Transcultural Nursing Teaching/Practice Essay

Market globalization and the entrance of China into the World Trade Organization (WTO) have resulted in greater contact between nursing professionals and an increasingly multicultural patient base. A growing number of foreign nationals are establishing residency in the Shanghai, Pudong New District and throughout China which has resulted in a significant increase of patients from culturally diverse backgrounds in medical institutions.1, 2 The numbers of foreign-born patients who visited public hospitals in the Shanghai Pudong New District were 4979, 7001, 15280, 24653, 30082 and 40091 in 2005, 2006, 2007, 2008, 2009 and 2010, respectively, which represents a rate of increase of 705% over a five year period.3 However, formal education programs that teach cultural competency in China are lacking, and nurses are not prepared to provide optimal care for patients from different cultures.4, 5, 6, 7 As the healthcare landscape in China undergoes dramatic changes, meeting the needs of a multicultural patient population will become more complex and demanding. It might be difficult to determine the best practices for educating nurses to achieve cultural competency because few instructional programs that focus on this challenge have been developed in China. There is also limited evidence from the West or from within China with which to determine which teaching strategies and what content are best for developing cultural expertise within the Chinese nursing educational system.Transcultural Nursing Teaching/Practice Essay

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Driven by the urgency to provide quality care to diverse populations and confronted by a lack of research on what and how to teach cultural-specific phenomena in China, our research team embarked on a systematic process to develop, implement and evaluate an educational nursing program concerning cultural competency.

Keywords
culturehealthnursetranscultural nursinghealth services
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1. Introduction
It is useful to define the culture before discussing the term. According to the definition made by Turkish Language Institution Culture, the culture is described as the sum of all the material and spiritual values ​​created in the process of social development and the tools that are used to create and hand these values down to next generations and show the extent of the man’s authority and control over their natural and social environment [1].

According to another definition, the culture is the general total of beliefs, attitudes and behaviors, customs and traditions, learned and shared values, and sustains its existence through learning and teaching of attitudes, actions and role models [2].

As it can be understood from these definitions, culture is a non-written link from the past to the present day, bridging the individuals in society. As a phenomenon, The term “culture,” which diversifies in each community and so is experienced differently, also affects the way individuals perceive the phenomena such as health, illness, happiness, sadness and the manner these emotions are experienced [3].Transcultural Nursing Teaching/Practice Essay

Culture is a relative concept that varies according to health cultures as well as affecting the perception of health [4].

Health is determined by biological and environmental factors as well as by cultural practices [5].

Culture affects many aspects of human life, such as parental attitudes, child rearing patterns, how to speak, what language to speak, how to dress, believe, treat patients, what to do with and how to feed them and to deal with funerals [6, 7].

Individuals’ health behaviors and health perceptions are regarded inseparable from each other. Communities having endeavored to maintain their cultural characteristics for centuries have passed down this on their health behaviors and strived for finding cures to their health problems in their cultural lives. Types of food, cooking methods, sleeping habits, dressing patterns, forms of treatment of diseases, housing and residence, perception of diseases, modes of acceptance of innovations are characteristics varying from culture to culture and intertwined with culture. It is known that people cannot act independently of the culture they live in [8].

Culture is influential at many levels in health, ranging from the formation of new diagnostic groups, to the diagnosis of disease to the determination of what is called a disease or not symptoms and disease cues [6, 7].

However, in almost all regions of the world, wars, ethnic conflicts, repressive regimes, environmental and economic crises along with globalization have forced many people to abandon their country and migrate in their country or to immigrate other countries as refugees. As a result, multicultural populations comprised of individuals, families and groups from different cultures and subcultures are rapidly emerging all around the world [9, 10, 11].Transcultural Nursing Teaching/Practice Essay

2. Cultural factors affecting health and disease
In order to improve the health behaviors of the community, cultural factors affecting health behavior and health care services need to be clearly recognized [12, 13].

The individuals’ beliefs about health, attitudes and behaviors, past experiences, treatment practices, in short their culture, play a vital role in improving health, preventing and treating diseases [14].

Cultural variables can be motivational factors in health-disease relationships, [8].

