TRANSCULTURAL NURSING
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Culture Awareness
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Cultural awareness is sensitivity to the similarities and
differences that exist between two different cultures and
the use of this sensitivity in effective communication with
members of another cultural group.
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Cultural Knowledge
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Means that you know about some cultural
characteristics, history, values, beliefs, and behaviors of
another ethnic or cultural group.
Cultural Skills
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Loosely defined as the ability to understand, appreciate
and interact with people from cultures or belief systems
different from one's own — has been a key aspect of
psychological thinking and practice for some 50 years.
Culture
Culture includes language, customs, and beliefs about
roles and relationships. In medicine, culture also refers to
the growth of microorganisms, such as bacteria and
yeast, or human, plant, or animal cells or tissue in the
laboratory.
Culture Identity
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Cultural identity represents an individual's identity as a
member of a group with shared characteristics, which
often (but not always) include racial, ethnic, or
geographical origins.
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Material Culture
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Refers to the physical aspects of a society, the objects
made or modified by a human. These objects surround a
people and its activities and are defined by their
properties, be they chemical, physical, or biological.
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Non-Material Culture
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The aggregate of values, mores, norms, etc., of a
society; the ideational structure of a culture that
provides the values and meanings by which it functions.
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Subculture
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An identifiable subgroup within a society or group of
people, especially one characterized by beliefs or
interests at variance with those of the larger group
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Bicultural
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Individuals are considered bicultural if they speak both
the language of their heritage cultural context and the
language of their receiving cultural context, have friends
from both cultural backgrounds, and watch television
programs and read magazines from both cultural
contexts.
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Cultural Imposition
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A situation where one culture forces their values and
beliefs onto another culture or subculture.
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Cultural Values
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Enduring ideals or belief systems to which a person or a
society is committed.
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Culture Shock
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A state where people experience the stages of
honeymoon, frustration, adaptation and acceptance.
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It is an intense feeling that follows the grief process.
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Religion
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Religion in nursing is therapeutic when it helps meet a
patient's need for love, understanding, meaning,
purpose, and hope.
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Ethnicity
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Refers to a shared identity related to social and cultural
heritage such as values, language, geographical space,
and racial characteristics.
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Ethnic Group
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Broadly, it refers to the identification of population
groups based on social, cultural and historical
variations.
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Ethnic groups are characterized by organized cultural
boundaries such as language, religion and country of
origin (Platt, 2006).
Diversity
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Variety.
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The practice or quality of including or involving people
from a range of different social and ethnic backgrounds
and of different genders, sexual orientations, etc.
Race
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A class or breed of animals; a group of individuals
having certain characteristics in common, owing to a
common inheritance.
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Cultural Encounter
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Interactions between two or more people who work
according to different social norms.
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Cultural Desire
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Is the motivation of the healthcare professional to “want
to” engage in the process of becoming culturally aware,
culturally knowledgeable, culturally skillful and seeking
cultural encounters; not the “have to.”
LESSON PROPER:
Culture
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The collection of beliefs, values, behaviors, and
practices shared by a group of people and
passed from one generation to the next
Learned from birth
Molded by environment
Guides thinking, decisions, and actions
Is a patterned behavioral response that develops
over time as a result of imprinting the mind
through social and religious structures and
intellectual and artistic manifestations.
Non-physical traits that are shared by a group of
people and passed from one generation to the
next.
Material Culture
 Refers to objects (dress, art, religious artifacts)
Non-Material Culture
 Refers to beliefs customs, languages, social
institutions
Culture-specific
 Particular values, beliefs & pattern 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
 Commonly shared values, norms of behavior, and
life patterns that are similarly held among cultures
about behavior & lifestyles (Leininger 1978, 1991,
1995)
TRANSCULTURAL NURSING
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Focuses on the study and analysis of different cultures
and subcultures with respect to cultural care, health
beliefs and health practices, with the goal of providing
health care within the context of the client’s culture
(Leininger, 1978)
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As a “humanistic and scientific area of formal study and
practice which is focused upon differences and
similarities among cultures with respect to human care,
health (or well-being), and illness based upon the
people’s cultural values, beliefs, and practices.”
(Leininger,1991 & McFarland, 2006).
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The ultimate goal of transcultural nursing is use of
relevant knowledge to provide culturally specific and
culturally congruent nursing care to people.
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Below the individuals, families, groups,
communities, & institutions are the Diverse Health
Systems that all persons deal with in various ways.
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Generic or Folk Systems are the everyday
remedies an individual, family or group may use to
promote wellness and healing. Some examples
might include:
o Chicken soup
o Chamomile Tea or other herbal teas
o Voodoo
o Sacrifices of birds or animals to the spirits
o Prayer
o Curandero - traditional native healer
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Nurses need to assess in all these areas to plan
safe, effective care
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Professional Systems are different depending
upon the health Care Delivery System of
that culture. Whether there is socialized medicine,
private insurance, communal healthcare, poor
economic support vs. great wealth, all contribute
to the influence of the utilization of Professionals to
prevent illness, heal illness, and promote health
and wellness
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Nursing must collaborate within the healthcare
delivery system to plan and implement safe,
effective, culturally competent care.
