analyzing the meaning of the couple health-illness for the professional nurse,
we come to face the complex phenomenon of caring, which emanates from the relation
established with the human being as source of attention while presenting different
ethnic groups, religions, genders, customs, beliefs, or educational and socio-economical
levels among others. The diversity of cares provided by this professional will
not have enough quality unless the vital experiences of these persons, as well
as their own interactions with their surrounding environment, are fully covered,
understood, analyzed and articulated.1,2
the enumerated characteristics of the nursing practice are understood, the discussion
about the management of Care should revolve around the nursing knowledge. Care
management implies the permanent building of a nursing language and its positioning
in the social and health organizations. It also implies, care as a communicative
act that requires scientific and technological knowledge as well as consciousness
of the cultural context in which the subjects of care live, recreate and fall
1. Connection Medicine-Anthropology
to start this analysis, we must remember the fact that the links between Medicine
and Anthropology are ancient, deep and complex. Up to the end of the XIXth
century, Anthropology was one of the basic Medical Sciences and as such, it
had a fundamental role in the consolidation of the Medical Theory and its political
The medical model is the result of a coyuntural process throughout which the
technical Hippocratic-Galenic Medicine, which had a empiric-naturalistic approach,
incorporated the biological paradigms of the experimental sciences to end up,
at the end of the XIXth century, abandoning the political-social discourse about
health and illness.4,5
Some years later, in countries like France, Germany and USA at a later stage,
the hegemony of the medical model strengthened the process of medicalization,
that is, the penetration of the view or medical perspective into the popular
and illustrated knowledge. This process of medicalization was frequently used
as strategy to ensure the monopoly on the health attention.
hegemonic implantation of the medical model was making the Medicine become more
dependent on the biological parameter, and more focused on the cure than on
prevention. It used the anthropological discourse to legitimate the fight against
intrusiveness and to deny the possibility and effectiveness of selfcare.6
Nowadays, in spite of multiple researches that have reported the need of adopting
a more holistic model, this medical model is still valid in the education of
the health professionals, within which nursing is not an exception.
2. The Culture
but not less important aspect that should be considered, is the own culture
of each nurse, related to his religious beliefs, his familiar relationships,
his mother tongue, etc. This personal culture is entwined with other subcultures
inherent in the context, such as the professional identity or the identity of
the institution in which the profession is fulfilled, among others. This cumulus
of cultures and subcultures may originate cultural barriers between the professional
and the patient, giving as a result deficient care or a questionable quality
of this care.
The Cultural Competence can be defined
as the complex integration of knowledge, attitudes and abilities that increases
the communication between different cultures (cross-cultural communication),
and the effective/appropriate interactions with the others.7
Using this definition, it could be stated that in order to favour nursing care
with a certain quality, the professional should have knowledge, sensibility
and the will to collaborate on it.
The social commitment
that the nurse has to care for the individual, family and community, requires
that in addition to the knowledge of the technique, the instrumental aspects
of caring, and beyond the intellectual understanding, the knowledge of this
other person exists through a holistic relation. The current social dynamic
makes the nursing care becomes an ongoing challenge, as it must take into account
the values, beliefs and practices of the individuals under care, as well as
showing respect for the difference when offering such care.
is one of the central issues of the profession. Even if it has had many different
meanings, all of them have as common feature of interaction between human beings.
This fact implies, from one side, a way of being, throughout which the person
gets out of himself and focuses on the other with effort and solicitousness.
On the other side, this fact implies a concern and interest from the person
providing care, which makes this person, feel involved and emotionally bound
to the other.8
implies understanding and this necessarily includes a process of empathy, identification
and projection; besides, as human phenomenon, care contains a dimension of inter-subjectiveness
which requires openness, sympathy and generosity.
care as such is a permanent partner of the human being, as he/she will
never stop loving and nor caring for others, nor will stop concerning for somebody,
in the case of the profession of nursing these two meanings of care are valid
if it expects to promote life, prevent illnesses and encourage healthy actions.
we observe the changing, plural and diverse nature of our society, we can notice
that the type of originated relations are culturally heterogenic. This condition
points out the need of including the transcultural dimension in the professional
education, in order to offer a humanistic care, focused on the well-being of
people, and open to cultural diversity, through the process of attention.