2.1. Cultural factors/variables can be listed as in the following list
Socioeconomic status

Family pattern

Gender roles and responsibilities

Marriage patterns

Sexual behavior

Preventive patterns

Population policy

Pregnancy and birth practices

Body

Nutrition

Dressing/wearing

Personal hygiene

Housing arrangements

General health regulations

Professions

Religion

Habits

Culture-induced stress

Status of immigrants Transcultural Nursing Teaching/Practice Essay

Substance use

Leisure time habits of

Pets and birds

Self-healing strategies and therapies [8].

3. Health culture
Today, health-related cultural traits are under the influence of a medical approach that may be considered as highly conservative almost all around the world. There is an increasing tendency to perceive and evaluate health and disease-related processes explained in medical terms. The rigid medical approach, engaged in extending human life with costly inventions, with a narrow level of knowledge and practices, makes it impossible for individuals to use the potential for qualified living. Modern medicine overwhelms the will of people to experience their own facts and solve their problems. On the other hand, the concept of health should be regarded as a dynamic phenomenon in life and be removed from some patterns of thought. Hence, healthcare should be assessed with a comprehensive understanding of culture in order to promote the art of living healthily among people [15].Transcultural Nursing Teaching/Practice Essay

Individuals who embrace contemporary public health, evaluate health with a holistic approach, give the other individuals an opportunity to participate in their health care issues, and have the potential to solve problems with appropriate preferences can only be the output of cultural constructs supporting health, values, knowledge, attitudes, behaviors and norms. Health culture is concerned with every individual’s or the society’s patterns of living, celebrating, being happy in life, suffering and dying. It is not enough for the individual to acquire only health-related information, but basic skills such as comprehending health-related values, developing a healthy lifestyle and self-evaluation must be developed. The main purpose of developing health culture is to raise the level of health in the country scale. This can only be ensured by the fact that health education standards be established by well-trained and conscious individuals into practice with the help of their knowledge and skills [15].Transcultural Nursing Teaching/Practice Essay

4. Transcultural healthcare

It is vital that health services are also appropriate for the target cultures to the extent that they are compatible with contemporary medical understanding. People’s beliefs and practices are part of the culture of the society in which they live. Cultural characteristics should be seen as a dynamic factor of health and disease. In order to be able to provide better health care, it is necessary to at least understand how the group receiving care perceives and responds to disease and health, and what cultural factors lie behind their behaviors [7, 13, 16, 17, 18, 19, 20].

Unless health care initiatives are based on cultural values, it will be impossible to achieve the goal and the care provided will be incomplete and fail [2, 21].

For this reason, healthcare providers should try to understand the cultural structure of a society. Health workers must collect cultural data to understand the attitudes of towards coping with illness, health promotion and protection [2, 21].Transcultural Nursing Teaching/Practice Essay

Cultural differences and health beliefs have been recognized for many years as prior knowledge in practice. Despite that, cultural health care is unfortunately not part of a routine or common health practice. Knowing cultural beliefs related to health can enable us to build a framework for data collection in health care [2, 22].

Today, health policies focus primarily on the prevention of health-related inequalities and discrimination, especially ethnic characteristics. In order for the societies to regulate health care that will meet the needs of different groups in terms of culture, all health team members must be equipped with the necessary knowledge and skills [23, 24].Transcultural Nursing Teaching/Practice Essay

5. Understanding transcultural nursing

The term health, with its changing nature and meanings from one culture to another, requires care, including cultural recognition, value and practice. The main element in the transcultural approach in which every health professional has an active role is the individual. The transcultural approach can be applied at all levels of health care institutions; but nurses are in a privileged position in this approach. According to Leininger’s model, only nurses can provide transcultural health services. Because the main aim of nursing is to provide a caring service that respects people’s cultural values and lifestyles. Nurses should offer acceptable, affordable and culturally suitable care to individuals under the conditions of the day [2].

Knowing what cultural practices are applied in the societies receiving healthcare services and identifying the cultural barriers to accessing health care services positively affects the caring process [25].

The nursing profession, which plays an important role in the health team, is a cultural phenomenon. The patient’s cultural values, beliefs and practices are an integral part of holistic nursing care [26, 27].

