This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice.
Chapter three:Transcultural nursing care of adults.
Section three: application of transcultural nursing models
This section extends our understanding of how a nurse's knowledge of transcultural care can be transferred into practice in order to provide nursing care in a culturally sensitive manner. As such it utilises the elements of the nursing process; assess, plan, implement, and evaluate, in conjunction with Roper, Logan and Tierney's (1983) 'Activities of Living' model in a problem-solving manner, concepts that will be familiar to nurses. Whilst it is recognised that Roper et al's model is predominantly focused around the physical aspects of nursing care, non-the-less its use provides a framework for describing the kinds of problems adult and older patients/clients may present with, in an acute hospital setting or in the community. When combined with a transcultural nursing model the nurse is enabled to engage with the patient/client in a culturally sensitive manner in the provision of culturally appropriate nursing care.
The nursing process
The nursing process is described as being cyclical, made up of four interconnecting elements and having a dynamic nature (Pearson et al, 1996). It has long been a feature of nursing care in the UK and when used in conjunction with a nursing model it facilitates consistent, evidenced-based nursing care, and necessitates accurate, up-to-date care documentation. The nursing process consists of four distinct phases, each having a discreet role in the process, whilst also being interdependent upon each other. The phases of the process are:
In this phase the nurse makes an assessment of the patient/client as soon as possible following admission to hospital or first encounter in the community. Biographical details e.g. name, date of birth, age, address are noted and observations of blood pressure, pulse and respiration are taken. Relevant medical, personal and social details are noted. Although considered to be the starting point of the nursing process, the assessment phase is ongoing throughout the patient/clients period of care.
This phase of the nursing process extends from the assessment and in conjunction with the patient/client wherever possible, family members/carers/significant others, determines how the individuals needs, wants and desires in relation to health are to be met.
This part of the nursing process details explicitly the care given to and received by the patient. It is an accurate, up-to-date account and is signed by each nurse engaged in delivering the care as detailed in the care plan.
Evaluation takes place at designated points during the patient/clients period of receiving health care. This is determined by the nursing assessment which identifies the specific needs of each individual and the subsequent plan for delivering the required nursing care. Evaluation is ongoing and leads directly back to the assessment phase of the nursing process, culminating in further planning of care or discontinuation of the need, want or desire for intervention.
In order to facilitate the nursing process, a number of nursing models are available that reflect certain attitudes, values, and beliefs about health, health care and nursing. When choosing a model for use in practice it should be consistent with the nursing team's attitudes, values, and beliefs about health, health care and nursing. The model used here to describe how nursing care may be assessed, planned, implemented and evaluated utilises the 'Activities of Living Model' developed by Roper, Logan and Tierney (1983). The framework incorporates a number of elements which make it applicable to adult and older patients/clients requiring care in acute and community settings. However, it should be noted that alternative models of care might be more appropriate with other patient/client groups, for example children, people with learning disabilities, or mental health problems. The nurse is advised to refer to the appropriate modules in this series for more information on the transcultural care of these patient/client groups.
The activities of living model
This model incorporates a life span approach, wherein the characteristics of the person are considered with respect to prior development, current level of development, and likely future development (Safarino, 1990). In conjunction with the life span approach an independence/dependence continuum is used. The model then incorporates a set of twelve activities of living (AL's), which represent those activities engaged in by individuals whether sick or well. Together these elements are referred to as "a model of living". When using the model of living in conjunction with the nursing process a model of nursing is utilised. The AL's are as follows:
- maintaining a safe environment
- eating and Drinking
- personal cleansing and dressing
- maintaining body temperature
- working and playing
- expressing sexuality
Assessment of the patient/client is made within each AL and taking into account the lifespan / independence/dependence continuum a plan of care is formulated.
In conjunction with the nursing process and the 'Activities of Living' model the 'Transcultural Nursing Assessment' is used to ensure that a culturally sensitive care plan is developed. Each interrelated factor of the Transcultural Nursing Assessment, i.e. communication, space, social organisation, time, environmental control, and biological variations is used to guide assessment within the 12 ALs. Although it could be argued that the 'Activities of Living' model encompasses these elements albeit in a different format, by using a combined assessment model it is envisaged that a full and complete plan of care can be formulated taking into account all transcultural factors, which affect the adult and older patient/client from any designated ethnic group.
