Narayanasamy’s ACCESS model (1998).
Culture is defined as the sum of all the material and spiritual values created in the process of social development and the tools that are used to create and hand these values down to next generations and show the extent of the man’s authority and control over their natural and social environment. The term “culture”, which diversifies in each community and so is experienced differently, also affects the way individuals perceive the phenomena such as health, illness, happiness, sadness and the manner these emotions are experienced. The term health, whose nature and meaning is highly variable across different cultures requires care involving cultural recognition, valueing and practice. The nursing profession, which plays an important role in the health team, is often based on a cultural phenomenon. The cultural values, beliefs and practices of the patient are an integral part of holistic nursing care. The aim of nursing is to provide a wholly caring and humanistic service respecting people’s cultural values and lifestyles. Nurses should offer an acceptable and affordable care for the individuals under the conditions of the day. Knowing what cultural practices are done in the target communities and identifying the cultural barriers to offering quality health care positively affects the caring process. Nurses should explore new ways of providing cultural care in multicultural societies, understand how culture affects health-illness definitions and build a bridge for the gap between the caring process and the individuals in different cultures.
- transcultural nursing
- health services
It is useful to define the culture before discussing the term. According to the definition made by Turkish Language Institution Culture, the culture is described as the sum of all the material and spiritual values created in the process of social development and the tools that are used to create and hand these values down to next generations and show the extent of the man’s authority and control over their natural and social environment .
According to another definition, the culture is the general total of beliefs, attitudes and behaviors, customs and traditions, learned and shared values, and sustains its existence through learning and teaching of attitudes, actions and role models .
As it can be understood from these definitions, culture is a non-written link from the past to the present day, bridging the individuals in society. As a phenomenon, The term “culture,” which diversifies in each community and so is experienced differently, also affects the way individuals perceive the phenomena such as health, illness, happiness, sadness and the manner these emotions are experienced .
Culture is a relative concept that varies according to health cultures as well as affecting the perception of health .
Health is determined by biological and environmental factors as well as by cultural practices .
Culture affects many aspects of human life, such as parental attitudes, child rearing patterns, how to speak, what language to speak, how to dress, believe, treat patients, what to do with and how to feed them and to deal with funerals [6, 7].
Individuals’ health behaviors and health perceptions are regarded inseparable from each other. Communities having endeavored to maintain their cultural characteristics for centuries have passed down this on their health behaviors and strived for finding cures to their health problems in their cultural lives. Types of food, cooking methods, sleeping habits, dressing patterns, forms of treatment of diseases, housing and residence, perception of diseases, modes of acceptance of innovations are characteristics varying from culture to culture and intertwined with culture. It is known that people cannot act independently of the culture they live in .
Culture is influential at many levels in health, ranging from the formation of new diagnostic groups, to the diagnosis of disease to the determination of what is called a disease or not symptoms and disease cues [6, 7].
However, in almost all regions of the world, wars, ethnic conflicts, repressive regimes, environmental and economic crises along with globalization have forced many people to abandon their country and migrate in their country or to immigrate other countries as refugees. As a result, multicultural populations comprised of individuals, families and groups from different cultures and subcultures are rapidly emerging all around the world [9, 10, 11].
2. Cultural factors affecting health and disease
The individuals’ beliefs about health, attitudes and behaviors, past experiences, treatment practices, in short their culture, play a vital role in improving health, preventing and treating diseases .
Cultural variables can be motivational factors in health-disease relationships, .
2.1. Cultural factors/variables can be listed as in the following list
Gender roles and responsibilities
Pregnancy and birth practices
General health regulations
Status of immigrants
Leisure time habits of
Pets and birds
Self-healing strategies and therapies .
3. Health culture
Today, health-related cultural traits are under the influence of a medical approach that may be considered as highly conservative almost all around the world. There is an increasing tendency to perceive and evaluate health and disease-related processes explained in medical terms. The rigid medical approach, engaged in extending human life with costly inventions, with a narrow level of knowledge and practices, makes it impossible for individuals to use the potential for qualified living. Modern medicine overwhelms the will of people to experience their own facts and solve their problems. On the other hand, the concept of health should be regarded as a dynamic phenomenon in life and be removed from some patterns of thought. Hence, healthcare should be assessed with a comprehensive understanding of culture in order to promote the art of living healthily among people .
Individuals who embrace contemporary public health, evaluate health with a holistic approach, give the other individuals an opportunity to participate in their health care issues, and have the potential to solve problems with appropriate preferences can only be the output of cultural constructs supporting health, values, knowledge, attitudes, behaviors and norms. Health culture is concerned with every individual’s or the society’s patterns of living, celebrating, being happy in life, suffering and dying. It is not enough for the individual to acquire only health-related information, but basic skills such as comprehending health-related values, developing a healthy lifestyle and self-evaluation must be developed. The main purpose of developing health culture is to raise the level of health in the country scale. This can only be ensured by the fact that health education standards be established by well-trained and conscious individuals into practice with the help of their knowledge and skills .