The nurses should explore new ways of providing cultural care in multicultural societies, understand how cultures affect health-disease definitions, and bridge the gap between care for individuals in different cultures [13, 28, 29].Transcultural Nursing Teaching/Practice Essay

Transcultural nursing provides effective nursing care to meet the cultural needs of individuals, families and groups [30].

The concept of “Transcultural Nursing” derived from the need to care for individuals in different cultures in nursing was first used by Madeleine Leininger in 1979 [30, 31, 32].

In addition to Leininger, a pioneer model of transcultural nursing, many nurses worked in the field of cultural care. Giger and Davidhazar developed the “Cross-Cultural Diagnosis Model” to assess various variables related to health and illness and provide a practical diagnostic tool for nursing so that culturally competent care could be offered [33].

Campinha-Bacote described the cultural competence model [34].

Culturally competent nurses are in contact with cultural experiences and aware of their own personality traits and contribute to socio-cultural knowledge in nursing care by providing individualized care [35].

Nurses who are aware of cultural differences and the effects of these differences on the health of the individual enhance the therapeutic environment by communicating more effectively with the patients [13].Transcultural Nursing Teaching/Practice Essay

The role and significance of transcultural nursing has been increasingly recognized in the world challenged by cultural diversity. Cultural differences can be seen among ethnic groups as well as within any ethnic group [36].

It has been reported that cultural differences may exist among individuals who live in the same or different regions in Turkey [37].

Although studies on cross-cultural nursing care in our country are limited, several studies have examined the views of nursing and midwifery students regarding patient care [37, 38, 39].

In a study conducted, the views of nurses working in two different hospitals on the cultural problems they faced in patient care were compared [11, 36].

In recent years, it has been recognized that nurses must explore new ways of providing cultural care in culturally diverse societies, understand how culture affects disease-health definitions, and act as a bridge between the biomedical system and care for individuals in different cultures [2, 40].Transcultural Nursing Teaching/Practice Essay

The nature and importance of providing culturally sensitive nursing services is multidimensional, including individual and professional aspects. The transcultural approach allows nurses to broaden their horizons and perspectives in addition to making them competent in offering creative care to individuals. Culturally based approaches and knowledge can enhance both the nurse’s and the patient’s self-esteem [2, 41, 42].

The American Nurses Association (ANA) refers to three reciprocal interactions: the culture of the individual (patient), the culture of the nurse, and the culture of the environment in relation to the patient-nurse:

Culture of the individual: When nurses understand the specific factors affecting individual health behaviors, they will be more successful in meeting their needs [2].Transcultural Nursing Teaching/Practice Essay

Individuals’ beliefs about health, culture, past illness/health experiences form a wholistic structure and play a vital role in improving the health of individuals [43].

Culture is influential in how people think, speak the language, how to dress, believe, treat their patients and how to feed them and what to do with their funerals etc. Moreover, it plays a significant role in a variety of aspects such as new diagnostic methods, prognosis, symptomatic patterns and determination of whether there is an illness or not [7].

Culture of the nurse: The only factor influencing the patient-nurse relationship is not the patient himself/herself. The nurses’ own customs and traditions, beliefs and values are also important in transcultural relationships. The nurse’s self-awareness can be the starting point to understand the patient culturally.Transcultural Nursing Teaching/Practice Essay

Culture of the environment: The last element of the transcultural trio is the culture of the environment. The environment is an integral part of the culture. Individuals as physical, ecological, sociopolitical and cultural beings are continuously interacting with each other. Nurses may have to intervene in the patient and family relationship because of frequent bureaucratic arrangements and procedures. The transcultural approach should be considered in a wide range of subjects, starting from asking if there are any religious practices to be followed or done by the patient during the hospitalization, and writing the signs in the hospital in two different languages [13].

