ENTRAR            

CONSENSUS

Research, Nursing care and Cultural diversity*
María Nubia Romero B.
Lecturer, College of Nursing. Pedagogical and Technological University of Colombia. Director, Working Group on Exclusions and Resistance in Healthcare -GERCUS-. Tunja, Colombia

Manuscript received by 23.12.2007
Manuscript accepted by 27.08.2008

Index de Enfermería [Index Enferm] 2009; 18(2):100-105
*Contents of the Round Table developed inside the International Symposium about Community Nursing Research (Granada, Spain, Escuela Andaluza de Salud Pública, 2007 October 4-5)

How to cite this document

Introduction

    Research and theory regarding cultural care experienced a significant boost in the late 20^th and early 21^st Centuries. Rising poverty which marginalises and excludes; increasing migration and glocal displacements - a term we shall explain later; the exclusion of traditional and popular wisdom; the inefficiency of healthcare systems, along with many other phenomena have all urged sensitive people the world over to call for resistance against the dogmatism inherent to modern science and to embark on research on cultural care. Diversity became a hot topic in nursing when the excluded made their voice of resistance heard, leading to friction between traditional and professional care.
    Dr. Madeleine Leininger has played a remarkable role in this new thrust with her theory on "Cultural Care Diversity and Universality" which promotes cultural competence among professionals so that they may be in a position to learn, understand and care for others according to the patient's cultural context. This approach not only benefits quality of health, but it also fosters peace in the world.¹ Her contributions are joined by many others - the authors of close to forty research projects, theories and discussions in the literature which I have reviewed for this presentation, seeking to further clarify the significance of cultural diversity in community nursing research.

