stress that although a woman may see her man as a “victim,” that
does not mean she must tolerate abuse.
 The nurse can identify shelter facilities in the woman’s neighborhood and other areas. If
the woman feels uncomfortable going outside her neighborhood (and many do for fear they will
not be understood outside their culture), the nurse can encourage her to go to members of her
extended family, a situation that might be more acceptable within culture.
 The nurse should not only assess for current abuse by the spouse or significant other but
also evaluate the other types of abuse inflicted over the mother’s lifetime, such as alcohol or drug
abuse.
 The nurse should also learn to become comfortable with periods of silence after
questions. This does not mean that clients are not listening but rather just the opposite.
 The nurse must then intervene by providing information, discussing alternatives, and
supporting the woman in her decision.

Transcultural Perspectives in the Nursing Care of Children

Model depicting the interrelation of culture, communication, and parental decisions about
childrearing practices.
 
The figure above provides a visual representation of the interrelationship among culture,
communication, and parental decisions/actions during child rearing. This schematic
representation also serves as a model for understanding culturally significant decisions that
affect the care of children.
 
Parent
- refers to the primary care provider whether natural, adoptive, relational (grandparents, aunts,
uncles, cousins), or those who are unrelated but who function as primary providers of care
and/or parent surrogates for varying periods of time.
 

Children as a Population

When defining children as a population, it is important to consider various elements that

shape this population as a whole, such as its racial and ethnic makeup, the impact of poverty on
this population, and the health status of children and adolescents. Other important
considerations when examining this population are cross-cultural differences in growth and
development, infant attachment, and crying.
A. Poverty
The impact of poverty on children’s health is cumulative throughout the life cycle, and
disease in  adulthood frequently is the result of early health-related episodes that become
compounded over time. For example, when poverty leads to malnutrition during critical growth
periods, either prenatally or during the first 2 years of life, the consequences can be catastrophic
and irreversible, resulting in damage to the neurologic and musculoskeletal systems. If the brain
fails to receive sufficient nutrients during critical growth periods, the child is likely to experience
diminished cognitive development, leading to poor academic performance and later poorer job
performance, lower pay, and thus perpetuation of the cycle of poverty and poor health.

B. Children’s Health Status

Indicators of child health status include birth weight, infant

mortality, and immunization rates. In general, children from diverse cultural
backgrounds have less favorable indicators of health status than their white counterparts.
Health status is influenced by many factors, including access to health services.
Barriers to quality health care services for children:
 Poverty
 Geography
 Lack of cultural competence
 Families from diverse cultures might have trouble in their interactions with nurses and other
health care providers, and these difficulties might have an adverse impact on the delivery of
health care. Because ethnic minorities are underrepresented among health care professionals,
parents and children often have different cultural backgrounds from their health care providers.

C. Growth and Development

Although the growth and development of children are similar in all cultures, important
racial, ethnic, and gender differences can be identified. For example, there is cross-cultural
similarity in the sequence, timing, and achievement of developmental milestones such as
smiling, separation anxiety, and language acquisition. However, from the moment of
conception, the developmental processes of the human life cycle take place in the context of
culture. Throughout life, culture exerts an all-pervasive influence on the developing infant,
child, and adolescent.
Although it is difficult to separate nongenetic from genetic influences, some populations
are shorter or taller than others are during various periods of growth and in adulthood. Certain
growth patterns appear across cultural boundaries. For example, regardless of culture,
neuromuscular activities evolve from general to specific, from the center of the body to the
extremities (proximal-to-distal development), and from the head to the toes (cephalocaudal
development). Adult head size is reached by the age of 5 years, whereas the remainder of the
body continues to grow through adolescence. Physiologic maturation of organ systems, such as
the renal, circulatory, and respiratory systems, occurs early, whereas maturation of the central
nervous system continues beyond childhood.