2. Literature review
Currently, didactic (teacher centered) teaching and self-directed learning are two of the principal methods for teaching nursing in China. China’s pedagogical approach to nursing education is a subset of the Chinese higher education system, which embodies the central importance of the teacher and face-to-face lecture.8 Whether the nature of knowledge is theoretical or applied, the preference for the lecture method honors a long-standing tradition of teacher-directed instruction. Traditional didactic teaching is considered to the best way to ensure that the standards for the transmission of knowledge are maintained at the highest level.9 Although Chinese scholars have recognized the need to modernize higher education by adopting Western contemporary methods, such as problem-based learning and evidence based learning, according to Wang and Kreysa,10 current and future Chinese teaching practices are likely to retain traditional didactic methods that are teacher-dominated.Transcultural Nursing Teaching/Practice Essay

Nursing researchers in China have recognized that with the marked increase in international mobility, the spread of cultural traits and ideas between societies and ethnic groups is accelerating. Cultural diffusion has progressed quickly in China with increased globalization and the opening of the Chinese economy and resulted in the need for cultural competency as an essential component in the preparation of healthcare professionals. With a foreign-born population that is rapidly expanding and a patient population that is becoming more diverse, cultural competence and cross-cultural communication are increasingly viewed as a prerequisite for addressing developing racial and ethnic disparities in healthcare in China.Transcultural Nursing Teaching/Practice Essay

As the Chinese nursing profession prepares to address increasingly diverse populations, the definition of health is being more closely examined. Nurse researchers in China have not reached a consensus on the definition of health; some maintain a traditional Chinese perspective, while others have attempted to integrate their views with Western beliefs. In the Theory of Culture Care,11 Leininger’s definition of health as culturally defined strengthens and broadens the view of the importance of culture in the conceptualizations of illness, health and wellness. As encounters with patient diversity grow, the notion of culture as an important dimension of care will likely receive increasing emphasis and support by the Chinese nursing profession. Leininger’s theoretical tenets of the cultural diversities and universalities of human caring provide a framework to guide nurses in adapting care that is congruent with the patient’s culture. Because change is occurring quickly, nurses need to be competent in recognizing and supporting cultural traditions and the evolution of care to greater universality for the Chinese people; nurses also require the ability to work with persons from other cultures who are receiving care in China.

Nurse educators in China acknowledge the importance of delivering care based upon the best evidence available and supported by the latest research. They have advocated for an integration of evidence based nursing with traditional nursing education curricula to improve the analytical and problem-solving abilities of nurses. A number of programs have been launched to address this need. One such program that was performed in Hubei province used self-directed learning and was organized around the students’ clinical practice.12 Self-directed learning was selected as the instructional method to provide maximum flexibility to accommodate work and study schedules based upon different shifts, encourage independent study and be consistent with the Chinese value of life long learning. Although the focus of this project was self-directed learning, students voiced a preference to combine this method of instruction with more direction and guidance from the teacher because they felt this combination would improve learning proficiency.Transcultural Nursing Teaching/Practice Essay

As nurse educators in China anticipate the need to prepare nurses in cultural competency, they have examined literature to identify the learned that can be learning regarding the development of educational programs while maintaining respect for their teaching and learning traditions. Numerous strategies, whether through stand-alone courses or integrated across the curriculum, have been used to teach cultural content.13 Examples of methodologies that have been used in cultural education in nursing include lectures, case scenarios, immersion, role modeling and service learning. Despite the widespread acknowledgement that cultural competence education is necessary, there is little agreement regarding the most effective approaches to teach this subject matter.13 Future research is needed to determine the effectiveness of instructional methods in the preparation of culturally competent nurses. Therefore, the purpose of this study was to evaluate the effectiveness of three teaching methods, i. e., case study, traditional didactic and self-directed learning, in the development of cultural competency among nursing students in China.Transcultural Nursing Teaching/Practice Essay

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3. Methods
The research team embarked on a systematic process to identify the learning needs and goals for developing expertise in cultural competency. The team conducted brainstorming sessions with senior nursing staff, medical doctors and foreign-born people working in a healthcare capacity in Shanghai to obtain a clearer picture of the desirable educational goals, objectives and practice outcomes. The team then continued with a closer analysis of the characteristics of the target students and their probable instructional needs in terms of attitudes and the extent of prior experience with cultural content. Reflection on the input from the healthcare professionals and the student needs guided the educational design process.

