TransculturalConceptsinNursingCarebyMargaretM – Health Essays Help

● Seventh Edition
Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan
Joyceen S. Boyle, PhD, RN, MPH, FAAN Adjunct Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Adjunct Professor of Nursing College of Nursing Georgia Regents University Augusta, Georgia
Transcultural Concepts in Nursing Care
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Library of Congress Cataloging-in-Publication Data Transcultural concepts in nursing care / editors, Margaret M. Andrews, Joyceen S. Boyle. — Seventh edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-9397-8 I. Andrews, Margaret M., editor. II. Boyle, Joyceen S., editor. [DNLM: 1. Transcultural Nursing. 2. Culturally Competent Care. WY 107] RT86.54 362.17’3—dc23
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Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan
Martha B. Baird, PhD, APRN/CNS-BC, CTN-A Assistant Professor School of Nursing University of Kansas Medical Center Kansas City, Kansas
Joyceen S. Boyle, PhD, RN, MPH, FAAN Adjunct Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Adjunct Professor of Nursing College of Nursing Georgia Regents University Augusta, Georgia
Joanne T. Ehrmin, PhD, RN, CNS Professor Department of Health Promotion College of Nursing University of Toledo Toledo, Ohio
Patricia A. Hanson, PhD, RN, APRN-BC, GNP Professor College of Nursing and Health Madonna University Livonia, Michigan
Jana Lauderdale, PhD, RN, FAAN Assistant Dean for Cultural Diversity School of Nursing Vanderbilt University Nashville, Tennessee
Patti Ludwig-Beymer, PhD, RN, CTN-A, NEA-BC, FAAN Vice President and Chief Nursing Officer Edward Hospital and Health Services Naperville, Illinois
Margaret A. McKenna, PhD, MPH, MN Clinical Associate Professor Department of Health Services University of Washington Seattle, Washington
Margaret Murray-Wright, MSN, RN Associate Director, Undergraduate Programs and Clinical Assistant Professor of Nursing University of Michigan-Flint Flint, Michigan
Dula F. Pacquiao, EdD, RN, CTN-A, TNS Cultural Diversity Consultant Education, Research and Practice Lecturer, University of Hawaii Hilo School of Nursing Hilo, Hawaii
Maureen J. Reinsel, MA, MSN, APRN, AGPCNP-C Technical Writer for Patient and Program Monitoring Improving Data for Decision-Making in Global Cervical Cancer Programs (IDCCP) Jhpiego Corporation Baltimore, Maryland
Barbara C. Woodring, EdD, CPN, RN Professor Emerita Byrdine F. Lewis School of Nursing and Health Professions Georgia State University Atlanta, Georgia
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I am pleased for the opportunity to write the Foreword to Drs. Margaret Andrews and Joyceen Boyle’s seventh edition of their book, which illu- minates the historical and theoretical foundations and evolution of transcultural nursing emerging from the disciplines of nursing and anthropology. I have been asked to “fill the shoes” of our men- tor and colleague, the late Dr. Madeleine Leini- nger, who wrote the previous Forewords to their book. Dr. Leininger, the first nurse anthropologist and the “mother” of transcultural nursing, passed away in 2012 leaving us a legacy of transcultural nursing scholarship and a body of knowledge that has accelerated exponentially from its earli- est beginnings in Cincinnati, Ohio, in the 1950s to its adoption in most nations of the world. Le- ininger addressed the human condition through knowledge of what it means to be human, caring, understanding, and open to all cultural traditions by creating the discipline of transcultural nurs- ing. At the outset of the programmatic develop- ment of the discipline of Transcultural Nursing, Joyceen Boyle and I were asked by Dr. Leininger to become her first two doctoral students in 1977 at the University of Utah, College of Nursing, Salt Lake City, Utah. Both of us had backgrounds in public health or anthropology and a great inter- est in the study of diverse cultures. As friends and students, Joyceen and I felt privileged to be pioneers as Dr. Leininger put into motion her be- liefs, and values of transcultural nursing, focusing on nursing and human science, caring science, theory development, anthropology, culture, and transcultural nursing. Leininger advanced her theoretical understanding developing The World- wide Nursing Theory of Culture Care Diversity and Universality and her Ethnonursing method- ology. Her transcultural beliefs and values have been infused into nursing program objectives for
education, research, administration, and practice and were the foundation for the development of standards of practice for culturally competent care for individuals, groups, local and global communities, and organizations. Dr.  Andrews teamed up early in her scholarly career with her mentor, Dr. Joyceen Boyle and they, with other major contributors, wrote one of the earliest text- books, Transcultural Concepts in Nursing Care published first in 1989 who also was influenced by Dr. Leininger.
