5. TRANSCULTURAL NURSING ASSESSMENT

Leininger (1978) defines cultural care assessment as the systematic identification of the cultural basic beliefs, meanings, values, symbols, and practices of individuals or groups within a holistic perspective including the worldview, life experiences, environmental context, ethnohistory, and social structure factors. Throughout the years she has identified several purposes of a culture care assessment, they are as follows:

1. to discover the client's culture care and health patterns and meanings in relation to the client's worldview. Lifeways, cultural values, beliefs, patterns, and social structure factors;
2. to obtain holistic culture care information as a basis in providing nursing care decisions and actions;
3. to discover specific culture care patterns, meanings, and values, that can be used to make differential nursing decisions that fit the client's lifeways and aspects of professional knowledge;
4. to identify potential areas of culture care conflicts or clashes due to value differences between clients and professional health personnel;
5. to identify general and specific dominant themes or patterns that need to be understood in context to develop and implement congruent care practices;
6. to identify comparative culture care information among clients of different cultures, so that information can be shared and used appropriately by nurses in clinical, teaching, and research practices;
7. to identify similarities and differences in human needs that require nurses to think and make critical judgments in order to provide quality care; and
8. to demonstrate the importance of theoretical ideas and research approaches that can be readily used to improve health care practices across cultures and to advance the body of transcultural nursing knowledge.

PRINCIPLES OF EFFECTIVE TRANSCULTURAL NURSING ASSESSMENT

• The Culture Care Theory with the Sunrise Model can serve as a guide to obtain a holistic view of the individual, family, or group, and for institutional assessments. The worldview, social structure factors, ethnohistory, language uses, and environmental context are the elements essential to getting comprehensive, yet specific information. The following elements are necessary towards obtaining an accurate assessment from culturally diverse clients.
• Throughout the assessment the nurse maintains the role of an active listener, learner, and reflector rather than a teacher.
• The nurse refrains from using professional jargon or medical terms, as it tends to suppress clients from sharing their thoughts and feelings.
• The nurse keeps the assessment focused on the client's internal world of knowing rather than the nurse's ideas about care, health, and lifeways.
• The nurse's professional ideas on health and care should be viewed as secondary to that of the client's. Cultural conflict, clashes, or latent backlash responses can result when a nurse attempts to sell his or her healthcare beliefs to the culturally diverse client.
• The nurse encourages clients and their families to think about some of their cultural values, beliefs, and lifeways and how they think these areas influence their health care lifeways.
• The nurse usually asks few direct questions but instead focuses on areas of inquiry with open ended comments such as "Tell me about yourself".
• The nurse uses the client's words and frame of reference rather than the nurses in order to keep in the client's world of knowing and understanding.
• The nurse recognizes that most clients are capable of explaining and interpreting their experiences related to care, health, and maintaining wellness. This may be accomplished through narratives, poems, cultural taboos, songs, pictures, and symbols.
• The client's cultural secrets are not generally shared unless the client believes that the nurse can be trusted, is genuinely interested, and can respect and protect cultural secrets and viewpoints.
• The nurse can learn much about the culture, health, caring, and healing modes by respecting and encouraging the practice of wearing traditional dress, adornments or symbols for the assessment if the client indicates a desire to do so.
• Throughout the cultural care assessment the nurse tries to make the client or family comfortable and enjoy sharing ideas with the nurse. Ethical considerations with the client must be respected when confidential matters are presented.
• The nurse appreciates the sharing of cultural values and symbolic material by the client and knows that this information can be used to improve healthcare.
• Throughout the assessment the nurse seeks to assess if the information is accurate or credible to the client's lifeways, their family, or as representatives in the community.

Understanding the importance of gathering data across cultures, Leininger developed the Acculturation Health Care Assessment Guide for Cultural Patterns in Traditional and Nontraditional Lifeways primarily for the ethnonursing method and the theory of Culture Care. This guide has been developed, refined, and used since the early 60's by Dr. Madeleine Leininger and is in frequent demand by anthropologist, transcultural nurses and other disciplines interested in gathering information across cultures. It provides qualitative indicators to meet validity and reliability criteria for qualitative study. This copyright guide is available through the Journal of Transcultural Nursing (1991) and may be used if the full title of the guide, recognition of the source (M. Leininger) and publication outlet (Journal of Transcultural Nursing) are cited.