3.1. Setting and sampling
This study was performed with a random sample of 305 nursing students in three teaching hospitals (A, B and C) in Shanghai Pudong New District. Hospital A had 900 beds, and 108 students (35. 40%) participated in the study; hospital B had 850 beds, and 99 students (32. 46%) participated in the study; and hospital C had 900 beds, and 98 students (32. 13%) participated in the study. Among the 305 participants, 63 students were enrolled in a diploma-level program (20. 66%), 182 students were enrolled in an associate degree-level program (59. 67%), and 59 students were enrolled in a BSN-level program (19. 34%) (see Table 1).Transcultural Nursing Teaching/Practice Essay

Table 1. Survey respondent sample distribution (N = 305).

Variables n %
Hospital
A 108 35. 40
B 99 32. 46
C 98 32. 13
Nursing Program
Diploma 63 20. 66
Associate degree 182 59. 67
BSN 59 19. 34
Missing value 1 0. 33
Time spending on study the content per week
<1 h 46 15. 08
1–2 h 101 33. 11
≥3 h 158 51. 80
Level of English Proficiency
Level 6 24 7. 86
Level 4 76 24. 92
Level 3 107 35. 08
Fail 95 31. 14
Missing value 3 0. 98
Although the participants attended programs of different levels (i. e., diploma, associate, or bachelor) within the Chinese nursing education system, they were considered senior level students within each program during the time of their participation in the study.Transcultural Nursing Teaching/Practice Essay

3.2. Study procedure
The study was approved by each of the hospital ethics committees before its implementation. All participants from hospitals A, B and C were informed about the purpose of the investigation, and those who agreed to participate signed consent forms before beginning their involvement in the study. The participants then completed the Transcultural Nursing Questionnaire (TNQ), which was designed by the research team as a pre-test, to determine their baseline knowledge of concepts of transcultural nursing. Two hundred ninety-nine (98%) of the students had never taken a course or training session related to culture prior to the study. None of the students received a good or outstanding score on the pre-test evaluation of cultural knowledge, and only 5. 56%(n = 17) received a minimum passing score. Once the pre test was completed, the majority of students(97. 7%) expressed a strong willingness to take the course on transcultural nursing  Transcultural Nursing Teaching/Practice Essay

After a careful review of various nursing models for culturally competent care, the research team selected Leininger’s Theory of Cultural Care Diversity and Universality11, 14 as a framework to guide the study because this model is widely recognized in the nursing literature on culture and health. This model also provides a strong theoretical approach for navigating nursing care that is relevant to China’s current situation in terms of the integration of extensive exposure to diverse values, habits, beliefs, etc. within the population and the need to provide care for many diverse individuals coming into the country. The participants were then provided a transcultural nursing manual that was prepared by the research team as a reference to be used throughout the study. The research team examined a number of transcultural publications based upon Leininger’s theory11, 14 and selected topics that were specific to the healthcare contexts of the patient characteristics and work environments of the three participating hospitals.

The transcultural manual consisted of the following eight content areas based upon Leininger’s theory11, 14: theoretical foundations of transcultural nursing; culturally competent nursing care; religious beliefs and practice; health beliefs and nutrition; cultural beliefs and taboos; language and communication; rituals; and holidays and festivals of selected nations. The three teaching methods were then randomly assigned to each hospital as follows: Hospital A, case study; hospital B, traditional didactic; and hospital C, self-directed learning. The specific implementations of each of the teaching methods are described below. The same eight content areas were used consistently in each of the three teaching methods.Transcultural Nursing Teaching/Practice Essay

3.3. Case study
Case study was used as teaching method to engage students in critical and reflective thinking and problem solving.15, 16 This method relied on a paper-based narrative approach in which clinical cases featuring descriptions of a patient’s background, health issues and cultural factors were used to facilitate learning by developing culturally sensitive nursing care solutions. Through student–teacher interactions, the narrative cases served to synthesize theory and practice by assisting the students in the application of their knowledge within the framework of transcultural theory, concepts and principles. The case study method consisted of the following six segments: (a) the teacher presents a background of transcultural nursing concepts to provide context for the use of case studies, (b) the teacher presents a case with details of the clinical scenario that is based on real-life patient situations, (c) student analysis and discussion of the case leads to the development of a nursing diagnosis and care plan, (d) specific nursing actions are proposed by the student to address and solve the problems in the nursing care situation, (e) discussion of the case and outcomes via student teacher interaction is used to connect transcultural nursing theory and practice, and(f) the teacher conducts a review of the case-based instruction to summarize the outcomes with a focus on the application of theory and practice.Transcultural Nursing Teaching/Practice Essay