Because of their long history of knowledge generation in transcultural nursing, this work of Andrews and Boyle is very comprehensive and shows the depth of their scholarship in terms of culture, theory development and application, research, and their commitment to the delivery of culturally competent care in practice. Rapid changes in science, technology, genetics, health care, economics, geopolitics, transportation, demographics, migration and immigration, reli- gious ideologies, unrelenting wars, and global issues including human rights and social justice have challenged nurses to understand new ways of engaging with clients and families, and also professional colleagues in terms of transcultural nursing. By means of the new sciences of com- plexity and the generation of enormous quanti- ties of research of every affiliation, and diverse philosophical, political, and religious perceptions, we can see the interconnectedness of everything in the universe and the necessity for discernment and evaluation of what is really happening in the world. Theoretical and experiential knowledge about our responsibilities to one another thus is growing and impacts the need for intense com- munication to examine and solve problems both locally and globally. Continuing to identify rel- evant issues to promote health, human safety, and
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Foreword v
improve the quality of life of all people is a major goal of thoughtful national and international health care professionals. For example, we can explore, within the United Nations Millennium Development Goals for 2015 and beyond, the framework for the world community. These devel- opments are now shaping Andrews’ and Boyle’s paradigmatic thinking in the seventh edition and their interest in addressing the challenges of the interconnectedness of all by their Transcultural Interprofessional Practice (TIP) Model with a theoretical foundation. Their model illuminates the necessity for increased collaboration and communication with clients and multiple health care and folk participants to address complex approaches to transcultural issues in the provision of culturally congruent, safe, and competent care.
The beginning chapters in their book highlight foundational and evolutionary knowledge of the concepts of culture, subculture, race, ethnicity, context, communication including digital com- munication—the Internet and social media— evidence-based practice and problem solving, culture-specific nursing care, interprofessional collaboration and best practices, transcultural nursing, genetics, and theory development. The chapters focus on culturally competent nursing care by highlighting transcultural nursing across the life span, multicultural health care settings including the culture of organizations, the deliv- ery of mental health care, a focus on family and community, a spotlight on the cultural diversity of the workforce, and the challenges in trans- cultural nursing (religion, ethics, and interna- tional nursing). Each chapter follows with a set of review questions and learning activities that illu- minate what students, faculty, and clinical practi- tioners will have integrated into their plan of care to meet mutual goals presented in the chapter case studies. The seventh edition reflects many of the changes in the concept of the culture-at-large, especially genetics. While giving attention to Leininger’s theory in Chapter 1, what is significant in this seventh edition, as stated, is the develop- ment of their own theory, the Andrews and Boyle Transcultural Interprofessional Practice (TIP)
Model. The key concepts identified in the TIP model are context, interprofessional health care team, communication, and problem-solving pro- cess. The cultural context (health-related beliefs and practices that weave together environmental, economic, social, religious, moral, legal, political, educational, biophysical, genetic, and technologi- cal factors), the interprofessional health care team (nurses, physicians, social workers, therapists, pharmacists, and others), cross-cultural commu- nication among client, family, and significant oth- ers, and members of the interprofessional health care team including folk and traditional healers, and religious and spiritual healers facilitate the foundation of the problem-solving process that has five steps. These five steps include compre- hensive holistic client assessment, mutual goal setting, planning, implementation of the plan of action and interventions, and evaluation of the plan for effectiveness to achieve the stated goals, and desired outcomes; provide culturally congru- ent and competent care; deliver quality care that is safe and affordable; and ensure that the care is evidence based with best practices.
As I reflect on the work of my colleagues, Andrews and Boyle, not only within the pages of this book but also what each of them has accom- plished over many years as leaders, teachers, researchers, online educators, and as Presidents of the Transcultural Nursing Society, what comes to mind is their deep dedication and devotion to the discipline and profession of Transcultural Nursing. Through their intellectual astuteness and creative actions, they have been and are role models and mentors to students and other lead- ers who have spread and broadened transcultural care knowledge worldwide. They are commit- ted to the primary goal of transcultural nursing to facilitate culturally congruent knowledge and care so that people of the world are understood and their health care needs can be met within the dynamics of their cultures and cultural under- standing. A seventh edition of a book attests to the fact that students, faculty, and other practi- tioners find within its pages relevant and chal- lenging information to learn about cultures and
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vi Foreword
ethnic groups, know how to relate and serve them, conduct research, facilitate the solving of problems, and “making things work.” Today collaboration and communication are the key. Margaret Andrews and Joyceen Boyle have cap- tured that essence in their Transcultural Inter- professional Practice (TIP) theory and model, which is presented in this work. I wholeheart- edly endorse this new edition. I am most proud to call these authors not only my colleagues but also my friends as they move forward in the evo- lution of what can be termed authentic trans- cultural nursing by means of collaboration and interprofessionalism. Nursing students, faculty, other health care professionals, and practitioners
of every health care and anthropological disci- pline will be stimulated by the theory and the content expressed by the authors and the many contributors in this new edition to improve the health of and help people of diverse cultures worldwide.