Research on cultural diversity and globalisation

    In seeking to unravel the role of nursing research in generating knowledge regarding cultural care diversity, I have come across the debate addressing the various ways in which the world and its cultures are conceived. This is also clearly a further thread in the discussion between the global and local arenas, or between mainstream and alternatives, between domination and emancipation. In the light of the fact that current globalisation "leads to the universality of modernity based on a Euro-American style",² this debate is highlighted explicitly and implicitly in the research projects, theories and discussions - published in both national and international journals - that have been reviewed.
    In the context of understanding the meaning of diversity of care from the point of view of alterity (or feeling of otherness), the topic of globalisation arises given the significant presence of immigrant populations in both Europe and the United States. This has triggered the need to "provide culturally sensitive care";³ to expand the components that make up Leininger's "cultural competence" model to also encompass research on care;⁴ to adapt nursing care delivered in the hospital setting to cultural differences;⁵ to learn to live amid these differences and "home in" on immigrants;⁶ or to highlight cultural clashes that arise when interpreting the meaning of illness,⁷ drawing from anthropological contributions in the field of nursing. As a result of these issues, academia is also keen to provide cross-cutting professional training in the entire curriculum to ensure that healthcare delivery is useful and respectful of multiculturalism.⁸
    However, globalisation displays a plethora of nuances, depending on the interests that it pursues. For instance, imperial globalisation² seeks to exercise control over populations and resources to benefit those who staunchly advocate the neo-liberal model. Indeed the healthcare sector has been trapped in this category. Currently, modern healthcare systems are being clearly "commercialised", leading to exclusion/subordination in care delivery, therapeutic approaches and quality of care, as human beings are being treated as "things", and given there are no public healthcare policies in place that may help to build equity, justice and the right to welfare, without dismissing other traditional or popular forms of wisdom. Nursing, through the generation of knowledge, has made some efforts to draw attention to global exclusions, rolling out local hospital initiatives aimed at adapting care to the cultural differences that mark the globalisation process.
    In opposition to the dominant notion, the concept of solidarity-based globalisation or global justice has now emerged.² These foster a new logic for the social arena, based on self-organised structures, in non-hierarchical and non-excluding structures, through which trans-cultural nursing can address otherness - be it that of immigrants, the displaced, excluded or marginalised - as an opportunity "to look at ourselves in the mirror".⁶ The aim is to see otherness as equal but different, and to ensure that those disparities are not used to justify exclusion or denial, but rather involvement, liaison and re-arrangement. Another aim is to seek cultural competence among nursing professionals, to promote a humane approach to trans-cultural care in order to achieve consistent and efficient care in the light of cultural diversity, as explained by Ibarra Mendoza.⁹ However, diversity should not involve levelling out; diversity should bring together variety and uniqueness, the global and the local, to ensure that "a place" is not consumed by global forces to the point that it is stripped of its own peculiarities.
    Studies on cultural care diversity suggest that the world is not only global, since in all cases "globalisation entails localisation". Hence, I believe that cultural care is not genuinely universal, in the hegemonic and homogenous sense. So-called universal care - in Leininger's theory - or global care, comprise forms of care configured on a local basis, through diversity and multiple structures, relationships, cosmovisions, representations, popular wisdom and practices of care that have migrated along with individuals and groups of individuals, whether they are included in or excluded from society. This multicultural concept has been shaped on the basis of local cultures that have characterised the countries and regions studied by other US and European colleagues. That is why I believe that there is no dwelling without roots, or roots without dwelling, as opposed to Moreno's standpoint.⁶ This broad range of features, where local aspects are vital for the type of globality that we wish to achieve, is referred to as glocality by Arturo Escobar,² as a more appropriate term.