D. Infant Attachment

Infant attachment
- the relationship that exists between a child and their primary caregiver, which provides “a
secure base from which to explore and, when necessary, as a haven of safety and a source of
comfort”.
Studies suggest that differences in infant attachment are linked to cultural variations in
parenting behavior and life experiences. Parental socialization, values, beliefs, goals, and
behaviors are determined in large measure by how a culture defines good parenting and
preferred child behaviors for each gender. Other factors include the move from rural to urban
residences and the associated social, economic, and lifestyle changes that shift children to more
independent and autonomous behaviors. Some researchers argue that contemporary
urbanization has created complex and highly technological societies that simultaneously foster
children’s autonomous, cooperative, and prosocial behavior.
Crying
Cultural differences exist in the way mothers perceive, react, and behave in response to
their infants’ cues, behaviors, and demands. Knowledge of cultural differences in parental
responses to crying is relevant for nurses because assessment of the severity of an infant’s
distress is often based on the parent’s interpretation of the crying. The seriousness of a problem
may be overestimated or underestimated because of cultural variations in perception of the
infant’s distress. The degree of parental concern toward an infant may be misinterpreted if one’s
cultural beliefs and practices differ from those of the parent.
 

Culture-Universal and Culture-Specific Child Rearing

The values, attitudes, beliefs, and practices of one’s culture affect the way parents and
other providers of care relate to a child during various developmental stages. In all cultures,
infants and children are valued and nurtured because they represent the promise of future
generations.

Model depicting cultural perspectives of childrearing

Influences on the parents include:
 cultural and socioeconomic factors
 educational background
 political and legal considerations
 religious and philosophical beliefs
 environmental factors
 contemporary technologies
 personal attributes
 individual preferences
 
These influences, in turn, shape and form parental beliefs about normal growth and
development; nutrition and diet; sleep; toilet training; communication patterns; and parent-
child interactions and relationships, including beliefs and practices concerning parental
authority. Beliefs and practices also influence discipline and culturally appropriate relationships
with siblings, extended family members, nurses, physicians, teachers, law enforcement and
other authority figures, and peers. Similarly, parental cultural beliefs and practices influence
behaviors and interventions that promote the child’s health (immunizations, foods,
exercise/activity) and the manner in which he/she is cared for during illness, how parents know
when their child is sick or injured, the perceived seriousness of the illness or injury (and the
need for primary, secondary, or tertiary care), type(s) of healers and interventions used to cure
or heal the child. Lastly, factors are inherent in the child, such as genetic and acquired
conditions, gender, age, and related characteristics.
Throughout infancy, childhood, and adolescence, girls and boys undergo a process of
socialization aimed at preparing them to assume adult roles in the larger society into which they
have been born or to which they have migrated. As children grow and develop, their
communications and interactions occur within a cultural context. That which is considered
acceptable is strongly influenced by parental education, social expectation, religious
background, and cultural ties. However, all parents want their children to treat them
respectfully and to show respect toward others, thus becoming a source of pride and honor to
their family and cultural heritage.
 
A. Nutrition: Feeding and Eating Behaviors
In many cultures, breast-feeding is traditionally practiced for varying lengths of time
ranging from several weeks to several years. The growing availability and convenience of
extensively marketed prepared formula have resulted in a decrease in the number of women
who attempt to breast-feed.
 
Some cultural feeding practices might result in threats to the infant’s health:
 The practice of propping a bottle filled with milk, juice, or carbonated beverages to quiet
a child or lull them to sleep is known in many cultures and can result in dental caries.

 The practice of mothers premasticate, or chew, food for young children in the belief
that this will facilitate digestion.
 
Health status is dependent in part on nutritional intake, thus integrally linking the child’s
nutritional status and wellness.

Malnutrition
- is described as undernutrition (not enough essential nutrients or nutrients excreted too
rapidly) or overnutrition (eating too much of the wrong food or not excreting enough food)
(WHO, 2010).
Malnutrition is not exclusive to children from poor, lower socioeconomic groups. By
definition, many middle- and upper-income families have obese children who are also
malnourished. Obesity frequently begins during infancy, when some mothers succumb to
cultural pressures to overfeed. For example, among many who identify themselves as Filipino,
Vietnamese, Somali, Hispanic American, and Mexican, to name a few cultures, fat babies
generally are considered healthy babies.
The popularity of fast-food restaurants and “junk” foods has resulted in a high-calorie,
high-fat, high-cholesterol, and high-carbohydrate diet for many children. Parents and children
are frequently involved in numerous activities outside the house and have less time for
traditional tasks such as cooking or seating the family together for a meal. Because fast foods
have some intrinsic nutritional value, their benefit should be evaluated based on age-specific
requirements. Poverty forces some parents to provide inexpensive substitutes for the expensive,
often unavailable, essential nutrients. These lower nutrients, high-fat, high-calorie foods are
referred to as “empty calories” and have led to the epidemic of childhood obesity.
The extent to which families retain their cultural practices at mealtime varies widely.
However, when a child is hospitalized, their recovery might be enhanced by familiar foods, and
nurses should assess the influence of culture on eating habits. For example, most Asian parents
believe that children should be fed separately from adults and that they should acquire “good
table manners” by the time they are 5 years old; these practices can be supported during
hospitalization.
 
