Understanding cultural differences is the key to transcultural nursing

Understanding cultural differences is the key to transcultural nursing

1987, VOL. 45, NO 5 AORN JOURNAL Opinion Understanding cultural differences is the key to transcultural nursing N urses who deal with patients fro...

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1987, VOL. 45, NO 5

AORN JOURNAL

Opinion Understanding cultural differences is the key to transcultural nursing

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urses who deal with patients from other cultures must develop a respect for those patients’ cultural beliefs, as well as a strong insight into their own attitudes and values as health care providers. When cultural values of the nurse and the patient clash, the potential exists for inferior nursing care and, ultimately, for poor patient outcomes. We cannot limit our care to giving medications, positioning patients properly, and practicing aseptic technique. As perioperative nurses, we have an obligation to treat our patients as unique individuals. With some patients, this means developing an insight into their cultures.

Transcultural Nursing

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y interest in transcultural nursing began in 1981 when I became associated with Interplast. Interplast is an organization of physicians, nurses, and other health care professionals who donate their time to travel to other countries to do plastic and reconstructive surgery for those who cannot afford it or do not have access to this kind of specialized care. During my association with Interplast, I have traveled to Honduras, Peru, and Ecuador for twoweek stays. Each time, I have been faced with the completely unexpected, and made friends with people I never dreamed I would meet. I have been made part of the family in all types of homes and environments. In the process, I have learned more about myself and others than I ever thought possible. In the United States, transcultural nursing is

getting more attention from American nurses than ever before. The additional attention has been caused, in part, by the influx of immigrants and by the ethnic pride that immigrants have in their culture and in their determination to preserve it. In my home city of San Francisco, for example, there are little mini-countries: Chinatown, little Italy, little Vietnam, “Japantown,” and small enclaves of Central and South American natives. There are some city blocks that resemble Ireland, the Philippines, Portugal, and other European countries. Each of these areas has so many characteristics of the country itself that you feel as though you are there. You will find physicians, grocers, and other workers transacting business in their native language, creating a little microcosm of that country. Some elders can live within such a community and never need to learn English. You can travel around the world by going on a seven-mile walk around San Francisco-these are our patients. International travel has also made us more aware of life and reality outside of Western civilization. Terrorism has certainly made inroads on this, but the increased exposure to other customs and values is still felt. Five years ago, Madeleine Leininger, RN, PhD, Ruth Lahde Rothenburger, RN, BA, is a perioperative staff nurse at the University of California at San Francisco. She has an associate degree in nursingfrom Fayetteville (NC) Technical Institute and a bachelor of arts degree in Spankh from Seattle University. I203

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Increased cultural awareness and appreciation for the cultures of our international neighbors is eroding the “ugly American” stereotype. Wayne State University, Detroit, founded the Transcultural Nursing Society, which focuses on research, workshops, and networking. Her work has led to the recognition of transcultural nursing as a vital area of study and practice in the United States and overseas. This year, universities in Salt Lake City, Boston, and Detroit are offering graduate programs in transcultural nursing.

Cultural A wareness

Another subconscious misconception is that our way of communicating is correct. If someone does not understand the meaning of what I am saying, surely something is wrong with that person. A third belief is the one the “ugly American” has to overcome-that the values and beliefs of our culture are correct because they are backed by science, statistics, and results. Thus, our values are correct and theirs are not. If a culture will not accept these proven premises then they have major defects.

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n increased awareness and appreciation for the cultures of our international neighbors is eroding the “ugly American” stereotype of an insensitive, demanding visitor who takes and talks instead of listening, sharing, and learning. Although there will always be that type of individual, we are getting to know our international neighbors and accept what seems strange to us. As a result, the “ugly American” is slowly evolving into a person of greater sensitivity and awareness, a better neighbor. A patient’s cultural background can directly affect his or her attitudes and responses toward treatment. Certain cultures have different educational standards and/or superstitious beliefs that may change a clear and rational explanation into one unacceptable to the patient. For example, if the patient is a matriarchal or patriarchal figure, as in American Indian or gypsy communities, the nurse may represent a distinct invasion of privacy. Language differences can also present a problem. A language translation could lead to a completely changed meaning. One of the conscious and/or unconscious misconceptions we have about other cultures is that because a person does not speak our language (or does not speak it well), he or she is less intelligent. If we cannot communicate with someone, how can we know that person is unintelligent? It would be more appropriate to respect each person as a human being who communicates his or her own way.