    This paradigm shift in modernity, which is gradually taking hold as a result of intense theoretical, epistemological, historical and political debate regarding the implications of unipolarity, has enabled globalisation to be postulated -from the Latin American school of thought- as a process leading to a pluriverse;² in other words, a plural space where many worlds -in the plural- are indeed possible, "a genuine multiplicity of political-cultural configurations, social-environmental designs and economic models".²
    This pluriverse appears in miniature form in all the literature reviewed for this presentation. Colleagues acknowledge the right to plurality, diversity, multiculturalism and hence seek how to deliver culturally consistent, safe and significant care to all subjects and groups in the context of their own cultural diversity. However, when I say all the literature reviewed, I am not implying there is a homogeneous approach; quite the contrary. In fact, the contents of this literature reveal cracks, heterogeneities, shortcomings, contradictions, concerns in both theoretical and empirical contributions. Rather than being a problem, this particular feature is a normal and desired pre-requisite for this particular stage in the theoretical and practical approach to cultural care.
    The studies published by Juliet Lipson¹⁰ address care-related issues in excluded and marginalised groups, such as the case of female immigrants and refugees in the US. They share their marginality status with poor Afro-American women who are subjected to a double or triple status of exclusion and marginalisation in the context of cultural diversity. Josepha Campinha-Bacote,¹¹ on her part, proposes a care model called "The Process of Cultural Competence in Healthcare Delivery" for individuals with diverse ethnic and cultural backgrounds and ancestry. Lipson addresses culturally competent nursing care -expressed as culturally compatible, appropriate, sensitive, receptive and informed care- and focuses on issues such as culture, race, gender, sexual orientation, disability, and social class and economic status. Josepha Campinha-Bacote studies cultural competence in the light of five premises: social awareness, cultural knowledge, cultural technique, cultural encounters and cultural desire. These authors, together with Madeleine Leininger, have extended their conceptual models, such as "Cultural Care Diversity and Universality" and the "Theory on Transition and Marginalisation" by Melies and others, to a global level. These theories are now being quoted increasingly -without further discussion- in Latin American research.
    Understanding cultural care in the North American setting is broached using theories that have been established in the field of nursing, like Madeleine Leininger's and others - some in the making - such as the "Theory of Transition and Marginalisation". These theories allow us to gain insight into the significant changes that affect those facing transitions, who perceive their loss of identify and lack social support networks. As a result, they feel uprooted, vulnerable and their lives -both present and future- seem to be hanging in the balance, with great uncertainty.¹⁰ Leininger's theory is present in the discourse of both male and female US and European nurses addressing the problem of a culture of care, like a beacon guiding theory and building care models from this standpoint. This trend is barely beginning to be perceived in Latin America, except in Brazil where impressive progress has been made thanks primarily to post-graduate training.