Marilyn A. Ray, RN, PhD, CTN-A, FSfAA, FAAN
Colonel (Retired), United States Air Force, Nurse Corps
Professor Emeritus The Christine E. Lynn College of Nursing
Florida Atlantic University Boca Raton, Florida
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Given the large number of cultures and subcultures in the world, it’s impossible for nurses to know everything about them all; however, it is possible for nurses to develop excellent cultural assessment and cross-cultural communication skills and to follow a systematic, orderly process for the delivery of culturally competent care.
The Andrews/Boyle Transcultural Interprofes- sional Practice (TIP) Model, which we are intro- ducing in this seventh edition of Transcultural Concepts in Nursing Care and describe in more detail in Chapters 1 and 2, emphasizes the need for effective communication, efficient, client- and patient-centered teamwork, and collaboration among members of the interprofessional health care team.
The TIP Model has a theoretical foundation in transcultural nursing that fosters communication and collaboration between and among all mem- bers of the team and enables multiple team mem- bers to manage complex, frequently multifaceted transcultural care issues, moral and ethical dilem- mas, challenges, and care-related problems in a collegial, respectful, synergistic manner.
The process used in the TIP Model is an adap- tation and application of the classic scientific problem-solving method used to deliver nursing and health care to people from different national origins, ethnicities, races, socioeconomic back- grounds, religions, genders, marital statuses, sex- ual orientations, ages, abilities/disabilities, sizes, veteran status, and other characteristics used to compare one group of people to another.
The Commission on Collegiate Nursing Edu- cation, the American Association of Colleges of Nursing’s Essentials of Baccalaureate Education for Professional Nursing Practice, the National League for Nursing, most state boards of nursing, and
other accrediting and certification bodies require or strongly encourage the inclusion of cultural aspects of care in nursing curricula. This, of course, underscores the importance of the purpose, goal, and objectives for Transcultural Concepts in Nurs- ing Care, Seventh Edition.
Purpose: To contribute to the development of theoretically based transcultural nursing knowl- edge and the advancement of transcultural nurs- ing practice.
Goal: To increase the delivery of culturally competent care to individuals, families, groups, communities, and institutions.
1. To apply a transcultural nursing framework to guide nursing practice in diverse health care settings across the lifespan.
2. To analyze major concerns and issues encoun- tered by nurses in providing transcultural nursing care to individuals, families, groups, communities, and institutions.
3. To expand the theoretical bases for using con- cepts from the natural and behavioral sciences and from the humanities to provide culturally competent nursing care.
4. Provide a contemporary approach to trans- cultural nursing that includes effective cross- cultural communication, team work, and interprofessional collaborative practice.
We believe that cultural assessment skills, combined with the nurses’ critical thinking abilities, will provide the necessary knowledge on which to base transcultural nursing care. Using this approach, nurses have the ability to provide culturally competent and contextually meaningful care for clients—individuals, groups, families, communities, and institutions.
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The editors and chapter authors share a com- mitment to:
●● Foster the development and maintenance of a disciplinary knowledge base and expertise in culturally competent care.
●● Synthesize existing theoretical and research knowledge regarding nursing care of different ethnic/minority/marginalized and other disen- franchised populations.
●● Identify and describe evidence-based practice and best practices in the care of diverse indi- viduals, families, groups, communities, and institutions.
●● Create an interdisciplinary and interprofes- sional knowledge base that reflects hetero- geneous health care practices within various cultural groups.
●● Identify, describe, and examine methods, theo- ries, and frameworks appropriate for developing knowledge that will improve health and nursing care to minority, underserved, underrepresented, disenfranchised, and marginalized populations.
Recognizing Individual Differences and Acculturation
We believe that it is tremendously important to recognize the myriad of health-related beliefs and practices that exist within the population catego- ries. For example, the differences are rarely rec- ognized among people who identify themselves as Hispanic/Latino: this group includes people from along the U.S.–Mexico border, Puerto Rico, Mexico, Spain, Guatemala, or “little Havana” in Miami, as well as other Central and South American countries, who may share some similari- ties (speaking Spanish, for example) but who may also have distinct cultural differences.
We would like to comment briefly on the terms minority and ethnic minorities. These terms are perceived by some to be offensive because they connote inferiority and marginalization. Although we have used these terms occasionally, we prefer to make reference to a specific subculture or culture whenever possible. We refer to categorizations
according to race, ethnicity, religion, or a combi- nation, such as ethnoreligion, but we make every effort to avoid using any label in a pejorative man- ner. We do believe, however, that the concepts or terms minority or ethnicity are limiting, not only for those to whom the label perhaps applies but also for nursing theory and practice. We believe that concept of culture is richer and has more the- oretical usefulness. In addition, we all have cultural attributes while not all are from a minority group or claim a particular ethnicity.