Undertaking an assessment for a patient/client where English is not spoken or is not the preferred language requires attention to be paid to the means of interpretation. Successful interpersonal communication necessitates the interpretation of speech, tone and register of language, facial expressions, body language, gestures and assumptions shared between the communicants about the context of the exchange (Bradby, 2001). The distress and pain which brings a patient to the health service can render communication extremely difficult. The patient's ability to communicate in a non-native language about his or her cultural or religious background may be severely reduced by the nature of their illness or injury. Bradby (2001) suggests when working with or without professional interpreters, twice as much interview time as usual should be allowed. With professional interpreters, the nurse should schedule time to establish the terms of the interview with the interpreter before meeting the patient and should consult again once the interaction with the patient is over to confirm a common understanding of the interview. The interpreter should be given a few minutes to initiate rapport with the patient prior to the nurse consultation. The nurse should try to confirm that patient and interpreter speak a mutually comprehensive language and establish whether any social differences or similarities exist that might jeopardise communication (age, gender, religion) (Bradby, 2001).
Read Bradby, H (2001) 'Communication, interpretation and translation' pp129-148 in Culley, L and Dyson, S (Eds) (2001) Ethnicity and Nursing Practice. Buckingham. Palgrave.
Example of a transcultural nursing assessment
The following case study has been designed to illustrate the application of the Giger and Davhidzar (1998) model of transcultural nursing.
Read The Following Case Study
Mohammed Khalid Qureshi, a 71 year old Bangladeshi gentleman is admitted to hospital via the Accident and Emergency (A&E) department with a history of sudden onset chest pain. Mr. Qureshi speaks very little English, usually relying on his son, who was born in Britain, to communicate with people outside the Bangladeshi community on his behalf. Mohammed Khalid is accompanied by his wife, who does not speak any English and appears very anxious and upset. Mohammed Khalid and his wife live with their oldest son (a businessman), his wife and three children in a semi-datached house. Mr Qureshi's son has been informed of his father's admission to hospital by his mother. However, she has been unable to give him any further information. In the A&E department Mr Qureshi had blood tests and x-rays taken, and an Electrocardiograph (ECG). He was commenced onto continuous cardiac monitoring, along with continuous observations of temperature, pulse, respiration and blood pressure. Mr. Qureshi was given analgesia for his chest pain. He was transferred to the Coronary Care Unit with a diagnosis of 'Myocardial Infarction' (MI) for a period of intensive cardiac monitoring, further investigations and treatment. He was accompanied throughout by his wife.
Now examine the way in which a cultural assessment is formulated. The assessment draws upon general knowledge about health, and knowledge specific to the individual.
Transcultural nursing assessment
The first area of Giger and Davidhizar's model examined is 'communication'. The following information emerged during the assessment interview:
(a) Verbal Communication: Mr Qureshi speaks little English, Mrs Qureshi speaks no English, and Mr Qureshi's son who speaks English usually interprets and assists his father to communicate with English speaking people.
Aged parents usually live with their oldest son because it is considered disrespectful for old parents to live alone. According to the Qur'an, taking care of one's family is as important as other religious duties (Kulwicki, 1996). However, as health and social service professionals have discovered, it is a dangerous stereotype to assume that this applies in every instance. Within service provision stereotypical views about South Asian families 'looking after their own' (Ahmad and Atkin, 1996) can undermine the delivery of care.
You will find it useful to look at a discussion of the myth of extended family support in the section - Support for Carers in the module Ethnicity and Learning Difficulties by Ghazala Mir (2003).
(b) When asked, Mr Qureshi indicated that he wished to be addressed as Mr Mohammed Khalid Qureshi.
Most Muslim men have two or three names; a personal name, used by family members and very close friends, e.g. Khalid; a calling name, usually used by friends and acquaintances. Personal and calling names may be linked together. A religious name, e.g. Mohammed, may be used and is particularly sacred and should never be used alone. Some Muslim men use a hereditary name as a surname, to fit in with the British naming system, e.g. Qureshi.