4. Transcultural healthcare
It is vital that health services are also appropriate for the target cultures to the extent that they are compatible with contemporary medical understanding. People’s beliefs and practices are part of the culture of the society in which they live. Cultural characteristics should be seen as a dynamic factor of health and disease. In order to be able to provide better health care, it is necessary to at least understand how the group receiving care perceives and responds to disease and health, and what cultural factors lie behind their behaviors [7, 13, 16, 17, 18, 19, 20].
For this reason, healthcare providers should try to understand the cultural structure of a society. Health workers must collect cultural data to understand the attitudes of towards coping with illness, health promotion and protection [2, 21].
Cultural differences and health beliefs have been recognized for many years as prior knowledge in practice. Despite that, cultural health care is unfortunately not part of a routine or common health practice. Knowing cultural beliefs related to health can enable us to build a framework for data collection in health care [2, 22].
Today, health policies focus primarily on the prevention of health-related inequalities and discrimination, especially ethnic characteristics. In order for the societies to regulate health care that will meet the needs of different groups in terms of culture, all health team members must be equipped with the necessary knowledge and skills [23, 24].
5. Understanding transcultural nursing
The term health, with its changing nature and meanings from one culture to another, requires care, including cultural recognition, value and practice. The main element in the transcultural approach in which every health professional has an active role is the individual. The transcultural approach can be applied at all levels of health care institutions; but nurses are in a privileged position in this approach. According to Leininger’s model, only nurses can provide transcultural health services. Because the main aim of nursing is to provide a caring service that respects people’s cultural values and lifestyles. Nurses should offer acceptable, affordable and culturally suitable care to individuals under the conditions of the day .
Knowing what cultural practices are applied in the societies receiving healthcare services and identifying the cultural barriers to accessing health care services positively affects the caring process .
The nursing profession, which plays an important role in the health team, is a cultural phenomenon. The patient’s cultural values, beliefs and practices are an integral part of holistic nursing care [26, 27].
The nurses should explore new ways of providing cultural care in multicultural societies, understand how cultures affect health-disease definitions, and bridge the gap between care for individuals in different cultures [13, 28, 29].
Transcultural nursing provides effective nursing care to meet the cultural needs of individuals, families and groups .
In addition to Leininger, a pioneer model of transcultural nursing, many nurses worked in the field of cultural care. Giger and Davidhazar developed the “Cross-Cultural Diagnosis Model” to assess various variables related to health and illness and provide a practical diagnostic tool for nursing so that culturally competent care could be offered .
Campinha-Bacote described the cultural competence model .
Culturally competent nurses are in contact with cultural experiences and aware of their own personality traits and contribute to socio-cultural knowledge in nursing care by providing individualized care .
Nurses who are aware of cultural differences and the effects of these differences on the health of the individual enhance the therapeutic environment by communicating more effectively with the patients .
The role and significance of transcultural nursing has been increasingly recognized in the world challenged by cultural diversity. Cultural differences can be seen among ethnic groups as well as within any ethnic group .
It has been reported that cultural differences may exist among individuals who live in the same or different regions in Turkey .
In recent years, it has been recognized that nurses must explore new ways of providing cultural care in culturally diverse societies, understand how culture affects disease-health definitions, and act as a bridge between the biomedical system and care for individuals in different cultures [2, 40].
The nature and importance of providing culturally sensitive nursing services is multidimensional, including individual and professional aspects. The transcultural approach allows nurses to broaden their horizons and perspectives in addition to making them competent in offering creative care to individuals. Culturally based approaches and knowledge can enhance both the nurse’s and the patient’s self-esteem [2, 41, 42].
The American Nurses Association (ANA) refers to three reciprocal interactions: the culture of the individual (patient), the culture of the nurse, and the culture of the environment in relation to the patient-nurse:
Culture of the individual: When nurses understand the specific factors affecting individual health behaviors, they will be more successful in meeting their needs .
Individuals’ beliefs about health, culture, past illness/health experiences form a wholistic structure and play a vital role in improving the health of individuals .
Culture is influential in how people think, speak the language, how to dress, believe, treat their patients and how to feed them and what to do with their funerals etc. Moreover, it plays a significant role in a variety of aspects such as new diagnostic methods, prognosis, symptomatic patterns and determination of whether there is an illness or not .
Culture of the nurse: The only factor influencing the patient-nurse relationship is not the patient himself/herself. The nurses’ own customs and traditions, beliefs and values are also important in transcultural relationships. The nurse’s self-awareness can be the starting point to understand the patient culturally.