Problem Encountered

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aking care of the whole patient is a complex task. Often, OR nurses do not have the opportunity to conduct an in-depth preoperative interview. When checking the patient into the OR, nurses must quickly verify identification, procedure, allergies, and related information, and perform the perioperative nursing assessment. The pressure for quick turnover and effective use of every minute lurks over our shoulders as we check in patients, pinpoint factors that might affect the surgery, and follow through with any problems. For example, the circulating nurse must ensure that materials the scrub nurse needs are there, provide him or her time for a short break, and ensure that the anesthesiologists have all the lines, narcotics, IVs, warming or cooling equipment, and cleanup they need. At the same time, OR nurses field telephone calls and beeper pages for surgeons and residents, try to meet the emotional needs of patients, surgeons, anesthesiologists, and other nurses, give the patient adequate time to ventilate fears and ask questions, give the surgeons, anesthesiologists, and nurses time to verbalize concerns, and keep a smile on our faceall in five to 17 minutes. We have all been taught that the patient is the focal point of our care-giving activities. But where does the patient really stand after all the legal 1205

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To them, our behavior represented the opinion that they were not good enough medical professionals to take care of their own. red tape and team needs have been met? Is there time to take care of the whole patient creatively? And what if there is a cultural barrier? The answer is in resetting our priorities. First, we must look at the patient as the focus of all this activity. Nurses and all team members are patient advocates. Our adversaries are misinformation, lack of information, and fear. When it is shown that there is not enough time for all of our duties to be completed, patient advocacy must not be compromised; adjust one of the other duties instead. For example, in the anesthesia area, anesthesia technicians could take over the tasks of orchestrating lines, IVs, and narcotic medications. Or the scrub nurse could take a break at another time and assist with room turnover and case preparation to give the circulator more time with the patient.

Learning Cultural Differences Firsthand

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ifferences in values among cultures were vividly demonstrated to me four years ago when I traveled to South America with Interplast. The hospital staff there allowed us to use three of its four operating rooms for plastic surgery. The native surgeons used the other OR for cesarean sections and emergencies during our stay. Many times the native and the Interplast teams borrowed from or helped each other, and we began to develop a warm and friendly relationship. Even though our languages were different, our goals were similar. Between one of our rooms and the room used by the native surgical team, there was a small substerile anteroom with a sink and counter. Often we would hear the joyous sound of a baby hollering, and word would spread through our three rooms, “It’s a boy!” or ‘‘It’s a girl!” On the fourth day of this trip, one of our recovery nurses discovered a newborn infant on

the counter in the anteroom. There was no one around, and the infant was distinctly blue and still. Not knowing how long the baby had been there or what kind of problems the native team was having, we grabbed the baby, put it down on the nearest OR bed where a cleft palate procedure was underway, and resuscitated the baby. The sigh of relief was felt in all three of our rooms when that baby finally cried on its own. There were several considerations here. One, we did not know how long the baby had been anoxic or whether it had sustained brain damage. In addition, the native team, rather than being jubilant, stood back and frowned. I did not understand, and I assumed I was misinterpreting things. On the sixth day another such infant appeared, cyanotic and barely alive. We gave everything else a second priority, and pulled that child back from death. Meanwhile, the baby’s mother was bleeding and in shock after her cesarean section. We were asked to lend a blood pressure cuff to infuse blood products into the mother and we all rushed to help. One person started additional peripheral lines, another provided the anesthesiologist with medications, and so on-two crises going on at once in addition to the three cases going on in the Interplast rooms. When it was over and both had survived, we felt a distinct hostility from the native team, and it was never cleared up on the trip. I have returned there for other Interplast work, and gradually the significance of this incident has become clearer. With our life-or-death attitudes, high-tech knowledge, and money, we had invaded their OR and crowded them out of three rooms. We had been invited there as their guests, but in the crises that occurred, and in our rush to help (which we are accustomed to doing), we pushed them aside to manage the situations. To them, that behavior represented an opinion that

