In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of cultural awareness and influences on health in order to:

  • Assess the importance of client culture/ethnicity when planning/providing/evaluating care
  • Recognize cultural issues that may impact the client's understanding/acceptance of psychiatric diagnosis
  • Incorporate client cultural practice and beliefs when planning and providing care
  • Respect cultural background/practices of the client (does not include dietary preferences)
  • Use appropriate interpreters to assist in achieving client understanding
  • Evaluate and document how client language needs were met

Assessing the Importance of Client Culture and Ethnicity When Planning, Providing and Evaluating Care

Madeleine Leininger was a nursing professor, theorist and anthropologist who is now considered to be the leader in terms of transcultural nursing.

Madeleine Leininger's work relating to cultural care began in the 1950s, and she published her book "Culture Care Diversity and Universality: A Theory of Nursing" in 1991. Madeleine Leininger, herself, states that her theory is the only existing theory that "searches for comprehensive and holistic care data relying on social structure, worldview, and multiple factors in a culture in order to get a holistic knowledge base about care" (Leininger, 2006, p. 219)

The purpose of transcultural nursing research is to study cultures in order to better understand both the similarities and the differences among patient groups and cultures. Culture is a set of established beliefs that are held by a certain group of people that has been handed down from generation to generation and not held and shared by other groups or the members of other groups. These beliefs, values and perceptions are unique to the particular culture.

Nurses' practice must incorporate cultural needs and beliefs into their nursing practice to provide care that is individualized for the client and appropriate to the client's needs. During the assessment phase of the nursing process, the nurse assesses the client's and family member's cultural background, preferences and needs, after which the nurse modifies the plan of care accordingly.

This cultural assessment and culturally oriented care enables the nurse to:

  • Identify ways with which the client's culture and its features impact on their perceptions, beliefs, values, experiences with health, wellness, illness, suffering, and even death
  • Remain accepting, respectful and welcoming of human diversity
  • Facilitate more holistic assessments and plans of care as based on the client's culture
  • Deep and strengthen their commitment to nursing and their insight into the nursing profession as based on culturally based nurse-patient relationships which emphasize the importance of the whole person rather than viewing the patient as simply a set of symptoms or an illness
  • Integrate their full and in depth cultural knowledge into the treatment of patients
  • Develop and integrate open mindedness into nursing care which can lead to some innovative, non-traditional, alternative nursing interventions such as spiritually based therapies like meditation and anointing.

In the Transcultural Nursing Theory, nurses have a responsibility to understand the role of culture in the health of the patient. Not only can a cultural background influence a patient’s health, but the patient may be taking culturally driven home remedies that can affect his or her health, as well.

Leininger proposes that care is the dominant, unifying and distinctive essence of nursing. Caring, a universal phenomenon is primarily culturally driven as based on the variations among cultures in reference to their process, patterns and expressions.

Madeleine Leininger's theoretical thoughts also support three nursing modes of intervention that are necessary in order for nurses to care for, and assist, people of diverse cultures. These three nursing modes are:

  • Cultural preservation and maintenance
  • Cultural care negation and accommodation
  • Cultural care repatterning and restructuring

In today’s health care field, nurses and other health care providers have the professional responsibility to be sensitive to their clients’ cultural backgrounds. This sensitivity is particular important and vital to the quality of care because culture is so integral and intrinsic to who the client is as a unique individual. Culture can greatly affect client health, as well as their reactions to treatments and care. Madeleine Leininger’s Transcultural Nursing Theory facilitates the nurses' understanding of why and how the patient’s cultural background is important to health.

Recognizing Cultural Issues That May Impact on the Client's Understanding of and Acceptance of a Psychiatric Diagnosis

Cultural issues that may impact on the client's understanding and acceptance of a psychiatric mental health disorder and diagnosis are numerous and varied. For example, these cultural beliefs, values and practices can impact on the client's understanding and acceptance of a psychiatric mental health disorder and diagnosis among various cultures:

  • The meaning of the mental disorder or illness to the client and their family members: The meaning of a psychiatric mental health disorder can be viewed as imaginary or it can be viewed as real; some can view these psychiatric mental health illnesses as a disorder of the mind, or the body, or both; and still more may view these illnesses as a stigma which promotes shame that at times can be quite severe and other cultures view these illnesses like all other kinds of illnesses. Based on these views, different strategies and interventions are planned and implemented to accommodate for these various culture bound perceptions for the client and their significant others.
  • The way with which the client relates their symptoms to the health care provider: Some cultures state that they are experiencing somatic and physical symptoms rather than emotional symptoms such as anxiety and distress. For example, clients with an Asian culture may have somatic complaints rather than complaints relating to their mental health. It is, therefore, necessary that health care providers are cognizant of the fact that some subjective data given by the client during the assessment may be culturally driven and without any data about their psychiatric mental health signs and symptoms when indeed the client is adversely affected with a mental health disorder.
  • Culture also impacts on the ways which some cultures cope with stress: Some cultures cope with stress by openly expressing their feelings; other cultures avoid thinking about and expressing their feelings when confronted with stress. These cultures suppress their feelings. For example, members of the Asian culture tend to suppress their feelings and discussions about their true feelings rather than expressing their feelings; and, on the other hand, African Americans actively confront their stress and, more often than other cultural groups, they tend to resolve their stress and distress on their own, often drawing on spiritual influences to assist them during stressful times.
  • Whether or not treatment is sought for a psychiatric mental health disorder: Research indicates that minority groups within the United States are less likely to seek treatment for a mental health disorder than Caucasians in this nation. They are also more likely to delay getting treatment than whites.
  • The kind of help that is elicited when help is sought for a psychiatric mental health disorder: Research indicates that minority groups within the United States are more likely to seek treatment for a mental health disorder with their primary care physician and non health care related informal resources such as a member of the clergy, culturally based nontraditional "healers", rather than a mental health professional, when compared and contrasted to American Caucasians. For example, American Indians and Eskimos, for example, may tend to seek the help of a traditional healer such as a medicine man.