Leininger's Acculturation Health Care Assessment Guide for Cultural Patterns Traditional and Non-Traditional Lifeways

The assessment developed by Leininger starts with basic information concerning the name of the assessor, date. sex and age of client, and place or context of assessment. There is a rating scale from 1 to 5 with 1 indicating that die client is primarily operating from a traditional value system while 5 is an indicator that the client is mainly non-traditional. After gathering basic data during the first section of the assessment, the nurse will continue with Part 1 which is designed to question patients regarding traditional or non-traditional orientations.

Part I: Rating Criteria to Assess Traditionally and Non-Traditionally Patterned Cultural lifeways or Orientations

* Key: T - Traditional, M - Moderate, A - Average, NT - Nontraditional

Rating Indicators

Culture Dimensions to Assess Traditional or Non-Traditional Orientations

1. Language, communications and gestures (native or normative). Notations:
2. General environmental living context (symbols, material and nonmaterial signs). Specify:
3. Wearing apparel and physical appearance. Notations:
4. Technology being used in living environment. Notations:
5. Worldview (how person looks out upon the world). Notations:
6. Family lifeways (values, beliefs, and norms). Notations:
7. General social interactions and kinship ties. Notations:
8. Patterned daily activities. Notations:
9. Religious and spiritual beliefs and values. Notations:
10. Economic factors (rough cost of living estimates and income). Notations:
11. Educational values or belief factors. Notations:
12. Political or legal influences. Notations:
13. Food uses and nutritional values, beliefs, and taboos. Specify:
14. Folk (generic, lay or indigenous) health care-cure values, beliefs and practices. Specify:
15. Professional health care-cure values beliefs and practices. Specify:
16. Care concepts or patterns that guide actions, i.e. concern for, support, presence, etc.:
17. Caring patterns and expressions:
18. Informants ways to:
    1. prevent illnesses:
    2. preserve or maintain wellness or health
    3. care for self or others
19. Other indicators to support more traditional or non-traditional lifeways including ethnohistorical and other factors.

Part II: Acculturation Profile from Assessment Factors

The assessor is directed to plot an X with the value number placed on the profile to discover the orientation or acculturation lifeways of the informant. The clustering of numbers will give information of traditional or non-traditional patterns with respect to the criteria assessed.

Rating Indicators

Criteria:

1. Language and communication modes.
2. Physical-social environment (and ecology).
3. Physical apparel appearance.
4. Technology factors.
5. Worldview.
6. Family lifeways.
7. Social ties/kinship.
8. Patterned daily/nightly activities.
9. Religious/spiritual orientation.
10. Economic factors.
11. Educational factors.
12. Political and legal factors.
13. Food uses/abuses.
14. Folk (generic) care-cure.
15. Professional care-cure expressions.
16. Caring patterns.
17. Curing patterns.
18. Prevention/maintenance factors.
19. Other indicators, i.e. ethnohistorical.

LEININGER'S ALTERNATIVE SHORT ASSESSMENT GUIDE

Leininger also developed an alternative assessment guide used since 1985 by graduate and undergraduate nursing students as well as nursing staff in short term, emergency, and acute care centers. The assessment data offers information to develop a nursing care plan or to make decisions about a patient from a particular culture. The nurse begins with Phase I and proceeds to Phase V to get an overall assessment of the client.

Leininger's Short Culturalogic Assessment Guide

Phase I

Record observations of what you see, hear or experience with the client's experience, including: language, dress and appearance, body conditions and features, mannerisms and general behavior (attitudes and cultural features).

Phase II

Listen to and learn from the client about their cultural values, beliefs, and daily (nightly) practices related to care and health in the client's environmental context. Give attention to generic (home or folk) practices and professional nursing practices.

Phase III

Identify and document recurrent client patterns and narratives (stories) with client meanings of what has been seen, heard, or experienced.

Phase IV

Synthesize themes and patterns of care derived from the information obtained in Phase I, II and III.

Phase V

Develop a culturally-based client-nurse care plan as a co-participant for decisions and actions for culturally congruent care.