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they were not good enough medical professionals to take care of their own. In their view, we weresuperseding them because we believed our standards were higher than theirs. Never did we consider the overall picture: that death is a part of life for these people; that when our teams leave, life and death go on exactly as before; that they have equally high, but different, standards and values; and most importantly, that they have a tremendous pride and belief in what they are doing. In our horror to think of how many babies die when we are not there, we lost sight of the universal picture: that this is the way the life cycle is, this is the way nature is. In fact, we may have done harm by returning possibly brain-damaged infants to a society with little money and no resources to care for them; they were already overburdened with the problems of taking care of the healthy living. We had tampered with the “survival-of-the-fittest” law that rules in areas of the world where there is no access to technology and resources such as we are accustomed to. Although the “survival-of-the-fittest” attitude might be unacceptable to us, in that country it was not only acceptable, it was God‘s law. It took me a long time to understand this “supernurse” syndrome, that my values and beliefs are correct and take precedence over someone else’s values. I suspect that I never will be able to keep from moving quickly to initiate lifesaving procedures, because this reflex has been built into me for years. I cannot understand some values, especially how infants dying on counters can be part of someone’s reality, but I can now accept it. It is not my intention to say that we must replace our values and beliefs; that is impossible. We can, however, go in a different direction with our efforts and develop the sensitivity to know that other belief systems can be equally valid to another individual. Standards of practice in the United States sometimes cannot be followed in other countries. A decision may have to be made as to whether the patient is better off with or without a surgical procedure. Such a decision must take many variables into account such as the availability of supplies, equipment, and sterilizing facilities. I208

In addition, the question may arise as to whether the patient will fit back into his or her culture after surgery. What we might regard as a vital procedure here may not be so elsewhere. Has the patient and his or her community accepted a cosmetic or orthopedic deformity that we in our society would change? For example, there are tiny pockets of mountain people in the Peruvian Andes who believe that persons with a congenital cleft palate are blessed by God.

Conclusion

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nterplast provided me with my first exposure to transcultural nursing. Although transcultural nursing is not the end-all of nursing, I believe it is vital to gain an understanding of it to fully realize our increasingly comprehensive roles as perioperative nurse professionals. Furthermore, I believe we can all give better care by studying transcultural nursing, and have an obligation to do so. We can become more flexible, more accepting, and more tolerant, and better able to deal with the unexpected. The patient, at the center of all this, wins. There is an old American Indian prayer that seems to contain the spirit of transcultural nursing: “Great Warrior, grant that I should not criticize my neighbor until I have walked a mile in his moccasins.” RUTHLAHDEROTHENBURGER, RN, BA Suggested reading

Contemporary Minority Leaders in Nursing: AfroAmerican, Hispanic, Native American Perspectives. Kansas City, Mo: American Nurses’ Association, 1983. Lahde, R E. “OR team changes life for Hondurans.” AORN Journal 36 (August 1982) 195-204. Leininger, M. Transcultural Nursing: Concepts, Theories andhactices. New York City: John Wiley & Sons, 1978. Spector, R E. Cultural Diversity in Health and Illness. Norwalk, Conn: Appleton & Lange, 1985. Werner, D. Helping Health Workers Learn: A Book of Methods, Aids, and Ideas for Instructors at the Vilhge Level. Palo Alto, CaliE The Hesperian Foundation, 1982. Werner, D. Where There iiNo Doctor:A Vilhge Health Care Handbook. Palo Alto, CaliE The Hesperian Foundation. 1977.