Critical Thinking Linked to Delivering Culturally Competent Care
We believe that cultural assessment skills, com- bined with the nurse’s critical thinking ability, will provide the necessary knowledge on which to base transcultural nursing care. Using this approach, we are convinced that nurses will be able to provide culturally competent and contextually meaning- ful care for clients from a wide variety of cultural backgrounds, rather than simply memorizing the esoteric health beliefs and practices of any spe- cific cultural group. We believe that nurses must acquire the skills needed to assess clients from virtually any and all groups that they encounter throughout their professional life.
Many educational programs in nursing are now teaching transcultural nursing content across the curriculum. We suggest that Transcul- tural Concepts in Nursing Care can be used by fac- ulty members to integrate transcultural content across the curriculum in the following manner: Chapters 1 to 4 in the first clinical courses when students are learning how to conduct health his- tories, health assessments, and physical examina- tions; Chapters 10 and 11, mental health nursing and family and community nursing, in the appro- priate specialty nursing courses; Chapters 5 to 8, which include nursing care across the lifespan, in courses that focus on the nursing care of the childbearing family, children, adults, and older adults; Chapters 9, 12, and 14, which concern cul- turally competent organizations, diversity in the
viii Preface
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multicultural health care workforce, and compe- tence in ethical decision making, in courses that focus on nursing leadership and management; Chapter 13, which examines religion, culture, and nursing, an excellent resource throughout the curriculum; and Chapter 15 in courses that focus on global health/community health nursing.
New to the Seventh Edition
All content in this edition was reviewed and updated to capture the nature of the changing health care delivery system, new research studies, and theoretical advances, emphasis on effective communication, team work, and collaboration, and to explain how nurses and other health care providers can use culturally competent skills to improve the care of clients, families, groups, and communities. In writing the seventh edition, we have been impressed with the developments in the field of transcultural nursing. The Trans- cultural Nursing Society and the American Acad- emy of Nursing (AAN) have moved ahead with developing Standards of Practice for Culturally Competent Care that nurses around the world are using as a guide in clinical practice, research, education, and administration. In addition, a special task force from the Transcultural Nurs- ing Society has developed a Core Curriculum for Transcultural Nursing that is being used as a basis for certification in transcultural nursing and for instructional purposes by faculty and students in educational programs. The recognition of the Standards of Practice and Core Curriculum for transcultural nursing enhances the development of cultural competence in nursing, thus improv- ing the care of clients. Lastly, the Andrews/Boyle Transcultural Interprofessional Practice Model is introduced in recognition of the need to put the client or patient first and of the changing com- plexion of the health care workforce.
New Chapter Contributors
We welcome two new colleagues in the sev- enth edition, both from the University of
Michigan-Flint School of Health Professions and Studies. Margaret (Margie) Murray-Wright, Associate Director of Undergraduate Programs and Clinical Assistant Professor of Nursing, infused state-of-the art content on genetics and genomics and coauthored Chapter 3, Cultural Competence in the Health History and Physical Examination. An Adult-Gerontology Nurse Prac- titioner, Maureen J. Reinsel has extensive expe- rience in global public health and international development in Asia, Africa, and Europe. In addi- tion to her nursing background, Maureen earned her MA degree in International Affairs from the Johns Hopkins University School of Advanced International Studies. She wrote Chapter 15, Nursing and Global Health, which is available online.
Chapter Pedagogy
Learning Activities
All of the chapters include review questions as well as learning activities to promote critical thinking. When relevant web-based information is available to supplement the chapter content, references are provided on . In addition, each chapter includes chapter objectives and key terms to help readers understand the purpose and intent of the content.
Evidence-Based Practice
Current research studies related to the content of the chapter are presented as Evidence-Based Practice boxes. We have included a section in each box describing clinical implications of the research.
Case Studies
Case Studies based on the authors’ actual clinical experiences and research findings are presented to make conceptual linkages and to illustrate how concepts are applied in health care settings. Case studies are oriented to assist the reader to begin to develop cultural competence with selected cultures.
Preface ix
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Text Organization
Part One: Foundations of Transcultural Nursing
This first section focuses on the foundational aspects of transcultural nursing. The develop- ment of transcultural nursing frameworks that include concepts from the natural and behavioral sciences are described as they apply to nursing practice. Because nursing perspectives are used to organize the content in Transcultural Con- cepts in Nursing Care, the reader will not find a chapter purporting to describe the nursing care of a specific cultural group. Instead, the nursing needs of culturally diverse groups are used to illustrate cultural concepts used in nursing prac- tice. Chapter 1 provides an overview of the theo- retical foundations of transcultural nursing, and Chapter  2 introduces key concepts associated with cultural competence using the Andrews/ Boyle Transcultural Interprofessional Practice Model as the organizing framework. In Chapter 3, we discuss the domains of cultural knowledge that are important in cultural assessment and describe how this cultural information can be incorpo- rated into all aspects of care. Chapter 4 provides a summary of the major cultural belief systems embraced by people of the world with special emphasis on their health-related and culturally based values, attitudes, beliefs, and practices.