It must also be noted that psychiatric mental health professionals, including nurses, are affected and impacted by their own cultural beliefs, values and practices. It is, therefore, necessary that all health care providers eliminate their cultural biases towards clients with mental disorders and all other disorders and diseases; therefore, the nurse must recognize their own cultural biases and then overcome them with a full understanding, acceptance and respect for all clients regardless of their own integral cultural practices, values, beliefs and perceptions.

Incorporating the Client's Cultural Practices and Beliefs When Planning and Providing Care

In addition to the cultural practices and beliefs that were discussed immediately above this section, culture also impacts on other areas of the client-nurse relationships. Some of these cultural influences include:

  • General Perceptions Relating to Illness and Health: Some cultures place a high value on health, health promotion and wellness and others do not. Some cultures believe that illness is stigmatic and outside of any control by the members of the culture. Still more may have culturally bound rituals and practices to promote health, to prevent illness, and to cure disease.
  • Distance and Space Orientation: Space and distance orientation and tolerance for closed and open spaces may also vary among cultures. For example, research indicates that cultures that live in crowded areas, such as in heavily populated city, are more tolerant of closeness and proximity to others when compared to members of other cultures who are not tolerant to closeness, but instead, prefer to be in and live in less crowded and congested areas. This distance and space tolerance may influence and impact on a client's tolerance of crowded areas and being in close proximity to others as they are when they are in a hospital.
  • Family Dynamics: The size of the family unit, family member roles, internal family dynamics, power and decision maker powers, interpersonal interactions within the family, among members of the family, and with others outside of the family unit, and communication patterns within the family unit often vary according to one's culture. For example, some families have top to bottom communication patterns where the leaders communicate with the followers in the family unit and not from the bottom up from the children to the authority figures; some families are paternalistic with the male as the predominant figure of the family unit, others can be maternalistic and still more may share power equally in the family unit; some families and cultures value and honor their elders and others do not to the same extent; and still more culturally bound dynamics can include who makes the decisions and decision making. For example, some families elicit and seek out the help and support of those outside of the family unit to aid their decision making and others restrict discussions and decision making to only one person, only the nuclear family members, or only the members of the extended family in collaboration with the nuclear family.
  • Self Efficacy: Simply defined, self efficacy is the personal belief that one has the ability and capability to do something successfully. Cultures and members of cultures who hold the belief that they have self efficacy will be motivated to learn, they will be motivated to participate in their care, and they will also be motivated to change behaviors; on the other hand, cultures and members of cultures who hold the belief that they do not have the ability and capability to be successful will not be motivated to learn, they will be motivated to participate in their care, or be motivated to change behaviors when they lack self efficacy. These clients will be less likely to actively participate in their care and care decisions; they will depend on others, including health care professionals to make these decisions for them.
  • Communication Patterns: As fully discussed in the beginning of this review under the integrated process of "Communication and Documentation", verbal and nonverbal communication patterns and elements, such as terminology, silence, eye contact, choice of vocabulary, facial expressions, and touch, are impacted by different cultures.
  • Time Orientation: Some cultures focus more on the past than on the present or future; other cultures place an emphasis on the present, rather than the past or future; and sill more focus on the future rather than the past or present. This perspective and focus impacts on the client and their perspectives. For example, a client who focuses on the future will more likely be committed to sacrifice in the present to better insure a healthy future; and those with a focus on the past and the current time may not be as focused on the future by maintaining healthy life styles and participating in health and wellness activities and programs.

Culture is integral to the person as a unique individual. It impacts greatly on the client's health, and their reactions to treatments and care. Cultural beliefs, perspectives, values and practices are determined and assessed by the nurse, after which they are then integrated into the planning, implementation and evaluation of client care. All aspects of the direct and indirect care of the client is modified and changed according to the client's culture and cultural background. Additionally, all these cultural modifications must be documented as all other aspects of nursing care are.

Respecting the Cultural Background and Practices of the Client

Like religious and spiritual beliefs, nurses remain respectful and accepting of all cultural beliefs, practices and perspectives, regardless of those that the nurse possesses. They must, additionally, overcome their own cultural biases by recognizing that they have them and then detaching from them as they plan and render client care to clients from diverse cultures.

Using Appropriate Interpreters to Assist in Achieving Client Understanding

As previously mentioned in the "Integrated Process: Communication and Documentation" and the "Integrated Process: Teaching and Learning", interpreters and other aids such as large print and Braille reading materials, are used to facilitate the client's understanding of their health care status, their care and their treatments.

Although at first glance a nurse may think of only a foreign language interpreter for those who do not have English as their primary language, it should not be forgotten that American Sign Language interpreters should, and can, be used among those clients who cannot gain their understanding of their health care status, their care and their treatments when the client is adversely affected with an auditory impairment.

Evaluating and Documenting How the Client Language Needs Were Met

Interpreters and the use of instructional materials in multiple languages often have to be used in order to accommodate for the clients' language barriers. These accommodations, like all other accommodations and modifications of care, are thoroughly documented.

The most effective way to decide whether or not the client language needs were met is to assess whether or not the client has gained an understanding and insight into their health care status, their care and their treatments.

Documentation in the medical record should include the client's level of comprehension, or lack thereof, and the modifications that were used to facilitate this comprehension using an interpreter and/or appropriate reading materials.


SEE – Psychosocial Integrity Practice Test Questions

Alene Burke, RN, MSN
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