NOTE: The nurse starts with Phase I and indicates at the outset whether assessing an individual, small group, family or culture, proceeding through each Phase using culturally appropriate communication.

Leininger's short assessment is more likely to meet the time limitations of nurses on duty in hospital settings while the Leininger's Acculturation Health Care Assessment Guide for Cultural Patterns Traditional and Non-Traditional Lifeways can be used by home health care professionals to determine the level of acculturation in order to determine appropriate health care administration.

Transcultural Assessment Model

Another Transcultural Assessment Model was developed by Giger and Davidhizar (1995) to provide culturally appropriate and competent care. The assessment takes into account that each individual is culturally unique and therefore a product of past experiences, cultural beliefs, and cultural norms. Transcultural assessment is the basis for effective health care plans in a variety of healthcare settings regardless of whether the level of care is primary, secondary, or tertian. The Transcultural Assessment Model (1995) includes the following areas to consider when interviewing the culturally diverse client.

1. Culturally Unique Individual
   Information concerning place of birth, cultural definition, race, and if appropriate, length of time in the country is needed to determine the cultural identity of the client and when appropriate, adjust communication style and care plan to meet the needs of the individual.
2. Communication
   Communication is the base of understanding between the nurse and the culturally diverse client. Communication factors that may have to be adjusted to the client's cultural expectations include both verbal and nonverbal patterns of communicating across cultures
3. Space
   Degree of comfort can be determined by observing the level of discomfort patients exhibit when it is perceived that the client's space is being invaded.
4. Social Organization
   This area includes the normal state of health on the part of the culturally diverse patient and the social variables that can help or hinder their recovery. Social factors include; marital status, number of children, parental involvement, work, leisure, church, and friends.
5. Time
   Orientation to time differs across cultures. The culturally diverse patient's orientation of time may be past-oriented, present-oriented, or future-oriented. Their view of time may be social or clock-oriented. On the other hand, an individual's physiochemical reaction to time would include amount of sleep needed, and adjustment to schedules, for example, the probability that the patient will take medication and other treatments at a certain time.
6. Environmental Control
   Locus of control may be internal (belief in the ability to affect change) or external (belief that fate, luck and chance have a great deal to do with outcome). Culturally diverse clients may believe in magic, witchcraft, supernatural forces, and/or prayer to affect change or their value orientation could be the opposite, rejecting all their cultural values concerning non scientific methods of healing.
7. Biological Variations
   A complete physical assessment should be conducted including body structure, skin color, unusual skin discoloration, hair color and distribution, weight, height, and other visible physical characteristics such as: keloids and chloasma. Check lab work for variances in hemoglobin, hematocrit, and sickle phenomena if the client is African American or Mediterranean.

The following guidelines will enable the nurse to assess clients across cultures. This data needs to be included into the nursing care plan.

• Encourage the client to discuss cultural differences (people from diverse cultures who hold different world views can enlighten nurses).
• Make efforts to accept and understand methods of communication.
• Respect the individual's personal need for space.
• Respect the rights of clients to honor and worship die Supreme Being of their choice.
• Determine whether spiritual practices have implications for health, life, and well-being.
• Identify hobbies, especially when intervention is required for extended convalescence and for rehabilitation.
• Honor time and value orientation and differences in this area. Ally anxiety and apprehension if adherence to time is necessary.
• Provide privacy according to personal need and health status of the patient.
• Note cultural health practices, encourage efficacious practices, discourage dysfunctional practices and determine whether neutral practices will have long-term ill effect.
• Note food preferences and make as many adjustments in diet as health status and long-term benefits will allow and that dietary departments can provide.

In order to understand a culture, one needs to investigate it from a perspective of the multiple forces that contribute to the cultural group being studied. What seems strange or illogical to an outsider is often perfectly rational within a cultural context. The development of transcultural nursing is based on concepts borrowed from anthropology, sociology, and biology. Transcultural nursing concepts include cultural beliefs and values, health and illness systems, nurse-client interactions, and culture-specific nursing care. Since culture is a universal phenomenon, traits that are common to all cultural groups can be accurately assessed and used to formulate nursing care decisions and actions that are culturally congruent with the client's values and beliefs.