    Studies on cultural care diversity conducted in Spain and Latin America refer to colonisation, placing it at the forefront today. Pre-Hispanic American culture became known in Europe through the representations, imagery and social practices which were "globalised" by colonisers throughout the continent and assimilated under a global order that was only just emerging from obscurantism. In the process of designing a modern world, colonisation gradually suppressed the wisdom and cultures that were considered as inferior. Another thorny issue in the colonisation process is that, within this excluding and dogmatic logic, modern science has committed a sort of "epistemicide"¹² since, in the words of Sousa de Santos, this scientific knowledge marginalised other forms of wisdom which, from various cosmovision perspectives, explained and helped understand their worlds and the reality that surrounded them. Such is the case of local traditional medicine wisdom and practices which are now being snapped up by multinational companies for commercial exploitation. In addition, at a glocal level, colonisation brought violence, domination, exclusion and the displacement of indigenous and black peoples, which has since continued with other groups such as migrants, diasporas, peasants, women, the deprived and homosexuals, just to name a few. All these groups are now being studied from the ethnographical perspective to shed light on the current panorama of cultural care diversity in nursing.
    In the context of colonisation, it is worth noting the globalising effect of the San Juan de Dios community in Latin America, which led to the opening of hospitals under the same name and based on its philosophy, namely "humanisation and hospitality/ hospitalisation as actions intended to achieve people's well-being and happiness, while respecting their freedom and dignity".¹³ These principles turned Columbian hospitals into a symbol of legacy in delivering healthcare to the deprived, the excluded and socially downtrodden in the country. This emblem and its philosophy were destroyed, and the remaining rubble shows the footprint of savage capitalism which commercialises health putting an end to a fundamental right, turning health into a commodity that is bought and sold.
    We can now say that history is repeating itself, with certain local nuances and anecdotes that emerge in research on cultural healthcare. It is precisely the cultural diversity of those excluded from the right to access healthcare which points to other forms of care, other forms of knowledge, preventive practices, other cosmovisions on the meaning of health and illness, other forms of imagery and social representations. This has led nurses the world over to identify strategies that can build bridges, covering a broad range of approaches; from raising awareness,^3,8,11,14 assimilation,¹⁵ translation,^9,16 legitimisation¹⁷ to cultural competence.^8,9,11,14 What they all have in common is the intent to improve "care encounters" between disparate cultures. These histories of care were not assimilated by the hegemonic power of healthcare systems; they still resist demise from the local and global spheres while contributing to the forces of multiculturalism that are mapping today's world.
    Undoubtedly, despite years of cultural resistance, the backdrop to some histories of care display signs of local crossbreeding, as is the case of popular or peasant wisdom.¹⁸ These forms of knowledge and practices also migrate and transfer without shedding their representations and imagery. This places nurses in a situation of conflict since they feel incapable of understanding cosmovisions¹⁹ that appear so alien to their own cultural setting. Men and women referred to as the alterity on account of their differences, are an active or passive component of the social movements that resist the intentions and actions geared towards the "deepening and universalisation of modernity".² Some examples of this resistant alterity are traditional medicine systems in Latin America;²⁰ popular use of natural remedies;^21,22 mixed hospitals in Mexico;²³ clinical care units at Pennsylvania Hospital;²⁴ wisdom and care practices used by peasant,^18,25 black, migrant and marginalised women;¹⁰ endeavours made in the field of nursing to eradicate the stigma, fear and discrimination associated to diseases such as HIV and AIDS;²⁶ the construction of local conceptual models for the disabled, the poor and the elderly living under highly adverse circumstances;¹⁹ the preservation or invention of cultural spaces, such as the Osaka Maternity Home in Japan,²⁷ or a separate area at Cubará Hospital (Colombia) available for indigenous U'was women who wish to give birth accompanied by their relatives.