MADELEINE LEININGER:
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The founder of the theory of Transcultural Nursing/Culture
Care Theory
Her theory has now developed as a discipline in Nursing
Evolution of her theory can be understood from her
books:
o
Culture Care Diversity and Universality (1991)
o
Transcultural Nursing (1995)
o
Transcultural Nursing (2002)
Theoretical framework is depicted in her model called
the Sunrise Model (1997)
LEININGER’S SUNRISE MODEL
The model is based on the concept of culture care and
shows 3 major nursing modalities that guide nursing
judgements and activities to provide “Cultural Congruent
Care”
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The model looks like a Sunrise and the Worldview
encompasses everything that makes people who
they are
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The 7 Cultural and Social Structure Dimensions are
the large areas that nurses need to learn about
through interview and living among the people of
different cultures.
THE GIGER AND DAVIDHIZAR- TRANSCULTURAL ASSESSMENT
MODEL
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In the context of Giger and Davidhizar’s Transcultural Assessment
Model (1990, 2002), transcultural nursing is viewed as a culturally
competent practice field that is client centered and research
focused.
medical terms when explaining a procedure to a normal
person or patient.
Use of an interpreter
Every individual is culturally unique, and nurses are no exception
to this premise. Nonetheless, nurses must use caution to avoid
projecting on the client their own cultural uniqueness and
worldviews if culturally Appropriate care is to be provided.
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was developed in 1988 in response to the need for nursing
students in an undergraduateprogram to assess and provide
care for patients that were culturally diverse
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Giger and Dvidhizar have identified six cultural phenomena that
vary among cultural kgroups and affect health care
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Before locating an interpreter, first know the language the client
speaks at home
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Avoid interpreter from a rival tribe, state and region
Be aware of gender differences
Be aware of age differences
Ask the interpreter to translate a closely to verbatim as possible
Expect compensation for services rendered.
Nonverbal - conveyed through facial expressions and
body language, eye contact, also includes touch
and proxemics.
Silence: lack of audible sound.
COMMUNICATION
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means by which culture is transmitted and preserved
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Verbal and nonverbal patterns of communication vary across
cultures, and if nurses do not understand the client’s cultural rules
in communication, the client’s acceptance of a treatment
regimen may be jeopardized.
both verbal and nonverbal communications are learned in one’s
culture
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CONSIDERATIONS:
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Vocabulary
Grammatical structure
Voice qualities
Intonation
Rhythm
Speed w Silence
Vocabulary
For an Orthodox Jew, the word pig is synonymous with the
word unclean or unholy and thus should be avoided. On
the other hand, for a pig farmer the word pig implies a
clean, wholesome means of making a living.
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Verbal
Language barriers can create severe communication
problems.
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Language barrier may arise from the use of different language
system. e.g the sender is speaking English. English and the
receiver is speaking Spanish.
language barrier also arise when the sender uses technical
terms that are unfamiliar to the receiver. e.g. Nurses use
Consider this:
Many American Indians have this latter view of silence, as
do some traditional Chinese and Japanese persons.
Therefore, when one of these persons is speaking and
suddenly stops, what may be implied is that the person
wants the nurse to consider the content of what has been
said before continuing. Other cultures may use silence in yet
other ways. For example, English and Arabic persons use
silence for privacy, whereas Russian, French, and Spanish
persons may use silence to indicate agreement between
parties
Some persons in Asian cultures may view silence as a sign
of respect, particularly toward an elder. Mexicans may use
silence when instructions are given by a person in authority
rather than showing the disrespect of disagreement
(Quarnero, 2005).
Nurses need to be aware of possible meanings of silence so
that personal anxiety does not promote the silence to be
interrupted prematurely or to be nontherapeutic. A nurse
who understands the therapeutic value of silence can use
this understanding to enhance care of clients
o American Indian, Indo-Chinese, Arab patients who feel that
direct eye contact is impolite or aggressive.
Eye contact across the world
o An American Indian patient may stare at the floor during conversations.
That's a cultural behavior conveying respect, and it shows that he's paying
close attention to you
o Likewise, a Hispanic patient may maintain downcast eyes in deference to
someone's age, sex, social position, economic status, or position of authority.
o
Hispanic clients: eye contact is expected of you but will not be
reciprocated by patients.
Facial expressions
Used as a guide to a person’s feelings. Vary from culture to
culture.
Facial expressions across the world
o Americans: assumes that it is a negative sign when a person avoids eye
contact; it means shyness, lack of interest and dishonesty.
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value eye contact as symbolic of a positive self - concept, openness,
and honesty.
o Muslim Arab women: avoid eye contact with males (except for one’s
husband)
o African American; Mexican Americans comfortable with eye contact
o India: amount of eye contact depends on one’s social position
African Americans and Spanish
o Use many facial expressions along with gestures to
communicate feelings of happiness, pain or displeasure.
Northern Europeans
o Tend to use less facial expression and are generally less
responsive.