8. For hospitalized children, nurses can foster an environment that closely simulates the
home (e.g., use of chopsticks rather than silverware).
9. Family members can be encouraged to visit during mealtime to encourage the child to
eat. As the child’s condition allows, food may be brought from home, and/or the family
can be encouraged to eat with the child if this is appropriate.
 
In many cultures, illness is viewed as a punishment for an evil act, and fasting (abstaining
from solid food and sometimes liquids) is viewed as penance for evil. A situation may become
dangerous, and even deadly, should a parent view the child’s illness as an “evil” event and
consequently withhold food and/or water. Dehydration occurs rapidly and malnutrition may
quickly follow. These dangerous issues may require legal intervention to protect the child and
may produce difficult, culturally insensitive outcomes. Nurses must be vigilant to support
cultural eating habits and be prepared to educate parents and children about the prevention of
and intervention for malnutrition and dehydration.
Safe drinking water is not always available in many regions of the world. Contaminated
water is found in all countries at some time and in some countries at all times. Children die daily
from waterborne diseases that could be prevented with a few drops of bleach or a safe water
supply. Weather-related disasters, earthquakes, famine, and war typically escalate the water
crises. In cases of vomiting, diarrhea, and dehydration, contaminated water supplies should
always be investigated as a possible source.
 
B. Sleep
Although the amount of sleep required at various ages is similar across cultures, differences in
sleep patterns and bedtime rituals exist. The sleep practices in a family household reflect some
of the deepest moral ideals of a cultural community. Nurses working with families of young
children in both community and inpatient settings frequently encounter cultural differences in
family sleeping.

Bed sharing
- is the practice of a child sleeping with another person on the same sleeping surface for all or
part of the night.
Cosleeping
- the practice of parents and children sleeping together in the same bed for all or part of the
night
 
Research has found that the majority of parents bring their children into bed with them
at some time. Parents bring their children into bed with them to facilitate breast-feeding, to
comfort the child, to improve the child’s sleep or parent’s sleep, to monitor the child, to improve
bonding or attachment, and for other reasons; the constellation of reasons for bed sharing
depends largely on the culture of the family.
 A common transition from sleeping in a crib to a bed without side rails is a
developmental marker that is important to the child. This transition usually occurs during
preschool years, depending upon the physical space in the home, the parental attitude toward
the child’s independence, and the child’s neuromuscular development/coordination. For the
hospitalized child, caregivers need to identify the child’s usual bedtime routines. For example,
once children have gained the independence of leaving a crib, it may be emotionally traumatic
for them to be placed into a hospital bed with side rails of any kind. Health care providers need
to be sensitive to this situation and reassure both child and parent that any regressive behavior
that occurs as a result of reverting to a bed with side rails will be short-lived. Bedtime routines
and preparation for sleep might include a snack, prayers, and/or a favorite toy or story.
Common bedtime routines should be continued in the hospital as much as possible.
 
C. Elimination
Of primary concern to parents of toddlers and preschoolers is bowel and bladder control.
Toileting or toilet training is a major developmental milestone and is taught through a variety of
cultural patterns.
 Most children are capable of achieving dryness by 2½ to 3 years of age.
 Bowel training is more easily accomplished than bladder training.
 Daytime (diurnal) dryness is more easily attained than night-time (nocturnal) dryness

Some cultures start toilet training a child before his or her first birthday and consider the
child a “failure” if dryness is not achieved by 18 months. Often, there is significant shaming,
blaming, and embarrassment of the child who has not achieved dryness by the culturally
acceptable timetable. The nurse should remember that due to spinal cord/nerve development,
maintenance of dryness is not physiologically possible until the child is able to walk without
assistance. In some cultures, children are not expected to be dry until 5 years of age. Generally
speaking, “Girls typically acquire bladder control before boys, and bowel control typically is
achieved before bladder control”.
The role of the nurse is to acknowledge that toilet training can be taught through a variety of
cultural patterns but that physical and psychosocial health are promoted by accepting, flexible
approaches. A previously toilet-trained child might become incontinent as a result of the stress
of hospitalization, but will generally regain control quickly when returned to the familiar home
environment. Parents should be reassured that regression of bowel and bladder control
frequently occurs when a child is hospitalized; this is normal and is expected to be a short-term
occurrence.
 