Cultural Care Diversity, vis-à-vis places, disparities, practices, degrees of inequality and equality in Latin America

    The review conducted provides an amalgam of glocal concepts for Latin America which are used by nursing researchers to express the need to relate the broad range of traditional/local forms of care with professional care. These are some of concepts that emerge: hybrid care, adapted care, merged care, assesment care, legitimised care, seamless care, reciprocal and interactive care, universal care, cultural competence, trans-cultural care, multicultural competence, cultural integration, among others. With the aim of overcoming the conflict between modernity and tradition affecting our profession, two approaches emerge: one that I refer to as "translation with assimilation potential" and another "articulation with a transformation perspective".

On diversity of care that translates and has the potential to assimilate

    Some studies seek to translate traditions and the various forms of cultural care so they are assimilated or incorporated into the modern concept of professional care as a pre-requisite to achieve presumably successful integration or legitimisation. But what they actually do is deny cultural care alterities the right to be different since they do not accept other forms of care as equal, without hierarchies, but are considered as different instead. Nursing professionals, in community or clinical practice, invariably apply only those forms of care that have been legitimised by science, considering them as superior and set apart, leading to a breakdown in intercultural dialogue.²⁸ This dialogue should not only seek to interlink various forms of care, but also to establish initiatives to revisit tradition, so that it may be better understood and mutual understanding in the act of caring may also be achieved.
    This aspiration - namely linear translation of ethnic, popular or peasant language and thought into modern or neutral language, attempting to come closer to "Popper's truth"²⁹ to make them more easily understandable to readers, or to "harmonise" language so that it is more in line with the allopathic medical system - is extremely common in community healthcare centres in Colombia and is highlighted in the research conducted. One such example is the translation of diarrheic conditions. The classic acute diarrheic illness caused by polyparasitism is referred to as "entecos de primeriza o difunto" (weakness of first-time mother or the deceased); or terms such as "el serenado" (night watchman) or "alunado" (lunatic) which are used to denote schizophrenia.
    This logic which reduces differences and governs nursing care practices, is broadly accepted unaware, for instance, that indigenous people's beliefs or those of Andean peasants see "health not only as the absence of pain or disease, but also as the internal balance and harmony of a person, the family, communities, nature, and the cosmos; in other words, the holistic realisation of human beings within the Universe".²⁰ This concept of health displays an abundance of social representations which refer to their social structures, group communication dynamics, and internal and external interactions. So learning to recognise the representations of certain individuals or groups in relation to their illnesses⁷ means we must go beyond the straightforward information that can be obtained through the act of providing care, and also that we should not expect the representations of disparate cultures to coincide.^16,30 When attempting to understand, we should not translate linearly from our own logic and rationality since this would be like an act of phagocytosis that eradicates the meaning of varying cultural diversities, paving the way towards a homogenising diversity based on the consensus of established power relationships. Trans-cultural translation, as opposed to linear translation, should allow translation-reconstruction of alterity with its meanings, representations and the wisdom linked to each particular cosmovision. This form of translation is complex since it is not a question of compartmentalising or fragmenting in order to discern. The idea is to un-weave what has been woven as a whole, but with a conceptual basis. I believe this learning is aided by qualitative research which will ultimately be the horizon to conceive diversity-in-equality when referring to trans-cultural care.
    In Latin America, knowledge generation is primarily backed by a number of theories, discussions and descriptive and exploratory research projects - most of which adopt a qualitative perspective with ethnographical approaches - and Participatory Research, together with a few others based on the quantitative perspective. The latter attempt to translate in order to assess and legitimise differences, thus simplifying and limiting explanations to the area they represent, on the basis of the deductive logic of the facts, assuming objectivity and neutrality as criteria of truth regardless of the subjective states of those taking part in the research. This gives rise to cultural biases⁴ since these approaches dismiss the fact that validity criteria to assess popular wisdom have more to do with criteria relating to efficiency, justice, happiness and the beauty of colours and sounds.²⁰
    Some research projects address the need to "adapt" or "merge"^5,24 self-care and professional care or vice versa - traditional/modern - without posing the question of whether it is possible to merge an incommensurable, incomparable and untranslatable²⁹ form of rationality with another form of logic - more rational, western and commensurable - which characterises professional care. This trend to control, standardise, label, is typical of professional training, and as this is a subconscious paradigm, it is easy to fall into the trap. So we should perhaps ask ourselves, how can we convert a ritual of professional therapeutic care into a therapeutic ceremony - frequently practised in traditional medicine such as Cuban "Santeria", rituals using incense and branches, interpretation of dreams and card reading, visions, spitting on a child, or slaughter of animals? Or how to equate the sense of asepsis to the ritual of cleanliness based on whistling, sounds, chants, popular sayings, or the invocation of benevolent spirits?²⁰ These cleansing rituals are carried out in sacred rivers and lakes and the ceremonies mark the life cycle of the indigenous Andean people from the moment of birth, through male and female initiation and later the bathing of the "sovereign" once training is completed.
    How can we legitimise preventive cultural care delivered through collective rituals conceived to protect homes through prayers, sprinkling herbal water, or by fixing a cross made with an ox's horn,²⁸ or an aloe leaf behind the front door? How can we legitimise the objects and elements most commonly used in traditional care rituals such as images, incense, tinctures (alcoholic herbal beverages), medicinal plants, candles, music, small statues, incense, tobacco, stones, wood, symbols of nature, divine beings, saints etc.²⁰ when they are all part of caring for health and life according to traditional thought, and they have been developed outside the rationalist biologist logic which imbues hospitals in western medical practice?