(c) Non-verbal Communication: Expression of Pain - Mr Qureshi was admitted with severe chest pain resolved by administration of opioid analgesia. Mr Qureshi may indicate the return of his pain using non-verbal indicators e.g. pointing to his chest, groaning, grimacing, and perspiring.
The way in which each of us perceives, responds to and expresses pain is highly personal and is influenced by several factors (Melzak and Wall, 1996), including the general norms of our society or community as well as childhood experiences (Henley and Schott, 1999). In some families and cultures, people are brought up not to make a fuss, to be stoical, to show strength and fortitude, or to be a `good` patient. In other families and cultures, people are brought up to be vocal and demonstrative, which may include displaying agitation, moaning, crying out, rocking, chanting, calling on God, clicking fingers or slapping oneself. The use of a pain assessment chart, for example the McGill Pain Questionnaire, which shows the back and front of a naked body may be shocking and unacceptable to people who observe strict codes of modesty or for strict Muslims to whom making images of people is forbidden (Henley and Schott, 1999). An alternative pain assessment tool, for example a Faces Pain Assessment Scale (Bieri, Reeve et al, 1990) may be useful. However, some conservative Muslim patients may be prohibited from using a tool which depicts people.
A very useful extended discussion of the role of communication in ensuring the client's access to care and response to care provision should be consulted in the section - Communication and Information in the module Ethnicity and Learning Difficulties by Ghazala Mir (2003).
Space is the next area of assessment that was looked at. The following information emerged from the assessment:
(d) Mobility: Mr Qureshi usually walks unaided, but has recently had difficulty in climbing the stairs due to bouts of breathlessness and mild to moderate pain. At these times his grandsons assist him. Mr Qureshi may prefer to be assisted into and out of bed and to the toilet by family members.
(e) Personal Cleansing and Dressing: Mr Qureshi will require assistance with personal hygiene and may require personal objects to be available to him whilst in hospital, e.g. the Qur'an, and prayer beads.
People who feel dirty may become distressed if they cannot keep clean, especially if they are bed-bound and cannot wash themselves. Being dependent on others for washing, bathing and using the toilet is humiliating for most people, therefore it is important to protect the patient's dignity and to try and cater for their individual habits and preferences (Henley and Schott, 1999). Most religions and cultures contain ideas about purity and pollution. In South Asian culture, all body secretions including saliva, sweat, urine, faces, vomit, blood, semen, and menstrual fluid are traditionally considered polluting. Running water is believed to be the most effective cleansing agent. Most Muslims wash in a prescribed manner before each of the five daily prayers. The importance of being clean to pray or meditate may also mean that some people are more than usually distressed if they are unable to pray due to the presence of intravenous infusion lines.
Many Muslims always wash their perineal area with running water after using the toilet (a cultural and religious requirement). It is customary to use the left hand for cleaning oneself. In hospital there should be a bidet or basin in each toilet to enable people to wash themselves with running water. Dependent patients may appreciate having warm water from a jug poured over their perineal area before being taken off the commode, bedpan or toilet. As it is not possible to know who will require what assistance it is better to offer and be refused than to have the patient feel uncomfortable and dirty.
(Henley and Schott, 1999)
In many cultures special jewellery may be worn which symbolises good luck. Removing this jewellery signifies a very bad omen as it may be worn to protect against illness and danger. In most cases there is no reason to remove the jewellery or other items of religious significance. If there is a genuine medical reason, find out the significance of the item, and wherever possible, tape rather than remove it.
(Henley and Schott, 1999)
Social organisation is the third area of assessment undertaken. What did we find out?
(f) Expressing Sexuality: Mr Qureshi lives with his wife in a house, which belongs to his eldest son and his family.
Muslim men and women must perform the same religious duties: five daily prayers, fasting during Ramzan, almsgiving, and a pilgrimage to Makka (Henley, 1982). Muslims regard men and women as having the same rights, but different, though equally important, roles. In the Holy Quran, the different roles of men and women are made clear: men are responsible for all matters outside the home and for supporting their families: women are responsible for rearing and educating children, looking after the family and running the home. Within Muslim families, men and women generally share decisions, with women chiefly responsible for the comfort of the family, the upbringing and moral education of the children, and the atmosphere and conduct within the home. However, in most matters outside the home Muslim women should always be under the guardianship and protection of a man: her father, her husband, or her sons if she is a widow. This may be important in contacts with the health service (Henley, 1982).