Parent–Child Relationships and Discipline

In some cultures, both parents assume responsibility for the care of children, whereas in
other cultures, the relationship with the mother is primary and the father remains somewhat
distant. With the approach of adolescence, the gender-related aspects of the parent–child
relationship might be modified to conform to cultural expectations.
The use of physical acts, such as spanking or various restraining actions, is connected
with discipline in many groups, but can sometimes be interpreted by those outside the culture as
inappropriate and/or unacceptable.
With the approach of adolescence, parental relationships and discipline generally
change. Teens are usually given increasing amounts of freedom and are encouraged to try out
adult roles in a supervised way that enables parents to retain considerable control. In many
cultures, adolescent boys are permitted more freedom than girls of the same age.
 

Child Abuse
Child abuse and neglect have been documented throughout human history and are
evident across cultures.
Cross-cultural variability in childrearing beliefs and practices has created a dilemma that
makes the establishment of a universal standard for optimal child care, as well as definitions of
child abuse and neglect, extremely difficult. In defining child maltreatment across cultures, the
WHO and UNICEF have included Korbin’s (1991) classic three characteristics:
(1) cultural differences in childrearing practices and beliefs,
(2) departure from one’s culturally acceptable behavior, and
(3) harm to children.

Practices that are acceptable in the culture in which they occur may be considered
abusive or neglectful by outsiders; some examples follow. In many Middle Eastern cultures,
despite warm temperatures, infants are covered with multiple layers of clothing and might be
observed to sweat profusely because parents believe that young children become chilled easily
and die of exposure to the cold.
 

Gender Differences
From the moment of birth, differentiation between the sexes is recognized. Physical
differences between boys and girls appear early in life and form the basis for adult roles within a
culture. Normal newborn boys are larger, more active, and have more muscle development than
newborn girls. Normal newborn girls react more positively to comforting than do newborn boys.
Physiologically, adult men differ from adult women in both primary and secondary sex
characteristics. On average, men have a higher oxygen-carrying capacity in the blood, a higher
muscle-to-fat ratio, more body hair, a larger skeleton, and greater height.
 
Cross-culturally in six classes of behavior:
 nurturance,
 responsibility
 obedience
 self-reliance
 achievement
 independence
 

Health and Health Promotion

The concept of health varies widely across cultures. Regardless of culture, most parents
desire health for their children and engage in activities that they believe to be health promoting.
Because health-related beliefs and practices are such an integral part of culture, parents might
persist with culturally based beliefs and practices even when scientific evidence refutes them, or
they might modify them to be more congruent with contemporary knowledge of health and
illness.
A. Illness
- The family is the primary health care provider for infants, children, and adolescents.
- It is the family that determines when a child is ill and when to seek help in managing an illness.
- The family also determines the acceptability of illness and sick-role behaviors for children and
adolescents.
- Societal and economic trends influence the cultural beliefs that are passed from generation to
generation. Health, illness, and treatment (care/ cure) are part of every child’s cultural heritage.
 
B. Health Belief Systems and Children
Curandero
- refers to a traditional healer among Mexican American culture where the family take a child.
After visiting the physician and the curandero, the mother might consult with her own mother
and then give her sick child the antibiotics prescribed by the physician and the herbal tea
prescribed by the traditional healer. If the problem is viral in origin, the child will recover
because of his or her own innate immunologic defenses, independent of either treatment. Thus,
both the herbal tea of the curandero and the penicillin prescribed by the physician might be
viewed as folk remedies; neither intervention is responsible for the child’s recovery
Hispanic culture:

Susto - is caused by a frightening experience and is recognized by nervousness, loss of

appetite, and loss of sleep.