On the diversity of articulated cultural care

    The examples provided above illustrate the conflicts that arise when trying to translate/assimilate traditional care to the culture of professional care. They are a wake-up call; we have to overcome the issue, in the quest for new horizons for trans-cultural nursing. In producing knowledge, we find sketches that may be on the brink of "diversity-in equality",² with limitations, difficulties and hope. I shall show below the initial pointers that we can find in knowledge production, and which, I dare believe, are taking us along this route.
    Reading between the lines in the literature, one of the concepts that arises is that care culture is linked to territories, space (places, regions), cosmos and its biodiversity, as an uniduality³¹ in which men and women do not see themselves as autonomous, unarticulated beings, when they migrate - whether within their own country or overseas. This represents a profound logic of relation-articulation. This standpoint is opposed to and clashes with the world of representations^16,30,32 which we as nurses uphold. Our eyes are fixed on the idea that a person, an individual, is an aggregate totality, a holistic being, like a series of spheres, whose cultural unity is complete, homogenous, seamless, and free of contradictions and gaps; an easily predictable being, a free individual in the health market - that is why we demand acknowledgement of a person's right to decide - and we have been distanced from the group. Nursing programmes in these communities are designed to achieve measurable goals. The aim is to "standardise", "discipline" people and collective groups - in Foucault's style - through dominant care practices which we ourselves advocate as community nurses, oblivious of the traps inherent to language.
    In the light of this "standardising" perspective, I find that the language used by nurses justifies research, searching for avenues of cultural reciprocity in order to deliver efficient care. But we do not realise that this sort of reciprocity requires something in exchange and places intercultural relationships on the verge of a dangerous abyss. In other words, others are placed in situations of dependency or vulnerability which render this exchange unequal. For instance, for an individual to gain access to institutional care, he or she is forced into submission and is required to abandon pre-concepts, beliefs, values and representations regarding his/her illness. A patient will never discuss with a physician that before coming into consultation, they first visited their traditional doctor, or resorted to botanical remedies. And the reason they will not disclose this information is because they know that "they (conventional healthcare professionals) don't believe in any of that" and because they are "afraid of being reprimanded".^22,28 Quoting Moreno Preciado when he dissertated on the condemnation of others, the "suspicious gaze" of healthcare professionals sees a "different" patient as a threat to established medical order, and that is why exclusion/subordination is pursued.
    Cultural differences in care are indeed present and create tensions on a daily basis, despite the goodwill and efforts made by researchers to corroborate or affirm that there is indeed a cultural universality of care.³³ Researchers base their arguments on comparative research, in different contexts, that address the role of female caregivers, but do not focus on the diversity of cultural care delivered by these women. Perhaps the role of female caregivers is universal. But cultural care based on the places where these women deliver care should be considered as pluriversal, since they vary widely, depending on biodiversity, on the region, representations and imagery, social relationships, cosmovisions and other factors. This universalist affirmation arises from "cultural affinities"³³ with an interpretation based on some sort of homogenising consensus which may seem unnatural, forced, and by no means can this be the tactic adopted by local healthcare stories, as told by professional culture. We must seize this paradigmatic opportunity to tell the stories that modernity brushed under the carpet, in order to promote the wealth of care diversity that may lead to a platform of pluriversality starting from local wisdom and practices, which may be extended globally, through events like these.
    Care diversity sometimes expresses its own complexity through crossbreeding or hybridisation. For instance, while some women use rue to heal "el mal de madre" (mother's disease), others use camomile, or cover the abdomen with poultices made of warm medicinal herbs, "Samson" wine, biscuits and a freshly opened corncob, so that the patient can absorb the heat and energy of the poultice. The various interpretations of what causes "mother's disease" also vary. For some, the illness is accounted for because "the womb has gone mad, as a result of losing a child, and begins to search for it, and tries to leave the body however it can". For others, the illness is "because she got very cold after giving birth" or because "she ate cold food without saying prayers after delivery".³⁴
    These popular forms of care are cultural expressions that are deeply rooted in individuals' consciousness. They are practiced daily in private, within the home, where multiple forms of human relationships are re-created - relations with nature, with the cosmos, with religions, with their imagery, myths and legends, all of which explain the processes involved in health and disease.
    In popular culture, when coping with disease, first comes God or "the holy mother", then herbal remedies and finally pharmaceutical drugs.³⁵ The same applies in the face of disabling diseases which are addressed by a hospital culture that is rigid, hostile, adverse and unwelcoming as a result of impersonal relations. Individuals feel they are losing control over their own bodies. They do not understand the technical jargon used, and their social role is deprived of recognition and acknowledgement. Hence they become anonymous beings, or "things", simply represented by a clinical record reference number which has no meaning at all for them.^36,6 It is thus obvious why their own cultural abode is so welcoming and homely, and why the other setting is so adverse. Here, life-styles and the world of relations are challenged to understand these differences so that we can see each other as equals, through the prism of existential, axiological values and needs, while differentiating ourselves from those who meet those values and needs.³⁷
    Those who satisfy human needs relate to the sphere of culture-in-place. One such example is the research conducted by Lorenzo Juárez,³² who highlights the conflicts involved in linear-translation, described above. The author suggests that food programmes to combat child malnutrition focus on the biological aspects of the condition, and that they are unacceptable to indigenous and popular cultures which are so complex in terms of their representations of health and life issues. Inter-cultural dialogue, acknowledging diversity-in-equality, poses problems that can be overcome. Because any process that entails understanding is linked to interpretation, and the latter is based on a vehicle, such as language and dialogue to converse and thereby find a meaning for the experience of alterity. The opposite occurs when attempts are made to assimilate so that cultural differences in care are duly converted.
    Acknowledgement of the autonomy of communities in terms of their powers over self-care and their own approach to care, means that we must also recognise their plural nature, that they are based on place, region or territory - not only in geographical terms, but also regarding the body, the mind, symbols, and history. This is the only way to acknowledge the multi-cultural nature of care, without trying to assimilate so as to exert control, through a series of standards that professional culture imposes as "natural" and "universal" norms. Justice and equality should prevail in the area of diverse cultural care.