Asians
o Uses facial expression to convey opposite meaning
from the one that is felt.
o Conceal negative emotions with a smile
Eye contact
TOUCH
The meaning people associate with touching is culturally
determined to a great degree.
o In Hispanic and Arab cultures, male health care providers
may be prohibited from touching or examining certain
parts of the female body; similarly, females may be
prohibited from caring for males.
o Among many Asian Americans, touching a person's
head may be impolite because that's where they believe
the spirit resides.
Important tool in TCN assessment. Eye contact is also a culturally
determined behavior.
“the eyes are the windows of the soul’’
o Before assessing an Asian American patient's head or
evaluating a head injury, you may need to clearly explain
what you're doing and why.
o Eye contact is an important tool in transcultural nursing
assessment and is used both for observation and to initiate
interaction. In the United States, those of the dominant culture
(predominately Whites) value eye contact as symbolic of a positive
self-concept, openness, interest in others, attentiveness, and
honesty.
o Always consider a patient's culturally defined sense of
modesty when giving nursing care.
o For example, some Jewish and Islamic
women believe that modesty requires
covering their head, arms, and legs with
clothing. Respect their tradition and help
them remain covered while in your care.
o McKenzie and Chrisman (1977) reported that, for some Filipinos,
eye contact that turns away is associated with the possibility of
being a witch. Other groups who find eye contact difficult include
some Asian people and some American Indians, who relate eye
contact to impoliteness and an invasion of privacy.
o Many American Indians regard eye contact as disrespectful
because it is believed that “looking in an individual’s eyes” is
“looking into an individual’s soul”
(Galanti, 2003; Giger & Davidhizar, 2001; Henderson & Primeaux,
1981; Poole, Davidhizar, & Giger, 2003).
o A strong gaze may be interpreted as a sign of disrespect among
Asian
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Traditional Asian Cultures
o Kissing and hugging is reserved for intimate relationships in
private setting
Space
Religion
Refers to the distance between individuals when they
interact. All communication occurs in the context of space
o Religion is a social phenomenon (Carroll, Johnson, &
Marty, 1979).
Space and distance – perception of appropriate distance
zone varies widely among cultural groups
o Religious practices, therefore, are usually rooted in
culture, and each culture typically has a set of beliefs that
define health and the behaviors that prevent or treat
illness (Davidhizar, Bechtel, & Cosey, 2000).
There are four (4) distict zones of interpersonal space:
(1)
Inmate zone (extends from 1 ½ feet)
(2)
Personal distance (extends 1 ½ feet)
(3)
Social distance (extends from 4 to 12 feet)
(4)
Public distance (extends 12 feet or more)
Proxemics
o the term for the study of human use and perception of
social and personal space (Hall, 1974).
o Individuals tend to divide surrounding space into regions
of front, back, right, and left (Franklin, Henkel, & Zangas,
1995).
Territoriality
o Refers to the behavior and attitude people exhibit about
an area they have claimed and defend or react
emotionally when others invade it.
Space across the world
Middle Class Americans, Canadians, British
o when forced to stand or sit close to people they do not
know well they feel that their space is being violated.
Latin Americans, Africans, Black Americans, Indonesians
and French.
o Prefer to stand close to one another when holding a
conversation
o Jehovah’s Witness, Seventh-Day Adventist, Islam,
Christianity
Selected Cultured-Bound Syndrome
o These are the mental conditions or psychiatric
syndromes whose occurrence or manifestations are
closely related to cultural factors and which thus warrant
understanding and management from a cultural
perspective.
o Recent suggestions to rename it as “Culture Related
Specific Syndrome”
Example:
 Amok, a mental or emotional affliction known in
the Philippines that causes one to become a killer.
 Susto, an ailment widely associated with Spanishspeaking groups in which the soul is believed to
leave the body as a result of a frightening event
(Bonder, Martin, & Miracle, 2002).
Hispanic
o Empacho-When a fragrant or portion of food sticks or
settles to the inside of the intestines making it difficult to
process, creating serious problems for the digestive tract
(e.i. causing pain and cramping)
o Mal de ojo “evil eye” – is a folk illness primarily affecting
children, with infants being particularly vulnerable. This
supernatural belief holds that an admiring look or a stare
can weaken the child, leading to bad luck, sickness, and
even death.
o Pasmo- Paralysis- like symptoms of face or limbs,
prevented or relieved by massage.
Social Organization
Refers to the social group organization with which clients
and families may identify.
Types of Family structure
o Traditional nuclear family
o Nuclear dyad family
o Extended family
o Skip-generation family
o Alternative family
o Single-parent family
o Reconstituted or Blended family
o Special form of families: communal and gay family
o Susto- Anxiety, trembling, phobias from sudden fright.
Thought to be caused by fright that results in loss of soul from
the body; causes can be natural or “supernatural”.
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natural susto may occur after a near accident
supernatural susto may occur after witnessing a
supernatural phenomenon such as a ghost; and
might be sent by sorcerer
Those most likely to suffer from susto are culturally
stressed adults--women more than men.
oAnorexia nervosa: excessive preoccupation with thinness;
self-imposed starvation.
o Bulimia – gross overeating and then vomiting or fasting.