Pujos (grunting) - is an illness manifested by grunting sounds and protrusion of the

umbilicus. It is believed to be caused by contact with a woman who is menstruating or by the
infant’s own mother if she menstruated sooner than 60 days after delivery

mal ojo, (the evil eye) - caused by an individual who voluntarily or involuntarily injures a
child by looking at or admiring him or her.
 
Mexican American culture:

Caida de la mollera, or fallen fontanel - can be attributed to a number of causes such as

failure of the midwife to press preventively on the palate after delivery, falling on the head,
abruptly removing the nipple from the infant’s mouth, and failing to place a cap on the infant’s
head.

Empacho  - is a digestive condition believed by Mexicans to be caused by the adherence of

undigested food to some part of the gastrointestinal tract. This condition causes an “internal
fever,” which cannot be observed but which betrays its presence by excessive thirst and
abdominal swelling believed to be caused by drinking water to quench the thirst. Children who
are prone to swallowing chewing gum are believed to experience empacho, but it can affect
persons of any age
 
C. Biocultural Influences on Childhood Disorders
Children may be born with genetic traits inherited from their biologic parents, who have
inherited their own genetic compositions. The child’s genetic makeup affects his or her
likelihood of both contracting and inheriting specific conditions. In both children and adults,
genetic composition has been demonstrated to affect the individual’s susceptibility to specific
diseases and disorders. It is often difficult to separate genetic influences from socioeconomic
factors such as poverty, lack of proper nutrition, poor hygiene, and environmental conditions
such as lack of ventilation, sanitary facilities, and heat during cold weather, and clothing that is
insufficient to provide protection during the various seasons. Other factors responsible for
differing susceptibilities to specific conditions are variations in natural and acquired immunity,
intermarriage, geographic and climatic conditions, ethnic background, race, and religious
practices. Some studies have attempted to explain differences in susceptibility solely on the basis
of cultural heritage, but they have not succeeded in doing so.
  
 Immunity
Perhaps one of the most frequently cited examples of the connection between
immunity and race is that of malaria and the sickle cell trait in Africans. Black Africans
possessing the sickle cell trait are known to have increased immunity to malaria, a
serious endemic disease found in warm, moist climates. Thus, blacks with the sickle cell
trait survived malarial attacks and reproduced offspring who also possessed the sickle
cell trait. The transfer of immunity to many contagious diseases via injection/ingestion
of live or attenuated viruses has been a major factor in decreasing childhood deaths.
However, there is no evidence of culture-bound positive or negative effects where
vaccines are available. Some religious groups refuse immunizations and often experience
outbreaks of preventable communicable diseases within their community. Other parents
refuse immunizations based on the belief of a connection between childhood autism and
vaccines, which has not been supported by clinical research to date.
10. Intermarriage
Intermarriage among certain cultural groups has led to a wide variety of childhood
disorders. For example, there is an increased incidence of ventricular septal defects
(VSDs) among the Amish, amyloidosis among Indiana/Swiss and Maryland/ German
families, and intellectual disability in several other groups.
11. Ethnicity
Although the role of socioeconomic factors in tuberculosis—such as overcrowding and
poor nutrition—cannot be disregarded, ethnicity also appears to be a factor in this
disease. Groups with a relatively high incidence of tuberculosis are Native North
Americans living in the Southwest United States and in northern and prairie regions of
Canada, Mexican Americans, and Africans and refugees from third world countries.
Ethnicity is also linked to several noncommunicable conditions such as Tay–Sachs
disease, a neurologic condition affecting Ashkenazi Jews of Northeastern European
descent, and phenylketonuria (PKU), a metabolic disorder primarily affecting
Scandinavians.
 Race
Race has been linked to the incidence of a variety of disorders of childhood. For example,
the endocrine disorder cystic fibrosis primarily affects White children, and sickle cell
anemia has its primary influence among Blacks and those of Mediterranean descent.
Black children are known to be at risk for inherited blood disorders, such as thalassemia,
G-6-PD deficiency, and hemoglobin C disease. In addition, an estimated 70% to 90% of
black children have an enzyme deficiency that results in difficulty with the digestion and
metabolism of milk.
 