Part Two: Transcultural Nursing: Across the Lifespan
Chapters 5 through 8 use a developmental frame- work to discuss transcultural concepts across the lifespan. The care of childbearing women and their families, children, adolescents, middle-aged adults, and the elderly is examined, and information about cultural groups is used to illustrate common trans- cultural nursing issues, trends, and concerns.
Part Three: Nursing in Multicultural Health Care Settings
In the third section of the text (Chapters 9 through  12), we explore the components of
cultural competence in mental health and in fam- ily and community health care settings. We also examine cultural competence in health care orga- nizations and cultural diversity in the health care workforce, two very critical and current topics of concern. The clinical application of concepts throughout this section uses situations commonly encountered by nurses and describes how transcultural nursing principles can be applied in diverse settings. The chapters in this section are intended to illustrate the application of transcul- tural nursing knowledge to nursing practice.
Part Four: Contemporary Challenges in Transcultural Nursing
In the fourth section of the text, Chapters 13 to 15, we examine selected contemporary issues and chal- lenges that face nursing and health care. In Chapter 13, we review major religious traditions of the United States and the interrelationships among religion, cul- ture, and nursing. Recognizing the numerous moral and ethical challenges in contemporary health care as well as within the transcultural nursing, Chapter 14, available on , discusses cultural competence in ethical and moral dilemmas from a transcultural perspective. Chapter 15, available on , provides a global perspective of what is occurring in the international areas to promote human and health. This chapter is slightly different from the rest of the chapters as it highlights the field of inter- national nursing and the ways in which nurses can contribute to the global efforts to improve the health status of people across the world.
Instructor Resources
The following tools to assist you with teaching your course are available upon adoption of this text on
●● The Test Generator lets you generate new tests from a bank of NCLEX-style questions to help you assess your students’ understanding of the course material.
●● PowerPoint Presentations provide an easy way for you to integrate the textbook with your
x Preface
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students’ classroom experience, either via slide shows or handouts.
●● Instructor’s Guide for Teaching Transcultural Concepts includes activities and discussion top- ics to help you engage students in the material.
Student Resources
Students who have purchased Transcultural Concepts in Nursing Care, Seventh Edition have access to the following additional resources:
●● Chapter 14, Cultural Competence in Ethical Decision Making, discusses cultural compe- tence in ethical and moral dilemmas from a transcultural perspective.
●● Chapter 15, Nursing and Global Health, dis- cusses the field of international nursing and the opportunities available for nurses who would like to practice internationally.
●● Journal Articles corresponding to book chap- ters offer access to current research available in Wolters Kluwer journals.
Lippincott RN to BSN Online
Lippincott RN to BSN Online, a full curriculum online course solution aligned with The Essen- tials of Baccalaureate Education for Profes- sional Nursing Practice and Quality and Safety Education for Nurses Competencies, uniquely features self-paced multimedia modules that foster experiential, active learning. Lippincott RN to BSN Online capitalizes on the “flipped classroom” pedagogy trend by integrating qual- ity textbook content, assessments, and reme- diation with interactive modules. At its core is its exceptional instructional design strategies— storytelling, modeling, case-based, social, and collaborative learning. These innovative stu- dent and instructor resources take RN to BSN courses to the next level by featuring a guiding framework derived from the Cognitive Learning
Theory and the best practices for e-learning from the Next Generation Learning Initiative. For more information, go to http://thepoint.
We are pleased to acknowledge the assistance and support of our families, friends, and colleagues in once again making this book possible. We also appre- ciate the help of the many nursing faculty members, practitioners, and students who have offered helpful comments and suggestions. We have found it very gratifying to be able to call upon many of our col- leagues for help and advice in this new edition.
We would like to gratefully acknowledge and thank Elizabeth Connolly, Development Editor, Wolters Kluwer Health, for her helpful recom- mendations on ways to strengthen the seventh edition, her careful attention to detail, her flex- ibility, her invaluable input on the Andrews/Boyle Transcultural Interprofessional Practice Model, her assistance in locating suitable digital images, and the long hours that she spent reviewing and rereviewing the chapters and appendices.
We gratefully acknowledge the support of our friends, too numerous to list by name, who wrote encouraging e-mails or phoned to express their interest and encouragement. We thank all of our col- leagues who have purchased our book in the past and the many who have expressed interest in the seventh edition. We are always appreciative of their support.
Last of all, we would once again like to thank each other for what has been a lifetime of friend- ship that has withstood the test of time and now seven editions of this book! Through it all, we have found our professional endeavors in transcultural nursing and the friends that we have made along the way to be both satisfying and rewarding.