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Japanese:
o Wagamama- apathetic childish behavior with emotional
outburst
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Blacks
o Blackout: Collapse, dizziness, inability to move
o Low blood: Weakness or not enough blood
o High blood: Blood that is too rich in certain things
Biological Variations
Body structure
Skin color
Other visible physical characteristics
Enzymatic and genetic variations
Electrocardiographic patterns
Susceptibility to disease
Nutritional preferences and deficiencies
Psychological characteristics
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Measurements
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Time Orientation
Time is an important aspect of interpersonal
communication. Some cultures are considered future
oriented, others present oriented, and still others past
oriented.
 ese differences in time orientation may become
important in healthcare such as long-term
planning and explanations of medication
schedules.
 e.g Latin Americans, Native Americans, and
Middle Easterners are present oriented cultures
and may neglect preventive healthcare
measures. They may show-up late or not at all for
appointments.
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Campinha-Bacote (1997)
Compared time orientation among certain groups in
relation to future-time and present-time orientation:
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Dominant American: future over present
African Black: present over future
Puerto Rican American: present over future.
Mexican American: present
Chinese American: past over present
American Indian: present
Environmental Control
Environmental control refers to the ability of the person to
control nature and to plan and direct factors in the
environment.
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Some groups perceive man as having mastery
over nature others perceive humans to be
dominated by nature, while others see harmonious
relationships between humans and nature.
For example, Asians and Native Americans may
perceive that illness is a disharmony with other
forces and that medicine is only capable of
relieving the symptoms rather than curing the
disease. These groups are likely to look for
naturalistic solutions, such as a herbs and hot and
cold treatments to resolve or cure a cancerous
condition.
Height and weight vary among cultural group
Vital Signs
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Skin
Normal skin color ranges widely
Observation is labeled with the following adjectives:
Copper, Olive, Tan & Brown.
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Skin Condition
Mongolian spots
Vitiligo
Cyanosis
Jaundice
Pallor
§ Petechiae
Mongolian spots
Irregular areas of deep blue pigmentation usually
located in the sacral & gluteal areas
Present in 90% of Blacks, 80% of Asians and 9% of
Whites
Vitiligo
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Black men have lower BP than their White
counterparts from ages 18 to 34
Black women have a higher average systolic BP
than White counterparts at every age.
Characterized by unpigmented skin patches
Affects an estimated 2-4 million Americans,
primarily dark-skinned individuals
Cyanosis
The most difficult clinical sign to observe in darkly
pigmented persons
Exercise caution when assessing person from
Mediterranean descent, because their circumoral
region is normally dark blue
Jaundice
Exercise caution to avoid confusing other forms of
pigmentation with jaundice
EXAMPLE: African Americans, Filipinos have heavy
deposits o subconjunctival fat that contains high levels of
carotene in sufficient quantities to mimic jaundice
Pallor
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When assessing for pallor in darkly pigmented
patients, you might experience difficulty because
the underlying red tone are absent
Brown-skinned individual will manifest pallor with a
more yellowish-brown color Black-skinned person
will appear ashen or gray
Petechiae
In dark-skinned patients:Are best visualized in the area of
lighter melanization, such as the abdomen and buttocks
Black or very dark brown patients: Petechiae are most
easily seen in the mouth, buccal mucosa and conjunctiva
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Variations in Illness
land Islanders – Ocular Albinism
Amish – Hemophilia B
Blacks – sickle cell disease
Chinese – thalassemia
The Amish are a group of traditionalist Christian church
fellowships with Swiss Anabaptist origins.
Costa Ricans – Malignant Osteopetrosis
Eskimos – congenital Adrenal Hyperplasia
Jews – Tay-Sachs disease
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Bio cultural Aspects of Disease
Anemia – high incidence among Vietnamese
Asthma – six times greater for Native North American
Lactose intolerance – present among 66% of Hispanic
women
Sickle cell anemia – increased incidence
among Blacks
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Cancer
o Nasopharyngeal – high among Chinese North American
o Esophageal – no.2 cause of death for Black men
o Cervical – 120% higher in Black women
Lab Tests
Cultural Competence
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Definition
 the attitudes, knowledge and skills necessary for
providing quality care to a diverse population
 the act whereby a healthcare professional develops:
awareness of one’s existence, sensations, thoughts and
environment without letting these factors have un undue
effect on those for whom care is provided
Reflective Listening
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refers to a process of communication in which the nurse
or other healthcare providers listen to the patient for
understanding and intermittently seek clarification to be
sure that they are accurately interpreting the patient’s
words.
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is especially important when the patient’s verbal
communication does not seem to reflect the nonverbal.
 speaking to all patients in a language they understand
means minimizing the use of medical jargon as much as
possible and reserving it for use with colleagues and
other healthcare providers. (Andrews, Boyle, & Carr,
2003)
Stages of Intercultural Competence
Unconscious Incompetence
 People are not yet aware that they lack a particular skill
 tend to believe that their own way of doing things is the
only way of doing things
Conscious Incompetence
 people know that they want to learn something, but are
incompetent at doing it
 they start to notice the differences, but unsure about how
to cope.