In conservative Muslim families, a rigid code of public behaviour is followed. On visits among Muslim families, men and women do not normally shake hands. They sit separately and keep their eyes down in each other's presence. Outside the family Muslim men and women usually socialise separately.
As has been noted elsewhere the bonds of family connectedness, and the very definition of 'family', varies from culture to culture. In this case it is reasonable to expect that this patient will have an extended family wishing to express their concern, show affection and provide support. This may not sit comfortably with the routine hospital 'visiting rules' and particularly with the 'community of practice' of the Coronary Care Unit. How might this be managed sensitively?
What do we already know about the transcultural perspective of time?
(g) Admission: Mr Qureshi has been transferred to the Coronary Care Unit with a diagnosis of Myocardial Infarction (MI) for a period of intensive cardiac monitoring, further investigations and treatment.
Cultural religious beliefs and requirements, as well as personal values and experiences, influence patient's attitudes to their illness and to certain investigations and treatments. People who observe a strict code of modesty and are unwilling to undress or be touched, especially by a member of the opposite sex, can make examination very difficult. It is important to understand the depth of distress and humiliation that exposure and physical contact can cause and to try and understand the patient's point of view. Henley (1982) advises consideration of the following points:
- expose only a small part of the body at a time, keeping all other parts covered
- ensure all windows and doors are closed or screened, and bed curtains are drawn
- wherever possible have a health professional of the same sex to carry out the investigations
- ensure that only essential people are present
Ensuring respect for these concerns may require that a little more time is given to planning and delivering care. The routine time frame of the Coronary Care Unit should not be allowed to unthinkingly over-ride the needs of the patient.
Certain investigations and treatments may be difficult at certain times in the Muslim calendar. For example, during fasting for Ramadan, patients may refuse to have blood taken in case they become weak. Muslims may also be reluctant to take medications during fasts or to have investigations that involve eating and drinking: for example glucose tolerance tests and barium meals.
Confidentiality is very important. It is essential never to assume that patients have told their families or wish their immediate families to know what is happening to them or details about their diagnosis. In a situation where a patient declines to give consent for a procedure or treatment, especially when the illness is life threatening, it is important to find out their reasons sensitively and to see whether an alternative way forward can be found.
Again administrative procedures are being carried out it is appropriate to consider in whose interest urgency is being defined.
What do we already know?
(h) Diagnosis: Mr Qureshi has a diagnosis of myocardial infarction
Health professionals have the difficult job of telling patients the truth about their diagnosis and prognosis. Whether people want to be told their diagnosis is influenced by cultural and religious beliefs (Henley, 1982). The Nursing and Midwifery Council (NMC) (2002) incorporates the shared values of respecting the patient as an individual, obtaining consent for treatment, and protecting confidential information. Working within the guidelines of the NMC requires nurses to ensure that in times of conflict, they are first and foremost accountable to the patient. Henley (1982) advocates the following principles in difficult and painful situations:
- share a commitment to a duty of care, to patient autonomy, confidentially and consent, and to responding honestly to patients (for example, giving bad news)
- understand the importance of respecting different cultural and religious values as part of their duty of care to patients
- keeping well informed of patients and relatives needs, wishes and desires for knowledge of diagnoses, prognoses and available treatment options
- explain all reasons and actions to relatives and patients
- give support to relatives whose wishes conflict with the professionals understanding of what the patient' wants
- In seeking to fulfil these obligations it is appropriate to bear in mind how the patient understands the nature and cause of their illness, and what they regard as the appropriate treatment. The patient's health beliefs may powerfully impact upon how they respond to the diagnosis and to how they conceive of their role in shaping their recovery.
How individuals and communities perceive the nature of their illness, and how they understand their appropriate response to it has a major impact upon the process of care. An illustrative comparative example can be found in relation to the response to disability. You will find it useful to read the section 'Barriers to Independence' in the module Ethnicity and Learning Disabilities by Ghazala Mir (2003).