Margaret M. Andrews, PhD, RN, CTN-A, FAAN Joyceen S. Boyle, PhD, RN, MPH, FAAN
Preface xi
For a list of the reviewers of this book and the accompanying Test Generator questions, please visit at http://
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Part One: Foundations of Transcultural Nursing
Chapter 1 Theoretical Foundations of Transcultural Nursing 2 Margaret M. Andrews and Joyceen S. Boyle
Chapter 2 Culturally Competent Nursing Care 30 Margaret M. Andrews
Chapter 3 Cultural Competence in the Health History and Physical Examination 55 Margaret M. Andrews and Margaret Murray-Wright
Chapter 4 The Influence of Cultural and Health Belief Systems on Health Care Practices 102 Margaret M. Andrews
Part Two: Transcultural Nursing: Across the Lifespan
Chapter 5 Transcultural Perspectives in Childbearing 120 Jana Lauderdale
Chapter 6 Transcultural Perspectives in the Nursing Care of Children 153 Margaret M. Andrews and Barbara C. Woodring
Chapter 7 Transcultural Perspectives in the Nursing Care of Adults 186 Joyceen S. Boyle
Chapter 8 Transcultural Perspectives in the Nursing Care of Older Adults 213 Margaret A. McKenna
Part Three: Nursing in Multicultural Health Care Settings
Chapter 9 Creating Culturally Competent Health Care Organizations 242 Patti Ludwig-Beymer
Chapter 10 Transcultural Perspectives in Mental Health Nursing 272 Joanne T. Ehrmin
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Contents xiii
Chapter 11 Culture, Family, and Community 317 Joyceen S. Boyle and Martha B. Baird
Chapter 12 Cultural Diversity in the Health Care Workforce 359 Margaret M. Andrews
Part Four: Contemporary Challenges in Transcultural Nursing
Chapter 13 Religion, Culture, and Nursing 394 Patricia A. Hanson and Margaret M. Andrews
Chapter 14 Cultural Competence in Ethical Decision Making 447 Dula F. Pacquiao
Chapter 15 Nursing and Global Health 465 Maureen J. Reinsel and Margaret M. Andrews
Chapters 14 and 15 available on .
Appendix A Andrews/Boyle Transcultural Nursing Assessment Guide for Individuals and Families A-1 Joyceen S. Boyle and Margaret M. Andrews
Appendix B Andrews/Boyle Transcultural Nursing Assessment Guide for Families, Groups, and Communities B-1 Joyceen S. Boyle and Margaret M. Andrews
Appendix C Andrews/Boyle Transcultural Nursing Assessment Guide for Health Care Organizations and Facilities C-1 Joyceen S. Boyle, Margaret M. Andrews, and Patti Ludwig-Beymer
Appendix D Components of a Cultural Assessment: Traditional Native American Healing D-1 Joyceen S. Boyle
Appendix E Boyle/Baird Transcultural Nursing Assessment Guide for Refugees E-1 Joyceen S. Boyle and Martha B. Baird
Index I-1
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Part One
Foundations of Transcultural Nursing

Theoretical Foundations of Transcultural Nursing
●● Margaret M. Andrews and Joyceen S. Boyle
Learning Objectives 1. Explore the historical and theoretical foundations of transcultural nursing. 2. Critically examine the relevance of transcultural nursing in addressing contem-
porary issues and trends in nursing. 3. Analyze Leininger’s contributions to the creation and development of transcul-
tural nursing as a theory and evidence-based formal area of study and practice within the nursing profession.
4. Critically examine the contributions of selected transcultural scholars to the advancement of transcultural nursing theory and practice.
5. Discuss key components of the Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model.
Key Terms
Anthropology Assessment Assumptions Chronemics Communication Core Curriculum Cross-cultural communication Cultural competence Cultural context Culturally competent care Culturally congruent nursing
care Cultural-specific Cultural universals
Culture Culture-specific nursing care Culture-universal nursing care Ethnicity Ethnonursing research Evaluation Evidence-based practice Hijab Implementation Interprofessional collaboration Interprofessional health care
team Language Modesty Monochronic culture Mutual goal setting
Nonverbal communication Paralanguage Personal space Polychronic culture Problem-solving process Proxemics Race Subculture Transcultural Interprofessional
Practice (TIP) Model Transcultural nursing Transcultural nursing
certification Verbal Communication

Chapter 1 Theoretical Foundations of Transcultural Nursing 3
Introduction to Transcultural Nursing
In her classic, groundbreaking book titled “Nursing and Anthropology: Two Worlds to Blend,” Leininger (1970) analyzed the ways in which the fields of anthropology and nursing are interwoven and interconnected (c.f., Brink, 1976; McKenna, 1985; Osborne, 1969). Leininger used the term transcul- tural nursing (TCN) to describe the blending of nursing and anthropology into an area of special- ization within the discipline of nursing. Using the concepts of culture and care, Leininger established TCN as a theory and evidence-based formal area of study and practice within nursing that focuses on people’s culturally based beliefs, attitudes, values, behaviors, and practices related to health, illness, healing, and human caring (Leininger, 1991, 1995; Leininger & McFarland, 2002, 2006).