was the first nurse who conceptualized the Transcultural Nursery,9
based on an anthropological perspective. She proposed the Model of the Raising
Sun to illustrate the Theory of the Universality and Diversity of the Cultural
This theory indicates that in the same way that people from all around the world
have universal and diverse characteristics according to their culture, health
care has similarities and differences according to the cultural context in which
it takes place. For this reason, to make nursing care efficient and culturally
congruent, these similarities and differences must be identified and understood
by the professionals assisting this people.
the last decades Nursing has analysed the concept of integral human being, which
considers the human condition being at the same time physic, biological, psychic,
cultural, social, spiritual and historic. Nevertheless, the professional practice
is not as integral practice as this discourse indicates. The most of the patients
are taken care on emphasising biological aspects or bio-psychological aspects
in the best case, doing little efforts to widen the perspective towards an integral
dimension. An example of this could be the social factor that mainly appears
when inserting some elements of the environment or family.
transcultural dimension is an opportunity to include the humanistic stamp in
the nursing care as it promotes the discovery of the cultural perspectives of
the patients, of their practices, and their values associated to care. When
those last ones are considered, even the most difficult person to treat can
As an example of the former argument,
it can be pointed out the fact that the exploration of the logic basis of the
causal histories of the patient, related to his processes of health or illness,
can help to a better understanding of his expectations and perceptions related
to the effectiveness of his care practices.12
This knowledge helps the nurse to plan interventions facilitating not only an
informed decision from the patient side about the care that is provided to him,
but also the negotiation and restructuring of the care plan. The most important
fact is in this case, the fact that the patient feels that he is treated and
valued as a unique human being, being respected with his characteristics of
Working towards the transcultural
flexibility is an aspect on which it is necessary to go more deeply into. It
represents an effort which implies not only changing the security and comfort
of the recipes ready for every situation of care, but also having an empathic
relation with the individuals/families/communities, communicating with ability
in the different cultural scenarios, added to acquiring cultural knowledge of
the different communities in order to identify the differences and similarities
of care. The final objective is to offer sensitive and competent actions from
the cultural perspective. Considering this "Cultural Diversity" implies the
assimilation of the fact that, today's society is defined by relations of people,
cultures, traditions, ways of life and political and religious differences.
As a consequence of this consideration, the processes related to health-illness
cannot be abstracted from this pluralist reality, in which this diversity, as
a positive strength, defines a challenge to understand our personal differences,
while we recognize our similarities in the human values and needs.
the perspective of the nurse, taking care of the individuals, families or communities
under this point of view, implies the definition of a programme of care culturally
congruent and competent. In other words, it implies having the capacity of feeling
the other, recognizing the subjectiveness of the human being.
3. Cultural diversity
as element of evaluation in Nursing
into account their incidence in the cultural diversity of the human groups,
some of the dimensions that the nurse should consider when offering care will
a) Ethnicity and religion.
Normally those two elements are connected. Religion can act, to say it somehow,
as a moulding for the values, beliefs, and practices related to health. Religion
acts as guide for the daily living, for the interactions between individuals...
For example, decisions about what should be eaten or not, the medicines which
can be ingested, the way to face illness or death are, among others, aspects
which can be defined by the religion and ethnic group to which the persons belong.13-15
b) Immigration. Among
all the changes that the human being has to adapt along his life, few of them
are as wide and complex as the ones linked to the phenomenon of migration. Practically
everything surrounding the emigrant person changes: from aspects as basic as
food or family and social relations, up to the weather, the language, the culture,
the status, etc. It could be said that there are very few things remaining as
same as before around the person who emigrates.16
people move from one place to other for multiple reasons and in very diverse
circumstances. In any case, this phenomenon produces in them three common outstanding
characteristics that are important to consider in the assessment made by the
nurse: the break-up, the difference and the difficulties of access.17
because the most of the emigrant people have left behind the support of their
traditional values, the family circle, their friends, the social and familiar
ways of life and the contact with the ethnic group.
that is associated to the new culture to which they are exposed, leaving behind
a series of conceptions and attitudes about the world, and about how a person
should behave in it. This difference is also seen in the language that can be
very different to their mother tongue. This can derive into immigrants socially
isolated in their new environment.
of access, due to the fact that usually immigration affects the individual
making him move back in his level of social status compared to his society of
origin. This situation is associated to important physical risks to which the
immigrant is exposed as he counts on limited economic resources, and the social
security protection and health services become difficult to obtain.
and displaced people within each country are included in this category of immigrants.