(i) Ethnic Origin: Mr Qureshi is of bangladeshi origin
Research on ethnicity and health tends to be emphasis to genetic and cultural explanations (Nazroo, 1999). The reason for this is the way in which ethnic groups are identified in the research process, in spite of a general agreement that `race` is a concept without scientific validity. The notion that people can be divided into races on the basis of genetic differences has been shown to be false (Barot, 1996). There has been criticism of the well publicised so-called greater risk of `South Asians` in the UK of coronary heart disease (CHD) as it relies on the misuse of `race` as a way of identifying people for the purposes of research. The problem of CHD has been attributed to a combination of genetic (race) and cultural (ethnicity) factors that are apparently associated with being South Asian. Concerning genetics, there is a suggestion that South Asians have a shared evolutionary history that involved adaptation to survival under conditions of periodic famine and low energy intake. This resulted in the development of insulin resistance syndrome, which apparently underlies the greater risk of CHD affecting South Asians (Nazroo, 1999). Nazroo (1999) argues, that by taking this perspective South Asians are being viewed as a genetically distinct group with a unique evolutionary history- a race. Furthermore, in terms of cultural factors, the use of ghee in cooking, a lack of physical exercise and a reluctance to use health services were all mentioned - even though ghee is not used by all the ethnic groups that comprise South Asians, and evidence suggests that South Asians do understand the importance of exercise and how to use health services. The problem is apparently viewed as something inherent within a distinct biological group and nothing to do with the context of the lives of South Asians. Nazroo (1999) concludes that the tendency to view ethnicity in isolation leads to the racialisation of ethnic inequalities in health. Ahmad (1993, Chapter 2 pp.21-22) provides a robust critique of the simplistic use of consanguinity in the explanation of minority ethnic morbidity rates.
Read the following text
The above transcultural nursing assessment of a patient admitted into hospital with chest pain, explains how the nurse can provide culturally sensitive nursing care, whilst also providing for the physical, psychological and spiritual needs of the patient. The use of a combined model incorporating the nursing process and the activities of living framework ensures that holistic care is given. However, in care settings other than adult/eldery different nursing models may be more appropriate (see relevant modules in this series). Similarly, other transcultural nursing models may be used as an alternative to the Giger and Davidhizar (1998) Transcultural Nursing Assessment, for example the `Sunrise Model` (Leininger, 2002).
Exercise 3.10 Group Activity
The following scenarios are designed for use in developing the practice of providing culturally competent and sensitive care. A prescriptive view to the use of one particular framework in not advocated here, as the nurse should be encouraged to view patients as individuals requiring cultural care that is appropriate to their needs and to the environment of care. To this end nurses are encouraged to develop a transcultural nursing model that is appropriate to their specific area of care. This module should be used to support and inform the development/choice of suitable frameworks.
However, to begin to think of transcultural issues and transcultural assessment techniques you may find it easier to attempt Giger and Davidhizar's model of transcultural assessment with the following three scenarios:
Practice scenario 1
Mina Khan is a 20 year old married Pakistani women. She was admitted to the ward with acute abdominal pain. She is a practising Muslim and speaks no English. On admission she appears extremely agitated, frightened and in considerable pain.
Practice scenario 2
Frederick De Souza is a 30 year old Rastafarian, living alone. He is admitted for investigations following a bout of vomiting and diarrhoea and acute abdominal pain.
Practice scenario 3
Su Li Chan is an 80 year old Chinese woman, who lives with her husband. She is admitted in acute liver failure. Mrs Chan speaks very little English and relies on members of her immediate family for assistance with communicating with people outside of the Chinese community in which she lives.
Whilst undertaking these assessments try to adapt the model you are using to your area of practice. Make any necessary changes to ensure you have a user-friendly assessment framework, which will enhance the care you provide for all clients with whom you work.
This section has considered how the nurse's transcultural nursing knowledge can be translated into transcultural nursing practice through the use of a model of transcultural nursing in combination with the nursing process and a model of nursing. Whilst the example given combined the nursing process, the activities of living model (Roper et al, 1983) and the transcultural nursing assessment (Giger and Davidhizar, 1998), nurses are encouraged to reflect on their own particular areas of practice and client group in order to develop a model that is appropriate and sensitive to the needs of the patients in their care. In so doing, the problem of viewing people with ethnic backgrounds different to our own as `other` and therefore `apart from` ourselves is avoided and culturally sensitive care can be provided by nurses who are culturally competent practitioners.