TCN is sometimes used interchangeably with cross-cultural, intercultural, and multicultural nursing. The goal of TCN is to develop a scientific and humanistic body of knowledge in order to provide culture-specific and culture- universal nursing care practices for individuals, families, groups, communities, and institutions of similar and diverse cultures. Culture-specific refers to particular values, beliefs, and patterns of behav- ior that tend to be special or unique to a group and that do not tend to be shared with members of other cultures. Culture-universal refers to the commonly shared values, norms of behavior, and life patterns that are similarly held among cultures about human behavior and lifestyles (Leininger, 1978, 1991, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a). For example, although the need for food is a culture- universal, there are culture-specifics that deter- mine what items are considered to be edible; acceptable methods used to prepare and eat meals; rules concerning who eats with whom, the frequency of meals, and gender- and age-related rules governing who eats first and last at meal time; and the amount of food that individuals are expected to consume.
Given that culture is the central focus of anthropology and TCN, we begin this chapter by introducing, defining, and describing the con- cept of culture. We’ll then discus the historical and theoretical foundations of TCN, including its relevance in contemporary nursing practice and the significant contributions of Leininger and other TCN scholars, leaders, and clinicians to the global advancement of TCN research, theory, education, and clinical practice. In the remain- der of the chapter, we examine the Transcultural Interprofessional Practice (TIP) Model as a frame- work for delivering client-centered, high-quality nursing and health care that are culturally congru- ent and competent, safe, affordable, and accessible to people from diverse backgrounds across the lifespan. The term client is used throughout the book because nursing concerns not only the care of people who are ill but also those who strive for optimum health and wellness in their lives.
Anthropology and Culture
To understand the history and foundations of TCN, we begin by providing a brief overview of anthro- pology, an academic discipline that is concerned with the scientific study of humans, past and pres- ent. Anthropology builds on knowledge from the physical, biological, and social sciences as well as the humanities. A central concern of anthropolo- gists is the application of knowledge to the solution of human problems. Historically, anthropologists have focused their education on one of four areas: sociocultural anthropology, biological/physi- cal anthropology, archaeology, and linguistics. Anthropologists often integrate the perspectives of several of these areas into their research, teaching, and professional lives (American Anthropological Association, n.d.; Council on Nursing and Anthropology, n.d.). One of the central concepts that anthropologists study is culture. A compli- cated, multifaceted concept, culture has numerous definitions. The earliest recorded definition comes from a 19th century British pioneer in the field of anthropology named Edward Tylor, who defines

4 Part One Foundations of Transcultural Nursing
culture as the complex whole that includes knowl- edge, beliefs, art, morals, law, customs, and any other capabilities and habits acquired by members of a society (Tylor, 1871). Influenced by her formal academic preparation in anthropology (Meade, 1937), Leininger defines culture as the “learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group of people that guide thinking, decisions, and actions in a patterned way…. Culture is the blueprint that provides the broadest and most comprehensive means to know, explain, and predict people’s lifeways over time and in different geographic locations” (McFarland & Wehbe-Alamah, 2015a, p. 10).
Culture influences a person’s definition of health and illness, including when it is appropri- ate to self-treat and when the illness is sufficiently serious to seek assistance from one or more heal- ers outside of the immediate family. The choice of healer and length of time a person is allowed to recover, after the birth of a baby or following the onset of an illness, are culturally determined. How a person behaves during an illness and the help
rendered by others in facilitating healing also are culturally determined. Culture determines who is permitted, or expected, to care for someone who is ill. Similarly, culture determines when a person is declared well and when they are healthy enough to resume activities of daily living and/or return to work. When someone is dying, culture often determines where, how, and with whom the person will spend his or her final hours, days, or weeks. Although the term culture sometimes connotes a person’s racial or ethnic background, there are also many other examples of nonethnic cultures, such as those based on socioeconomic status, for example, the culture of poverty or affluence and the culture of the homeless; ability or disability, such as the cul- ture of the deaf or hearing impaired and the culture of the blind or visually impaired; sexual orientation, such as the lesbian, gay, bisexual, and transgender (LGBT) cultures; age, such as the culture of ado- lescence and the culture of the elderly; and occu- pational or professional cultures, such as nursing (American Nurses Association, 2013; International Council of Nurses, 2013) (see Figure 1-1), medicine,
Figure 1-1. The profession of nursing is an example of a nonethnic occupational culture. The faculty member on the left is transmitting the requisite knowledge and skills from one generation to the next by mentoring the nursing student on the right.

Chapter 1 Theoretical Foundations of Transcultural Nursing 5
and other professions in health care, business, edu- cation, and related fields.