Those people are grouped in marginal areas of the cities, or in camps that are
supposed to be temporary, or have no home at all. These individuals are generally
separated from the rest, either because of their culture or their mother tongue.
The nurse faces the difficult task of overcoming these differences, improving
his cultural sensitivity and his interpersonal communication in favour of the
no-discrimination, the sensitivity and the tolerance.
c) Residence and Regional
Differences. They constitute another dimension that influences the cultural
diversity of the society. Urban, suburban and rural areas define important variations
in the ways of life of people. As it happened with the dimensions mentioned
before, these variations demand the acquisition of a deep knowledge about them
in order to offer competent cares with high quality adjusted to the cultural
reality of each human being.
d) Generational Relation.
Different generations within a family may hold diverse perspectives of life,
which will affect with a higher or lower intensity their values, beliefs, and
health practices for example.
These changes of perspective
are fundamentally due to the continuous and rapid evolution of the world related
to the phenomenon of globalization, in which the elder adults are the ones who
manifest the bigger difficulties to assimilate and adapt to the vertiginous
4. Culture and Nursing
knowledge for nursing involves providing cultural care, for which the professional
must posses abilities to ease the cultural competence on it.18
Cultural competence implies the acceptance and respect for the cultural differences,
sensitivity to understand how these differences have an influence on the relation
nurse-patient and vice-versa, and the ability to find strategies to improve
the cultural gatherings according to the needs stated by the patient.19
developed a conceptual model that provides to nursing a guide to help making
efficient and culturally competent interventions. This model defines cultural
competence as the process with which the provider of health fights to acquire
the ability to work effectively within the cultural context of a client, a family
or a community. According to Capinha-Bacote,21
this process requires the health providers more to be perceived as becoming
culturally competent, than actually being culturally competent.
constructs included in the model to acquire cultural competences are: cultural
consciousness, cultural knowledge, cultural ability, cultural desire and
cultural gatherings. These constructs are interdependent among each other
and they can be experienced no matter the place or situation in which the professional
is offering care. Any of them can be exercised to improve its reach and effects.
term cultural consciousness defines the deliberated and cognitive process
throughout which the professional of health becomes a sensitive detector of
the values, beliefs, ways of life, practices and strategies for problems solving
in the culture of the clients. This process considers the knowledge of the own
values and the prejudices that each one has about other cultures, added to a
deep exploration of the own culture. This exercise is essential as it exists
a tendency to be ethnocentric and impose the own values and beliefs to the others.
Not being conscious about the own values and beliefs entails the risk of being
imposer when offering care. Nevertheless, being conscious about the personal
perspective, does not warranty culturally competent interventions.
cultural knowledge is understood as a search process to obtain different
views of the world in the different cultures. Cultural knowledge is focused
on knowing the viewpoint or the vision about the world of the client; that is,
the emic perspective. It is important to be aware of the fact that the
preconceived ideas, the rationalizations based on arbitrary ideas, and the inability
to practice self-criticism, are the origin, in the most of the cases, of the
ethnocentrism. With it, the potential deficiencies and weaknesses of the professional
are covered. This scheme can lead to a merciless behaviour of the professional
in the view of the deficiencies and weaknesses of the others.18
ability in this model is understood as the skill to collect cultural
data related to the health history of the client, in order to perform his/her
cultural evaluation. Regarding this concept, Leininger (1978) defines the cultural
evaluation as an assessment or systematic examination of the individuals, groups
and communities and their values, beliefs and practices, in order to determine
their needs and the interventions that should be made within their context.
During the interviews and observations, the professionals of health can obtain
information about the perceptions of the clients, added to information on possible
modalities of treatment. In this sense Bushy (1992) states that it is important
to explore, as an example, if the person trusts its own care, or if he likes
the traditional folklore practices. If this is the case, it is interesting to
know which are those practices and if they are oriented to the promotion of
health, the prevention of illnesses or the recovery. Likewise it is important
to know whether the person is being treated by quacks, and if he is interested
in sharing the information about the interventions that this person of the community
is offering him. In the same direction, it is remarkable the fact that many
patients would prefer to have quacks and nurses supporting them as a part of
the proposed plan of care. If this is the case, it is necessary to know how
these cultural quacks can be contacted. Finally, as a part of the cultural ability,
it is necessary to find out if the patients want to have a special person, a
friend or a relative, present during the process of care. In that case it is
necessary to know which one would be roll of that person within the procedure.