Conscious Competence
 people are able to perform task completely, but not
without being highly conscious of the behavior
 hyperaware and often worry about making mistakes
Unconscious Competence
 people have mastered the skill to the degree that they
can perform it without thinking about it
 naturally
5 step problem solving process for delivering culturally congruent
and competent nursing care for individual clients
4. What do you think your sickness does to you? How
does it work?
5. How severe is it? Will it have a short or long course?
6. What do you fear the most about your sickness?
7. What are the chief problems your sickness has caused
for you?
8. What kind of treatment do you think you should
receive?
9. What are the most important results you hope to
receive from this treatment?
LEARN Model
Use of Validation
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a therapeutic technique that nurses can use when
encountering “family member behavior, choices,
attitudes, or emotions as difficult, or challenging to deal
with”
Use of the model enables the nurse to focus on behaviors
rather than personality traits, and to develop new skills
that enhance interaction with patients and their family
members.
TIPS FOR MAKING VALIDATION EASIER
 claiming yourself
 realizing that someone else’s feelings are really about
themselves
 asking questions
 listening for answers without judging
 being mindful of nonverbal signs
GUIDELINES FOR THE PRACTICE OF CULTURALLY COMPETENT
NURSING CARE
knowledge of
cultures
nurses shall gain an understanding the
perspectives, traditions, values,
practices, and family systems of
culturally diverse individuals, families,
communities, and populations thay care
for, as well as knowledge of the complex
variables that affect the achievement of
health and well-being
education and
Training in culturally
Competent Care
nurses shall be educationally prepared
to provide culturally congruent health
care. Knowledge and Skills necessary for
assuring that nursing care is culturally
congruent shall be included in global
health care agendas that mandate
formal education and clinical training as
well as required on going, continuing
education for all practicing nurses
Critical Reflection
nurses shall engage in critical reflection
of their own values, beliefs, and cultural
heritage in order to have an awareness
Kleinman’s Explanatory Model
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1. What do you call your problem?
2. What do you think has caused your problem?
3. Why do you think it started when it did?
Metaphor
of how these qualities and issues can
impact culturally congruent nursing care
Cross-Cultural
Communication
nurses shall use culturally competent
verbal and nonverbal communication
skills to identify client’s values, beliefs,
practices, perceptions and unique
health care needs
Culturally
competent
Practice
nurses shall utilize cross-cultural
knowledge and culturally sensitive skills in
implementing culturally congruent
nursing care
Cultural
competence in
health care
Systems and
Organizations
healthcare organization should provide
the structure and resources necessary to
evaluate and meet the cultural and
language needs of diverse clients
Patient Advocacy
and Empowerment
Multicultural
Workforce
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Paradigm or Worldview
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N shall recognize the effect of health
care policies, delivery systems, and
resources on theur patient populations
and shall empower and advocate for
their patients as indicated. Nurses shall
advocate for the inclusion of their
patient’s cultural beliefd and practices
in all dimensions
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Nurses shall actively engage in the effort
to ensure a multicultural workforce in
health care settings.
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Evidensed-Based
Practice and
Research
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nurses shall base their practice on
interventions that have been
systematically tested and shown to be
the most effective for the culturally
diverse populations that they serve.
In areas where there is lack of evidence
of efficacy, nurse researcher shall
investigate and test interventions that
may be the most effective in reducing
the disparities in health outcomes
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Cultural Belief Systems
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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
considers the world as an arena dominated by
supernatural forces
The fate of the world and those in it, including 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.
Christian Scientists believe that physical healing can be
effected through prayer alone.
Events believed responsible for illness in the magico-religious
paradigm (Clements, 1932)
ability to influence individuals, group
and systems to achieve outcomes of
culturally competent care for divers
populations
Nurses shal have the knowledge and
skills to work with public and private
organizations, professional associations
and communities to establish policies
abd guidelines for comprehensive
implementation and evaluation of
culturally competent care
a way of viewing the world and the phenomena in it
includes the assumptions, premises, and linkages that
hold together a prevailing interpretation of reality.
Paradigms are slow to change and do so only if and when
their explanatory power has been exhausted.
a group’s prevailing worldview is the basis of theories of
health and disease or illness causation
Magico-Religious Health Paradigm
one measure to achieve a multicultural
workforce is through strengthening of
recruitment and retention efforts in the
hospitals, clinics, and academic settings.
Cross cultural
leadership
a common expression of symbolism wherein one aspect of
life is connected to another through a shared symbol
Explanations of a phenomenon usually involve metaphoric
imagery of magical, religious, natural/holistic, scientific, or
biological form.

Sorcery
breach of taboo
intrusion of a disease object
intrusion of a disease-causing spirit
loss of soul
Symbolic thought processes characterizing the scientific
paradigm
Determinism
 which states that a cause-and effect relationship exists for
all natural phenomena.
