Theoretical frameworks

2.12.1 Leininger’s transcultural nursing Theory

Transcultural nursing is a relative study of cultures to appreciate resemblances and contrast in human groups (Leininger, 1991). The goal of this theory was to help researchers and clinicians understand and explain the interdependence between care and cultural phenomena while acknowledging the differences between cultures (Leininger & McFarland, 2006). The theory proffers that nurses cannot separate cultural beliefs, worldviews, and social structure factors, from illness, health, wellness, or care in their work with cultures, as these factors are closely interrelated. Health and wellness are affected by cultural and social structure factors like religion, technology, cultural beliefs and practices, economics, family and kinship, politics,

physical conditions, and biological factors. (McFarland, 2018; McFarland & Wehbe-Alamah, 2019.)

Four tenets undergird Leininger’s transcultural care theory. The first theoretical tenet is that there are care diversities and universalities among cultures in the world. Culture care meanings must be discovered before a transcultural body of knowledge can be established. (Burkett et al., 2017; Chiatti, 2019.) The second theoretical tenet is that social structural factors such as

education, kinship, technology, religion, economics, politics, language, environment, and care factors influence cultural care expressions, meanings, and patterns in different cultures. An understanding of these factors is necessary to provide cultural groups with meaningful care and culturally based care. The third theoretical tenet is that the generic and professional health factors that occur in diverse environmental contexts influence the outcomes in health and illness (McFarland, 2018) and these factors need to be taught and applied in care practices. The fourth theoretical tenet is that culture care decisions and action modes be used to plan culturally congruent care for patients. (McFarland & Wehbe-Alamah, 2019.)

Culturally congruent care as discussed under this theory refers to “culturally based care knowledge, actions, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully fit the cultural values, beliefs, and lifeways of clients for their health and

well-being, or to prevent illness, disabilities, or death” (McFarland & Wehbe-Alamah, 2019, p.547).

Culture care diversity as discussed in Leininger’s theory refers to the variabilities that occur among human beings regarding culture care meanings, lifeways, symbols, patterns, values, or other features that relate to care delivery to persons from a specific culture. Culture care universality on the other hand refers to the similar culture care phenomena among groups or individuals that serve as guides for the provision of effective care. (McFarland & Wehbe-Alamah, 2019.)

The concept of transcultural nursing derives from this theory. The goal of transcultural nursing is to deliver care that is culturally congruent or care that aligns with the values, lifestyle, and

system of meaning, of the patient. Respecting the cultural needs of patients and communities is important to the success of health care. To be effective, nursing care must integrate the beliefs and cultural values of patients, their families, and communities with the decisions and views of the team of providers. By providing culturally congruent care, the nurse bridges cultural gaps to provide supportive and personalized care for patients. (Clarke, 2017.) Besides, utilizing cultural knowledge to treat a patient similarly benefits a nurse to be liberal to therapies that can be considered non-conventional, for example, spiritual treatments like meditation and blessing (Gonzalo, 2020).

Transcultural nursing involves a comparative study of cultures to understand similarities and differences among them. The information and its meanings must be generated by the patients themselves rather than predetermined criteria. (Clarke, 2017.) Transcultural nursing advocates the adjustment of patient care procedures to accommodate current cultural contexts

(Henderson et al., 2018; McFarland & Wehbe-Alamah, 2019), underscoring the need for institutions to provide continual training in cultural competence to their nursing staff (Henderson et al., 2018). According to McFarland & Wehbe-Alamah (2019), transcultural

prepared nurses can advance culture care knowledge by uniting culture and care, by conducting research, and by applying their knowledge regarding culture and care into practice. This

approach to nursing in turn results in positive outcomes for both nurses and patients.

2.12.2 Culturally competent care The concept of immigration is closely linked to concepts such as cultural diversity and cultural competence since immigrants and their host countries have different cultures. Increasing diversity creates challenges for health care practitioners and policymakers to develop and deliver culturally competent services and to reduce inequalities in health across the diverse cultural groups in a population. (Lin et al.,2016; Henderson et al., 2018.) Diversity is an integral concept of modern nursing. Several international studies conducted regarding cultural diversity issues that nurses are facing when providing care for multicultural patient populations. (Ogbolu et al., 2018.)

In actual practice, merely being aware of cultural differences does not mean that the health care worker will deliver satisfactory care or that racial, cultural, and ethnic discrimination will be mitigated. Being aware of cultural differences will also not automatically lead to a positive interaction between the patient and the health care provider. When health care providers emphasize cultural differences and equate that to respect for their diverse care populations, they inadvertently may be promoting ethnocentrism rather than displaying cultural competence.

What is appropriate for one cultural group, may not be appropriate for another. (Henderson et al., 2018.) A clear understanding of the concept of cultural competence and its dimensions is very important for health care providers. Therefore, providing culturally competent care is one of the priorities in organizations. (Hart & Mareno, 2014.)

In the health care context, cultural competence is defined as the ability to identify, appreciate, and respect the preferences, values, and expressed needs of patients. It includes the ability to resolve conflicts and identify solutions to problems in ways that reduce interference from culture. (Henderson et al., 2018.) There are several other definitions of cultural competence in the literature. One definition proffer that cultural competence is a set of congruent attitudes, behaviors, and policies within a system or group that enables that entity to work effectively in cross-cultural situations. Applying this definition to the health system, cultural competence represents the capacity of the health care system to deliver its goals of improving health by integrating culture into its processes and policies for the health services delivery. Another

definition of cultural competence is the integration of knowledge, skills, and attitudes that

enhance cross-cultural interactions and communication. This second definition in the health care context focuses on the ability of providers and health organizations to deliver health services

that effectively meet the cultural needs of patients. (Henderson et al., 2018.)

Lin et al. (2016) conceptualized cultural competence as comprising of three domains, cultural awareness and sensitivity, cultural knowledge, and cultural skill. Cultural awareness refers to the individual's recognition and acceptance of their cultural background, their ability to perceive cultural differences in others, and the appreciation that cultural perspectives and personal prejudice or values are influenced by personal views. Cultural awareness leads turn into cultural sensitivity. Health care providers who have cultural awareness are considered as being culturally sensitive. (Lin et al., 2016.) The second domain, cultural knowledge, is the knowledge regarding the concepts, theories, and evaluation of culture. The third domain, cultural skill refers to the application of the knowledge of culture to clinical care. It implies the ability of providers to perform culturally-based assessments and offer accurate diagnoses as well as the ability to use resources effectively while considering and respecting the beliefs and values of the patient.

(Henderson et al., 2018.)

To be able to translate cultural knowledge and awareness into culturally sensitive care, the nurse will be able to conduct the cultural assessment. The purpose of such culture assessment is to obtain reliable information from the patient that enables the nurse to create a care plan that is both acceptable and culturally relevant for all the health problems that the patient may have.

(Chiatti, 2019.) The nurse and all health care providers should have the skills to carry out a systematic cultural assessment that involves the values, practices, and beliefs of patients and their families (Clarke, 2017).