Culture of the environment: The last element of the transcultural trio is the culture of the environment. The environment is an integral part of the culture. Individuals as physical, ecological, sociopolitical and cultural beings are continuously interacting with each other. Nurses may have to intervene in the patient and family relationship because of frequent bureaucratic arrangements and procedures. The transcultural approach should be considered in a wide range of subjects, starting from asking if there are any religious practices to be followed or done by the patient during the hospitalization, and writing the signs in the hospital in two different languages .
6. The significance of cultural competence
It is essential for nurses to be able to offer appropriate holistic care to patients from different cultures and to know how the transcultural approach is to be put into practice, as it provides guidance on how to behave in the case of these situations.
Transcultural nursing is sensitive to the needs of families, groups and individuals who are representatives of groups with different cultures in a community or society. This sensitive approach provides support for the individual in achieving the well-being and happiness .
Culturally sensitive nursing practices involve the identification of cultural needs, the understanding of cultural links between family and individuals to provide care without affecting the cultural belief system of the family, and the use of emotional strategies for caregivers and patients to reach reciprocal goals. Building therapeutic relationships, offering appropriate and responsive care and treatment can be accomplished through transcultural nursing approach .
Nursing is a developing profession that can continuously adapt to changing situations. Changes in social rules and expectations, the advent of new medical treatments, and improvements in technical systems have helped shape contemporary nursing practices [4, 44, 45].
Nursing has been significantly influenced by the fact that an increasing number of societies around the world have become multicultural and cultural specific care has been recognized .
In multicultural societies, health care professionals need to be culturally competent, which is expected by the society. Interest in cultural competence has been manifested in the studies conducted on the cultural characteristics of the patients .
The nurses’ understanding of the cultures of patient groups is very important for the provision of meaningful effective nursing care .
The study performed by Chenowethm et al. titled as the “Cultural Proficiency and Nursing Care: With an Australian Perspective” and Giger and Davidhizar’s study titled as “Culturally Adequate Care: The Afghan, Afghan Origin American and the Importance of Understanding Islamic Cultural and Islamic Religion” can be cited as examples of conducted research on this subject [4, 33, 49].
Providing culturally adequate care is an obligation imposed by increased cultural diversity and disclosure of identities, an understanding of home care and inequalities in health care. Cultural competence is a dynamic, variable and continuous process. Although cultural competence is a basic component of nursing practice, this concept has not been clearly explained or analyzed but defined in many ways. At times, various terms such as “transcultural nursing”, “culturally appropriate nursing care” or “culturally sensitive nursing care” were used instead of the term cultural competence .
The literature review reveals that there is a common definition of cultural competence the term among researchers and a general consensus on the term. For example, the concepts of “ethnic nursing care”, “cultural care”, “cultural appropriateness” or “culturally appropriate care” are seen as terms close to cultural adequacy [4, 47].
Cultural competence is the application of knowledge, skills, attitudes, and personal manners anticipated from nurses to provide services and care appropriate to the cultural characteristics of the patients.
Başalan İz ve Bayık Temel reported that Vydelingum  made use of Murphy and Macleod-Clark, Bond, Kadron-Edgren and Jones, Spence, Blackford’s findings in his study. In Murphy and Macleod-Clark’s study on ethnocentric views, it was stated by nurses that patients from a minority group were generally regarded as a problem and these patients were perceived as inappropriate for daily routine, and there was lack of holistic care among nurses working to develop a therapeutic relationship with minority groups. Bond, Kadron-Edgren and Jones conducted a study evaluating the knowledge and attitudes of nursing students and professional nurses regarding patients from different cultures. This study has shown that undergraduate and post-graduate nursing programs are partially limited in terms of the knowledge and skills about special cultural groups. Spence, in his study on nurses’ experiences in caring for people from other cultures in New Zealand found that they experienced tension and anxiety when they encountered with an odd case. The subject of cultural well-being and nursing approaches in nursing education was reported in a study carried out by Blackford in Australia. The necessity of care structured under the roof of the white race culture has revealed that it does not consider the health care culture. The lack of cultural adequacy in the care of patients from different cultures has been recognized as an great challenge to all these studies. Cultural conflict has been shown as an output of ethnocentric focus, resulting in a lack of cultural competence, misunderstanding, lack of confidence, communication and obstacles to establishing a positive relationship .
The nurse experiencing cultural conflict must first recognize his/her subconscious cultural behaviors in order to understand the reason for the cultural conflict .
In a cultural conflict, the nurse can respond negatively from the cultural perspective in the following ways:
Ethnocentrism: It refers the individual’s interpretation of other cultures in terms of their own culture based on their own cultural heritage.
Stereotyping: The acceptance of the same characteristics of individuals or group members without considering individual differences.
Cultural blindness: A symptom of not paying attention to expressing cultural diversity.