Mechanism
 assumes that it is possible to control life processes through
mechanical, genetic, and other engineered interventions
Reductionism
 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
Objective Materialism
states that what is real can be observed and measured.
There is a further distinction between subjective and
objective realities in this paradigm.
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Biomedical Model
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all aspects of human health can be understood through
the natural sciences, biology, chemistry, physics, and
mathematics.
fosters the belief that psychological and emotional
processes can be reduced to the study of biochemical
exchanges.
Only the observable is real and worthy of study.
Effective treatment consists of physical and chemical
interventions, often without regard to human
relationships.
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Disease
Viewed metaphorically as the breakdown of the human machine
because of:
→wear and tear (stress)
→external trauma (injury, accident)
→external invasion (pathogens)
→internal damages (fluid and chemical imbalances,
genetic or
other structural changes).
Holistic Health Paradigm
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the forces of nature itself must be kept in natural
balance or harmony.
Considers human life is only one aspect of nature and a
part of
the general order of the cosmos.
Everything in the universe has a place and a role to
perform
according to natural laws that maintain order.
Disturbing these laws creates imbalance, chaos, and
disease.
Explanations for health and disease are based on
imbalance or disharmony among the human,
geophysical, and metaphysical forces of the universe.
• holistic paradigm
• disease is the result of multiple environment–host
interactions
• tuberculosis is caused by the interrelationship of
poverty, malnutrition, overcrowding, and
mycobacterium.
 health is viewed as a positive process that encompasses
more than the absence of signs and symptoms of
disease
 not restricted to biologic or somatic wellness but rather
involves broader environmental, sociocultural, and
behavioral determinants
 diseases of civilization, such as unemployment, racial
 discrimination, ghettos, and suicide, are just as much
illnesses as are biomedical diseases
 Illness is the outward expression of disharmony
 disharmony may result from seasonal changes,
emotional imbalances, or any other pattern of events
 Illness is not perceived as an intruding agent but as a
natural part of life’s rhythmic course
 Going in and out of balance is seen as a natural process
that happens constantly throughout the life cycle
 Health and illness are aspects of the same process, in
which the individual organism changes continually in
relation to the changing environment
Metaphor for health and illness in holistic paradigm. (Osborn,
2015)
Hot/Cold Theory of Disease
 founded on the ancient Greek concept of the four body
humors:
• yellow bile
• black bile
• phlegm
• blood.
 Humors are considered vital components of the blood
found in varying amounts.
 The four humors work together to ensure the optimum
nutrition, growth, and metabolism of the body.
• Ecrasia → refers to a state when the humors are
balanced in the healthy individual
• Dyscrasia → refers to a state when the humors are
imbalanced (Osborn, 2015)
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• biomedical model
• The cause of tuberculosis is clearly defined as the
invasion of mycobacterium.
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In the holistic health paradigm, because illness is
inevitable, perfect health is not the goal
Achieving the best possible adaptation to the
environment by living according to society’s rules and
caring appropriately for one’s body is the ultimate aim
This places a greater emphasis on preventive and
maintenance measures than typically occurs in
biomedicine
The treatment of disease becomes the process of
restoring the body’s humoral balance through the
addition or subtraction of substances that affect each of
these four humors.
Foods, beverages, herbs, and drugs are all classified as
hot or cold depending on their effect, not their actual
physical state.
Disease conditions are also classified as either hot or
cold.
Imbalance or disharmony is thought to result in internal
damage and altered physiologic functions.
Medicine is directed at correcting the imbalance as well
as restoring body function.
Although the concept of hot and cold is itself
widespread, found in Asian, Latino, Black, Arab, Muslim,
and Caribbean societies, each cultural group defines
what it believes to be hot and cold entities, and little
agreement exists across cultures.
Health and Illness Behavior
Health and Illness Behaviors
 refers to the series of behaviors expressed in the roles
people assume after identifying a symptom
Health Behavior
 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
 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
 any activity undertaken by a person who considers
himself ill to get well or to deal with the illness
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Factors influencing the course of behaviors and practices
carried out to maintain health and prevent disease:
 one’s beliefs about health and illness
 personal factors
 age, education, knowledge, or experience with a
given disease condition
 cues to action
 advertisements in the media, the illness of a relative,
or the advice of friends
Mechanic’s Determinants of Illness Behavior
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Awareness of these motivational factors can help nurses offer the
appropriate assistance to clients as they work through the illness
process.
Healing System
refers to the accumulated sciences, arts, and techniques of
restoring and preserving health that are used by any cultural group

Types of Healing Systems
Self-care
 Practice of treating oneself when having minor illnesses
with various remedies believing that they have healing
powers
 OTC
 MEGAVITAMINS
 HERBS
 EXERCISE
 FOOD
 When self-treatment is ineffective, professional and/or folk
(indigenous, generic, traditional) healing systems are
restored
Professional Care Systems
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
 Professional care is characterized by specialized
education and knowledge, responsibility for care, and
expectation of remuneration for services rendered.