Beliefs Regarding the Cause of Chronic Illnesses and Disabilities

Illness is viewed by many cultures as a form of punishment. The child and/or family with
a chronic illness or disability might be perceived to be cursed by a supreme being, to have
sinned, or to have violated a taboo. In some cultural groups, the affected child is seen as tangible
evidence of divine displeasure, and its arrival is accompanied throughout the community by
prolonged private and public discussions about what wrongs the family might have committed.
Inherited disorders and illnesses are frequently envisioned as being caused by a family
curse that is passed along from one generation to the next through blood. Within such families,
the nurse’s desire to determine who is the carrier for a particular gene might be interpreted as
an attempt to discover who is at fault and might be met with family resistance.
Among those who believe that chronic illness and disability are caused by an imbalance
of hot and cold (as in Latino cultures) or yin and yang (as in Southeast Asian cultures), the cause
and potential cure lie within the individual. He or she must try to reestablish equilibrium
through regaining balance. Unfortunately for those with permanent disabilities who cannot be
fully healed, their community might perceive them as living in a continually impure or diseased
state.
Traditional beliefs can be tenacious and tend to remain even after genetic inheritance or
physiologic patterns of chronic disease progression are explained to the family. However, new
information is quickly integrated into the traditional system of folk beliefs more often, as is
evidenced by the addition of currently prescribed medications to the hot/cold classification
system embraced by many Hispanic families. An explanation of the genetic transmission of
disease might be given to a family, but this does not guarantee that the older, traditional belief
in a curse or “bad blood” will disappear.
 

Culturally Competent Nursing Care for Children and

Adolescents

Nursing Assessment of the Family

When assessing the family of a child or adolescent in a clinical setting, nurses should consider
the cultural background of the family, the belief systems of the family, as well as the relationship
between the child and their family. Each of these components plays a vital role in the cultural
assessment of the family and their ability to provide culturally competent care.
A. Cultural Background
Culture, like language, is acquired early in life, and cultural understanding is typically
established by age 5. Every interaction, sound, touch, odor, and experience have a cultural
component that is absorbed by the child even when it is not taught directly. Lessons learned at
such early ages become an integral part of thinking and behavior. Table manners, the proper
behavior when interacting with adults, sick role behaviors, and the rules of acceptable emotional
response are anchored in culture. Many beliefs and behaviors learned at an early age persist into
adulthood.
Over time, culture has influenced family functioning in many ways, including:
 marriage forms and ceremonies
  choice of mates
 postmarital residence
 family kinship system
 rules governing inheritance, household, and family structure
 family obligations
 family–community dynamics
 alternative family formations.
Each family modifies the culture of the larger group in ways that are uniquely its own. Some
beliefs, practices, and customs are maintained, whereas others are altered or abandoned.
Although it is helpful for you to have a basic knowledge of children’s cultural backgrounds, it is
also necessary to view each family on an individual basis. Assumptions or biased expectations
cannot be allowed to replace accurate assessment. It is essential for the nurse to remember that
not all members of a cultural group behave in the same fashion.
 
B. Family Belief Systems
The behavior of children and adolescents is influenced by childrearing practices, parental
beliefs about involvement with children, and the type and frequency of disciplinary measures.
Mothers’ attitudes toward health and illnesses are related to their educational level.
Mothers with little formal education tend to be more fatalistic about illness and less concerned
with detecting clinical manifestations of disease in their children than are well-educated
mothers. The former are also less likely to follow up on precautionary measures suggested by
health care providers. A mother who believes that people have no control over whether they
become sick is more likely to seek care in an emergency facility and less likely to have a
preventive approach to health. She is also less likely to seek preventative education and might
not comply with recommended immunization schedules. Nursing interventions with a mother
who believes that there is much a person can do to keep from becoming ill will be different with
regard to the nature of health education and counseling provided.
                Assessment data related to the belief system(s) of the family provide the nurse with
facts from which to choose approaches and priorities. For a mother who is not oriented to
prevention of illness or maintenance of health, focusing energies on teaching might not be
productive; it might be more useful to spend time designing family follow-up care or
establishing an interpersonal relationship that invites the parent to follow recommended
immunization schedules, well-child care, and other aspects of health promotion.
 
C. Family Structures
Nuclear or conjugal families
- those with two married biologic parents and one or more children.
Single-parent family
- most of whom live with a single female parent.
Blended families
- include children from a previous marriage of the wife, husband, or both parents, or families
formed outside of marriage.
Extended families
- in which parents and children coreside with other members of one parent’s family.
 