cultural gatherings refer to the processes throughout which the professionals
are encouraged to directly engage in cultural interactions with clients from
diverse cultures. Sometimes, these professionals think that they know all about
a cultural group just because they know two or three members of it. It might
happen that those two or three members sustain or not the beliefs and practices
of the group in general. This is due to the fact that, inside every group there
might be what is called intra-group variations. Nevertheless, interacting with
different groups might be difficult and uncomfortable. The good intention and
the non-verbal communication can be misunderstood by the patients.
the cultural desire is understood as the motivation that the providers
of health care have on the issue of willing to compromise in the process
of cultural competence.
of cultural competence to provide a sensitive and culturally competent care
is a task to which nurses should engage. There are diverse strategies throughout
which the world of our patients can be understood. Research has an important
role within those strategies. For example, values, beliefs and practices related
to health and their own procedures of care can be identified in a systematic
manner through ethnographic analysis. Besides, ethnographic researches have
contributed with substantial elements to determine health behaviours within
groups, and differences in those health behaviours among groups. According to
Leininger (1991), this type of knowledge qualifies the professionals of nursery
to offer a culturally congruent care, abandoning the ethnocentric positions
and easing the decision about which practices, beliefs, and values can be preserved,
which ones should be negotiated, and which ones, in sufficiently justified cases,
should be restructured.
The decisions and actions
of care determined by the professional will be beneficial and satisfactory for
clients/patients if based on the evaluation of benefits and risks of beliefs,
values and ways of life.
The protection and maintenance
of the cultural care is crucial, due to the fact that nowadays multiple strengths
capable of devaluating human life exist. The consumer society, the high technologies
and the lack of sensibility are some of the pressures that avidly affect and
produce the loss of some of the autochthon values, with the subsequent loss
of copious possibilities of care generated in the pure diversity of the human
being. Nursing must identify, for the individuals that take care of, those practices
and values worthy of keeping them due to their promotion of the well-being and
the appropriate life conditions to preserve health. In this sense, in case the
belief or practice is beneficial or does not represent danger for the life of
the patient, it could be preserved. On the other hand, in case the practice
could end up becoming a risk for health or favouring an illness, an agreement
should be negotiated, supporting the belief but suggesting or adapting a more
beneficial practice. Finally, if the practice or belief is potentially harmful
the nurse must hold a firm position in the explanation of the risks. He or she
must help the person to substitute the practice by a healthier one, always recognizing
the autonomy and decision of the individual himself.
into account these three ways of acting would favour a differential care, based
on the singularity of the human being. Nevertheless, if at the same time the
universality of the practices and values in the different communities was recognized,
the generalities of the method could be determined. In this sense, as Morin
this cultural model can prevent the destructive effect of a technical-civilitational
domination that would eliminate one of the biggest treasures of cultures: their
diversity. On the other side, it is also useful in order to appreciate the human
being as a unique being.
Nevertheless, not only the
ethnographic researches favour the development of the cultural competence. This
cultural competence can also be acquired through activities like counselling,
intense immersion experiences in different cultures, formal education or informal
education through workshops on transcultural care.
incorporation to the nursing work of a transcultural way of thinking promotes
a wider consciousness about the human complexity. This will promotes the discovery
of the multiple aspects that each human being posses within his condition of
human, instead of reducing the human being to the minimum part of himself or
the worst fragment of his past.
The acceptance and
respect for the cultural differences, the sensitivity to understand how these
differences influence the relations among individuals and the ability to offer
strategies to improve the cultural gatherings are essential requisites for the
transcultural care in nursing to consolidate.
of the Health Care depends strongly on the role assigned to nurses. Nursing
has obtained important achievements in the last 20 years. Nevertheless, the
traditional problems added to those emerging from the era of the globalization
configure together a complex scene. Improvements in such complex outlook can
be achieved by working on the following tasks in order to build up Nursing as
a profession that offers culturally competent cares:
of the educative models and reorientation of the education plans towards complex
-Orientation of the nursing education
towards the needs of health of the population, and creation of new integral
models of education based on concepts and practices within public health and
primary health attention.
-Promotion of the 'critical'
-Permanent analysis of the impact of globalization.
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