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Folk Healing System
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 (Andrews, Ybarra, & Matthews, 2014)
 key consideration that defines folk systems is their history
of tradition
 many folk healing systems have endured over time
through oral transmission of beliefs and practices from
one generation to the next

Healers and their scope of practice
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Complementary, Integrative, and Alternative Health System
umbrella term for hundreds of therapies based on health
care systems of people from around the world
 therapies that have ancient origins in Egyptian, Chinese,
Greek, and American Indian cultures
Allopathic or biomedicine is the reference point, with all
other therapies being considered
 complementary (in addition to)
 integrative (combined with selected magicoreligious or
holistic therapies whose efficacy has been scientifically
documented)
 alternative to (instead of)
Integrative health care
 Defined as a comprehensive, often interdisciplinary
approach to treatment, prevention, and health
promotion that brings together complementary and
conventional therapies.
 Worldwide, an estimated 33% to 47% of individuals use
complementary or integrative therapies to manage
symptoms, prevent toxicities, and improve quality of life
during cancer treatment (Hoerner, et al., 2014)
 An estimated 48% to 80% of North American breast
cancer survivors use complementary and integrative
therapies following diagnosis (Greenlee et al., 2014)
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Categories of Complementary Health Approaches
Alternative medical systems
 Alternative medical systems
• built on complete systems of theory and practice
Examples of alternative medical systems that have
developed in Western cultures
o homeopathic medicine
o naturopathic medicine
Examples of systems that have developed in Eastern
cultures
o traditional Chinese medicine
o Ayurveda, which originated in India.
Natural products
 Include:
 Herbs (also known as botanicals)
 Vitamins
 Minerals
 Probiotics.
 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.
 Deep breathing
 Meditation
 Massage
 Yoga
 progressive relaxation
 Hypnosis
 Guided imagery.
Manipulative and body-based methods
Based on manipulation and/or movement of one or more
parts of the body.
 Chiropractic or osteopathic manipulation
 Massage therapy
Energy therapies involve the use of energy fields
 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.
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AFRICAN AMERICANS: COMMUNICATION

Common medical terms and equivalent words used by
some AfricanAmericans (Stokes, 1977)
NAVAJOS:

COMMUNICATION: TOUCH
 Navajos extend a hand and lightly touch the hand of the
person they are greeting instead of shaking hands on
meeting another person.
IMPLICATIONS FOR NURSING CARE
 It is important to remember that the first encounter is not
always made to deal with official matters.
 It is meant to provide an opportunity for the nurse to
become acquainted with the family and vice versa.

Future rapport with the family is based on this
consideration
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IMPLICATION FOR NURSING CARE
COMMUNICATION: SPACE
For some Navajo people personal space is so important
and has no imaginary boundaries.
 Many Navajo people believe that shared space provides
a spiritual security and a sense of trust.
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IMPLICATIONS FOR NURSING CARE
 The nurse needs to remember that some Navajo clients
may have difficulty adapting to situations that place
them in spaces that are not familiar.
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It is important for the nurse to familiarize the client with
the space provided during hospitalization and when
personal space is limited during health care
administration.
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MEXICAN AMERICANS:
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IMPLICATION FOR NURSING CARE
Mexican Americans like consistent, close relationships and
physical touching.
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Female nurses should always assist a male physician in
examining a female client and guard against exposing
body parts other than those that are the focus of the
examination (Murillo-Rohde, 1977).
 Instructions should include all aspects of the client’s
condition and treatment and should be communicated
in simple, concrete terms with ample opportunity allowed
to raise questions and validate understanding.
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There should be continuous evaluation of learning by
questioning and return demonstrations, and problem
solving should be encouraged.
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SOCIAL ORGANIZATION
The elderly are respected and live with married children if
they are not self-sufficient.
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The elderly also pass down cultural and folk medicine
beliefs.
 Elder care is influenced by the belief that the family is the
most important and main source of assistance

Mexican American elders turn to their children and other
family members for assistance before seeking out any
services in the community.
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ENVIRONMENTAL CONTROL
Rituals: Implications for Nursing Care

Navajo healer may sprinkle certain foods, such as corn
and cornmeal, around the bedside during a curative
ritualistic ceremony.
 Nurse should keep in mind that this cornmeal (as well as
other rituals) is extremely important in the ritual
 because it does not have any negative health-related
implications, it should be left at the bedside until the
client and the family desire its removal (Primeaux, 1977).
APPALACHIANS
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COMMUNICATION:
IMPLICATION FOR NURSING CARE
 Positive interactions between an Appalachian person
and an outsider often require that a trusting relationship
first be established.
 Strategies to improve communication include making the
time to listen and talk about matters that are important to
the individual and the family.
 It may be helpful to use a direct approach, giving the
facts, discussing within the context of prior family
experiences, and soliciting the opinion and advice of
family members before making recommendations.
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SOCIAL ORGANIZATION- FAMILY
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If the family’s ideas and opinions are not incorporated
into the plan of care, the family and client may not
accept the health care recommendations or services.