The process described above was repeated for each case. A total of eight cases that reflected the topics selected from the manual were presented. Two hours were allotted for the presentation and discussion of each case. The students were then responsible for presenting their conclusions and outcomes from each case analysis to their fellow classmates and teacher.

3.4. Traditional didactic teaching
The traditional didactic (teacher-centered) teaching method is based on formal classroom teaching that is information-based and supplemented by visual presentations.17 Transcultural nursing theories and their application are taught using a traditional pedagogical approach that is teacher-centered and relies on the lecture method and textbooks. The lecture materials were based on the eight content areas in the manual and organized to cover the basic concepts, theoretical framework, patient cross-cultural assessment, and effectiveness of the nursing care plan. Each of the eight content areas was scheduled for a two-hour lecture that included 15 min for the students’ questions.Transcultural Nursing Teaching/Practice Essay

3.5. Self-directed learning
In the self-directed learning teaching method the students progressed through the subject matter individually but met with their teacher once every two weeks to evaluate their learning progress.18 The teacher selected two to three questions related to each of the eight content areas identified in the manual. After the students progressed through each of the topics, the answers to the questions were made available to them. The students reviewed each topic at their own pace within the two-week time period and were expected to learn the subject matter and answer the questions themselves. The students’ answers to the questions were reviewed by the teacher on a bi-weekly basis with subsequent discussions to clarify any issues.

All three methods of teaching, i. e., case study, traditional didactic and self-directed learning, were implemented continuously over the four-month period from August to November, 2008. The total time dedicated to the case study and didactic teaching methods was 16 h divided over eight sessions. Regarding the self-directed learning method, the students spent an unlimited amount of time on each topic within the two-week window.Transcultural Nursing Teaching/Practice Essay

3.6. Evaluation method
Although many transcultural nursing questionnaires have been developed in other countries, variations in culture, language and lifestyle practices motivated the research team to design two instruments to evaluate the participants’ fundamental knowledge of transcultural concepts. These instrument are the TNQ and the Evaluation of Transcultural Nursing Competency (ETNC). Prior to the study, both questionnaires were tested for validity and reliability by five content experts with graduate nursing degrees and who had worked as nursing faculty and/or nursing administrators in Shanghai.

The TNQ was used to evaluate the following four domains of knowledge: (a) theoretical foundations, (b) language and communication, (c) religious beliefs and practice, and (d) health beliefs and nutrition. The breakdown of the TNQ point system (the maximum score was 180) was as follows: theoretical foundations (12 questions, 48 points); language and communication (12 questions, 48 points); religious beliefs and practice (11 questions, 44 points); and health beliefs and nutrition (10 questions, 40 points). Pass, good and excellent scores in each section were defined as 60%, 75% and 90%, respectively.19 The internal consistency and reliability of the TNQ instrument were determined by computing Cronbach’s alpha coefficient, which was 0. 8322. The TNQ was used as a pre-test prior to the implementation of the three teaching methods and was then administered again as a post-test upon the completion of the learning experience. The response rate for the pre-test was 98%, and that for the post-test was 91. 48%.Transcultural Nursing Teaching/Practice Essay

The ETNC instrument was used to evaluate the following four areas of cultural competence in nursing care: (a) cultural awareness, (b) compassion, (c) cultural skills, and (d) cultural competency in practice (Table 2). The total possible score for the ETNC was 100. Higher scores corresponded to a higher levels of cultural competency. The internal consistency and reliability of the scores were determined by computing Cronbach’s alpha coefficient, which was 0. 8121.Transcultural Nursing Teaching/Practice Essay