Conclusions

    The enormous thrust of research and theory on cultural care in the late 20^th and early 21^st Centuries has not occurred as a result of Leininger's theory and its dissemination. This was simply a lead, an omen for community nursing. The reasons underlying this boost are increasing poverty - which marginalises and excludes individuals - massive migration and glocal displacements, along with the exclusion of popular and traditional wisdom, and the inefficiency of healthcare systems.
    Cultural care, as a category in itself, is not only highlighted in publications that focus on ethnic, marginalised groups or groups that differ from the mainstream culture. Cultural care must come to life in daily professional practice - be it clinical practice, management, community nursing, research - and should involve the entire process of professional training. This category must continue to be subject to debate; the trend that advocates compartmentalising and fragmenting is still very much alive, upholding the value of "factors", as if culture were an aggregate, a sum of "conditioning factors" which can be pulled apart in pieces for analysis. We have had to come a long way to face this paradigm shift with a clear conscience, to understand the difference between a fragmented and aggregate being and to move towards an articulated and complementary being. Much more remains to be done, but at least we are seeing some positive signs.
    If we claim to defend, as an ethical duty, the right to difference-in-equality in cultural care diversity, we have to take further steps. There are disparities that cannot be negotiated between the various forms of cultural care, but there are others where we may be able to build bridges. Then we will be talking about gaining cultural dominance to award a new meaning to glocal relations between traditional and modern forms of care, to ensure co-existence on the basis of respect and complementarity between both, through pluriversality. In other words, we will move on from a list of research projects that happened to see the light, to a genuine transformation.
    We are experiencing - and intellectually perceiving - this complex paradigm shift through several components, such as the boost of qualitative research, intent on exploring human experience, traditional and glocal wisdom, and the subjective worlds of individuals and groups in the framework of cultural diversity. The acknowledgement of the glocal component of the theory on "Cultural Care Diversity and Universality" and the promotion of trans-cultural care are further examples that will not only benefit quality of health, but will also contribute towards world peace. There is also wider recognition of the planet's cultural diversity and a wish for trans-cultural care to become a cross-cutting category, applicable to all the kinds of care delivered to individuals and groups. There is also growing support from up and coming social movements - such as the World Social Forum, indigenous and anti-globalisation movements, among many others. These are mere glocal glimmers of the dynamics of cultural diversity's pluriversal resistance which is still to be built up against the dominant, universalist health sciences.
    There is considerable ethical and social commitment to begin, or to continue, to take part in shifting paradigms. This involves greater commitment in terms of the quality of interactions that are agreed upon for community nursing, and methodological approaches aimed at improving two-way interpretation and understanding; i.e. translation-reconstruction of the symbolic, cognitive, affective world of subjects and groups involved in trans-cultural care. We must move on from a linear to a trans-cultural translation.
    The organisational, institutional and cultural discrepancies that arise among the various types of glocal care diversity should all be acknowledged. We should also ensure reciprocal respect for the autonomy of cultures that come together in acts of caring; and identify clearly what needs to be complemented and arranged in the act of caring, both at institutions and in training; ensure that professionals, institutions and educational organisations are more open to reciprocal transformation in care, as a result of their complementary relation-articulation; and finally we should forge glocal models and theories that will enable improved translation-understanding of cultural care diversity.
    The reasons underlying qualitative research in the field of cultural care diversity must be like a fabric that will allow us to reconstruct ourselves as inquisitive beings yearning for transformation. We should try to be less encyclopaedic and try to empathise with the anguish of humanity, becoming more communicative in our discourse, so that the seeds of our inquisitiveness are not lost like Diasporas in the desert. We should ensure that our philosophical, calm inquisitiveness turns into local actions that address diversity-in-the-place where care is delivered, adopting practices of transformation and not merely describing cultural care.
    Lastly, cultural diversity teaches us - from research - that in the face of such far-reaching planetary adversity, the human roots of the ethos of care, fortunately still survive. We care with love, patience, mystically - as indigenous and peasant men and women do. They care for Care in much the same way as they sow their fields, to ensure that a myriad of colours will emerge from the ground to form a carpet covering the mountains and hills of our Andean mountain ranges. The Ethos of Care will become the horizon of trans-cultural care because, in the words of Leonardo de Boff, "caring is the pre-requisite for intelligence and love to blossom".³⁸

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