Since health beliefs, practices, and religion are often
intertwined, it is important that an assessment of these be
done on admission to the health care system
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BIOLOGICAL VARIATIONS
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TIME
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focus on the present to meet overwhelming needs and
the uncertainty of what tomorrow will bring
may miss appointments or be late because they are
working to meet everyday needs, may lack
transportation, or are concerned about being fired if they
take off from work.
May live at a pace that facilitates an awareness of body
rhythms as opposed to clock time.
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Mongoloid heritage among Alaskan Eskimos is reflected in
the lumbar pigmented spots and the epicanthal eye
folds. •
nurse who cares for Eskimo children needs to be able to
distinguish between Mongolian spots and those bruises
that might be associated with child abuse. •
Enzyme deficiencies in lactase and sucrase have been
documented in Eskimos.
When given a lactose load equivalent to 3 to 4 cups of
milk, 80% of Eskimo adults and 70% of Eskimo children
demonstrated intolerance symptoms of flatulence and
diarrhea (Bells, Draper, & Bergan, 1973)
JAPANESE AMERICANS
 Implications for Nursing Care
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it is best and often necessary for the nurse to assess
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kinesthetic needs and gently access personal and
emotional space by visiting with the client before an
examination or treatment is performed.
NONVERBAL COMMUNICATION
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AMERICAN ESKIMOS: The Yup’ik and Inupiat
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COMMUNICATION:
TOUCH
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Through love, touch, and a combination of old and new
medicines, Keats reportedly healed her people (Pender,
1987).
The older Eskimo people give credence to the power of
touch as a direct result of a shaman’s healing powers
(Glassetter, 1989).
Shamanism, a belief that a person holds supernatural
powers, still exists among the Inupiat and Yup’ik of Alaska
but is not openly discussed, especially with non-Eskimos.
KINESICS

Eskimos use nonverbal communication extensively
through body posture and facial expression (Albert, 1988;
Boas, 1983).
 The nurse who understands the Eskimo culture will look for
nonverbal clues, such as watching the face for raised
eyebrows or blinking (indicating “yes”) or a wrinkled nose
(indicating “no”).
 Smiles and head nods in the Western culture may
indicate agreement, in the Eskimo culture they may
simply acknowledge the other person’s words.
 Among Eskimos, actual agreement is determined by
action.
IMPLICATION OF NURSING CARE
 Eskimos are very sensitive to the power of the dominant
culture and will withdraw from any form of judgment
implied by health care providers.
 It is of little value to lecture about alcohol use, chewing
tobacco, or dipping or pinching snuff, which Yup’ik
women may “chew” several times daily.
 The development of trust and acceptance is the best
form of demonstrating support for the community.
 This approach will allow the village community to
educate itself and seek to change unhealthy lifestyles of
community members.
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Relatively non–eye contact culture
Communication of feelings and attitudes is 5% verbal, 38%
vocal, and 55% facial expression.
Facial expression plays a crucial role in communicating
emotions and attitudes.
Viewed as a non-touch culture.
Do not appreciate aggressive or spoken forms of
communication and instead place a premium on intuitive
understanding of what is being communicated (Doutrich,
2000
ENVIRONMENTAL CONTROL
Death, Dying, Death Rituals, and Customs Observed
 Death is a natural part of the life cycle; thus death cannot
be overcome through human intervention (Bowman &
Singer, 2001)
 Mechanical interventions to prolong life may be difficult
to accept.
 Fresh flowers are acceptable to give to the dying or the
bereaved, a plant gift is considered taboo and is
associated with long-term illness
 A possible issue for Japanese and Japanese-American
families is the practice of diagnostic disclosure, the
discussion of a terminal diagnosis or poor prognosis with
the patient.
 The family is usually informed first, and they may decide
how and when or if the diagnosis is revealed to the
patient (Wros, Doutrich, & Izumi, 2004)

ENVIRONMENTAL CONTROL
Death, Dying, Death Rituals, and Customs Observed
 Death is a natural part of the life cycle; thus death cannot
be overcome through human intervention (Bowman &
Singer, 2001)
 Mechanical interventions to prolong life may be difficult
to accept.

BIOLOGICAL VARIATION
Somatization and Folk Traditions
 Folk healing is often used to treat physical ailments
because Asians tend to express emotional illness or
distress through physical symptoms.
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Japanese people are usually obsessed about a potential
problem related to their blood pressure.
Tracey, Leong, and Glidden (1986) found that AsianAmerican students appear to find it more acceptable to
react to emotional difficulties by focusing on academic
and vocational concerns.
When counseling was sought, Japanese-American
students tended to focus more on academic difficulties
than on emotional conflict.
IMPLICATIONS FOR NURSING CARE
 Preventive health care techniques should be
emphasized.
 Nurse must engage the support of other family members.
 To reduce chronicity and severity of hypertension, the
nurse must stress limiting use of soy sauce, salt-cured fish,
and pickles.
 Identify previous successful strategies in order to help the
client develop and refine coping strategies.
 To reduce stress, the nurse might suggest exercise
because it may be perceived by the client as a
nonconfrontational form of release.