Early in the nurse–parent relationship, it is necessary to identify members of the family
who play a significant role in the care of the child. In societies where the extended family is the
norm, parents—particularly those who married at a young age—might be considered too
inexperienced to make major decisions on behalf of their child. In these groups, key decisions
are frequently made in consultation with more mature relatives such as grandparents, uncles,
aunts, cousins, or other kin. Sometimes, nonkin is considered to be part of the extended family.
In many religions, the members of one’s church, synagogue, temple, or mosque are viewed as
extended family members who might be relied on for various types of support, including child
care. Not coincidentally, members of some congregations refer to one another as brothers and
sisters.
The influence of the extended family or the social support network on the child’s
development becomes particularly important when the number of single-parent families in
some culturally diverse groups is considered. The nuclear family is the unit for which most
health care programs are designed. Consider the implicit message about the family when two or
three chairs for visitors are placed in hospital rooms, physician or nurse practitioner offices, and
other health care settings, for example.
 

Application of Cultural Concepts to Nursing Care

Case Study: Presence of Immediate and Extended Family
A rural Amish community is located about 50 miles from an urban medical center, the
only facility available for care of an acutely ill child. An enthusiastic new RN emphatically
presents her case to allow the presence of family/extended family of a 6-month-old Amish child
who has been admitted for the repair of a cardiac VSD. The nurse is passionate about the issue,
rational in her approach, and assured that she can prevail to change existing visitation policies.
The problem of overnight accommodation for the extended community family has
become a topic of debate among the nursing staff. Sensitive to the cultural practices and beliefs
of the Amish child and his family, the new RN begins stating her position on behalf of the
family’s right to adhere to Amish cultural practices to her supervisor. The supervisor listens
impatiently and quickly interrupts with her decision. “These people are such a nuisance. The
child wouldn’t even have the VSD if they didn’t insist on intermarriage within their own
community. Then they come here in droves and think we have to give them a place to sleep. This
isn’t a hotel. They can just go back to their horses and buggies and old-fashioned ways. The
answer is NO! The natural, biologic mother and father may spend the night. Everyone else is to
go home. And that’s final.”
 The nurse leaves the discussion with her supervisor feeling dejected; however, she
completes her data collection. Using Leininger’s transcultural model, she examines the
underlying attitudes, values, and beliefs among the Amish parents and those of the health care
providers and then develops an individualized, culturally congruent, plan of care. Prior to
discharge, the nurse, in collaboration with the parents and other significant members of the
extended family, evaluates the effectiveness of the nursing care from a transcultural nursing
perspective. The young nurse must also review the process in which change can be accomplished
within the agency. She needs to determine what parts of the system can/should be manipulated
to bring about desired change and who are the formal and informal leaders who can effect
change.
 
Outcome:
There are no definitive solutions or answers for this dilemma. The case study is intended
to demonstrate the complexity of the cross-cultural issues and to emphasize the necessity for
thoughtful analysis of various facets of the problem. The ability to synthesize information from
previous learning—psychology, anthropology, religion and theology, history, economics,
sociology, principles of leadership, and others—to the nursing care of children from culturally
diverse backgrounds is invaluable.
The cultural assessment is the foundation of excellent transcultural care and cannot be
overlooked even in the face of major obstacles of attitudes of others or limited time. A cultural
assessment must become an integral part of the admission assessment of all children and
adolescents, thus enabling excellent, individualized, family-centered care
 
The case exemplifies the need for involvement of extended families of varying types. It also
reflects how the response of the nursing team affected the end result of the child’s care. In
addition, a specific, individualized plan of care for the Amish family is presented. As shown, the
nursing issues in each case are complex and multifaceted. The interconnectedness of the various
components of the child’s situation with the larger system is often minimized or disregarded.
The values and beliefs of both the nurses within the health care delivery system and the family’s
extended social network must be considered. For the purpose of analysis, some fundamental
conflicts in values and beliefs have been identified. Similarities and differences also have been
indicated in the nursing plan of care. In the case involving the Amish child, the young nurse was
clearly advocating for a patient, in a situation requiring change in hospital practice, if not policy.