In a classic study of culture by the anthropologist Edward Hall (1984), three levels of culture are iden- tified: primary, secondary, and tertiary. The primary level of culture refers to the implicit rules known and followed by members of the group, but seldom stated or made explicit, to outsiders. The second- ary level refers to underlying rules and assumptions that are known to members of the group but rarely shared with outsiders. The primary and secondary levels are the most deeply rooted and most difficult to change. The tertiary level refers to the explicit or public face that is visible to outsiders, including dress, rituals, cuisine, and festivals.
The term subculture refers to groups that have values and norms that are distinct from those held by the majority within a wider society. Members of subcultures have their own unique shared set of cus- toms, attitudes, and values, often accompanied by group-specific language, jargon, and/or slang that sets them apart from others. A subculture can be organized around a common activity, occupation, age, ethnic background, race, religion, or any other unifying social condition. In the United States, sub- cultures might include the various racial and ethnic groups. For example, Hispanic is a panethnic des- ignation that includes many subcultures consisting of people who self-identify with Mexican, Cuban, Puerto Rican, and/or other groups that often share Spanish language and culture (Morris, 2015).
Ethnicity is defined as the perception of one- self and a sense of belonging to a particular ethnic group or groups. It can also mean feeling that one does not belong to any group because of multieth- nicity. Ethnicity is not equivalent to race, which is a biological identification. Rather, ethnicity includes commitment to and involvement in cultural cus- toms and rituals (Douglas & Pacquiao, 2010). In the United States, ethnicity and race are defined by the federal Office of Management and Budget (OMB) and the U.S. Census Bureau; they provide standardized categories, which are used in the col- lection of census information on racial and ethnic populations and are also often used by biomedical researchers. There are six officially recognized eth-
nic and racial categories: White American, Native American, and Alaska Native; Asian American, Black, or African American; Native Hawaiian and other Pacific Islander; and people of two or more races; a race called “some other race” is also used in the census and other surveys but is not official. The Census Bureau also classifies Americans as “Hispanic or Latino” and “Not Hispanic or Latino,” which identifies Hispanic and Latino Americans as a racially diverse ethnicity.
In the traditional anthropological and biological systems of classification, race refers to a group of people who share such genetically transmitted traits as skin color, hair texture, and eye shape or color. Races are arbitrary classifications that lack defini- tional clarity because all cultures have their own ways of categorizing or classifying their members (Hesmondhalgh & Sala, 2013; Hunt, Truesdel, & Kreiner, 2013). Some define race as a geographically and genetically distinct population, whereas others suggest that racial categories are socially constructed (Zimitri, 2013). The most current scientific data indi- cate that all humans share the same 99.1% of genes; the remaining 0.1% accounts for the differences in humans (National Human Genome Institute, 2014).
Historical and Theoretical Foundations of Transcultural Nursing
More than 60  years ago, Madeleine Leininger (1925 to 2012; see Figure 1-2) noted cultural dif- ferences between patients and nurses while work- ing with emotionally disturbed children. This clinical nursing experience piqued her interest in cultural anthropology. As a doctoral student in anthropology, she conducted field research on the care practices of people in Papua New Guinea and subsequently studied cultural similarities and differences in the culture care perceptions and expressions of people around the world.
At the same time that Leininger (Leininger, 1978, 1991, 1995, 1997, 1998, 1999; Leininger & McFarland, 2002, 2006) was establishing TCN,

6 Part One Foundations of Transcultural Nursing
other anthropologists, nurse–anthropologists, and nurses who were studying, teaching, and writing about ethnicity, race, diversity, and/or cul- ture in nursing used terms such as cross- cultural nursing, ethnic nursing care (Orque, Bloch & Monrroy, 1983), or referred to caring for people of color (Branch & Paxton, 1976). The term trans- cultural nursing is used in this book, in recogni- tion of the historical, research, and theoretical contributions of Leininger (1978), who used this term in her research and other scholarly works.
Leininger cites eight factors that influenced her to establish TCN as a framework for addressing 20th-century societal and health care challenges and issues, all of which remain relevant today:
1. A marked increase in the migration of people within and between countries worldwide
2. A rise in multicultural identities, with people expecting their cultural beliefs, values, and ways of life to be understood and respected by nurses and other health care providers
3. An increase in health care providers’ and patients’ use of technologies that connect peo- ple globally and simultaneously may become the source of conflict with the cultural values, beliefs, and practices of some of the people receiving care
4. Global cultural conflicts, clashes, and violence that impact health care as more cultures inter- act with one another
5. An increase in the number of people trav- eling  and working in different parts of the world
6. An increase in legal actions resulting from cultural conflict, negligence, ignorance, and the imposition of health care practices
7. A rise in awareness of gender issues, with growing demands on health care systems to meet the gender- and age-specific needs of men, women, and children
8. An increased demand for community- and culturally based health care services in diverse environmental contexts (Leininger, 1995)

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