Cultural imposition: The situation emerges at a time when the nurse expects the patient to comply with his/her cultural norms or the norms of the health institution. The nurse may think, “You have to follow my hospital’s rule and comply with our procedures here.”
Cultural conflict: When a nurse, patient and family have different values, exhibit different behaviors, conflicts may arise in the case of differences in beliefs and traditions. However, the expected professional attitude from the nurse is cultural relativism. Cultural relativism means recognizing and understanding the individual’s culture in its own structure, without referring to other norms and judgments. The nurse approaching the patient with cultural relativism has a clear view of the characteristics of cultures, diversity of beliefs and practices in different environments resulting from different social needs .
6.1. In culturally sensitive care, there are three major approaches reducing cultural conflicts to minimum. These are listed below
The individual/patient’s own perspective and cultural beliefs must be respected and recognized.
The nurse should be competent and authorized to carry out professional actions and make decisions.
The nurse should help the individual to develop new patterns to lead a satisfying and healthy life in the case of harmful behaviors .
The nursing care plan must be individual, holistic and contemporary. Interpreters or religious leaders may need to be included in the caring plan if there are any linguistic problems. The patient’s view on the cause of his or her illness is also a key element in planning the care .
In preparing the nursing care plan, basic principles related to culturally sensitive nursing practices can be followed.
6.2. Basic principles related to culturally sensitive nursing practices are described below
The importance and influence of the culture should be considered,
Cultural differences should be valued and respected,
Cultural influences in the manners of individuals should be understood,
An empathic approach should be put into action towards individuals with cultural diversity,
Individuals’ cultures should be respected,
Health professionals should be patient with individuals in cultural issues,
Individuals’ behaviors should be thoroughly analyzed,
Cultural knowledge should be increased and enhanced,
6.3. The scope of cultural nursing practice
The scope of cultural nursing practice can be:
identification of cultural needs
understanding the cultural connections of the individual and the
using emotional strategies for the caregivers and the patients to reach the reciprocal goals
This short review provides the basis for a deeper cultural assessment that the nurse can do in the future. The nurse has the opportunity to communicate effectively with the individual through brief cultural assessment data collected [7, 13, 22, 52].
Nurses should make cultural evaluations when they first communicate with individuals. This evaluation may be in-depth, or a brief review that will form the basis for an in-depth assessment to be done later. In a brief review, several questions about health practices, diet, religious preference, ethnic background and family can be asked to the individual. This short review provides the basis for a deeper cultural assessment to be done by the nurse in the future. Thıs, the nurse has a chance to communicate effectively with the individual through brief cultural data [7, 13, 22, 52].
6.4. Data collection
Regional population density
Population density entering the region
Age distribution of the residents in the region
Distribution of demographics such as education, job, income etc.
The national origin of the population living in the region
Traditional health beliefs
Definition of illness
Definition of health
Reasons for your illness
Poor eating habits/nutrition
Bad eating arrangements
Viruses, bacteria and other organisms
A punishment/curse from Allah (the God)
Being affected by the evil eyes
Magic, charm, spell or jealousy
Sorrow or loss
Excessive or little labor
Methods for maintaining health
Health protection methods
Methods of restoring health-home treatments/household recipes
Utilization of health care resources and visitations
Traditional healers favored by sick people
Health beliefs and practices related to childbirth
Health beliefs and practices related to raising children
Traditional practices and ceremonies arranged for dying individuals and related to death
In addition to recognizing the cultural characteristics of the community, by depending on these data, nurses should recognize traditional medicines, places of worship and sacredness, and other such organizations and, if possible, should visit and observe such places in order to identify the service group.
6.5. The issues to be considered which enable nurses to make cultural assessment include the following
The nurses should be knowledgeable about the community receiving care services provided by themselves.
The nurses should identify the social gathering environments such as schools, hospitals, places of worship of the community they serve care.
The nurses should define the specific areas they want to focus on prior to cultural evaluation.
The nurses should determine the strategies that can help them collect data about cultural values.
The nurses should define the items that may act as bridges between the cultures.
The nurses should be able to ask appropriate questions without hurting the individuals.
The nurses should cooperate with colleagues and other health workers.
The nurses should discuss with the community leaders, whether official or non-official, about cultural characteristics deemed important in the lifestyle of the society.
The nurses should not resort to unethical traps to make an early generalization based on the cultural data of the society.
The nurses should be honest, open and sincere towards the individuals and the self.
6.6. Transcultural nursing focuses on four major concepts below
Nurses are transcultural care personnel.
An individual is considered as a cultural asset and cannot be separated from his/her own cultural heritage and background.
Environment is a structure or framework
Transcultural care is a sensitive nursing care service addressing to the needs of individuals from different cultural groups .
A manual of guidelines has been prepared by International Nurses Association (ICN), American Nursing Academy, Transcultural Nursing Association, with the aim of creating a common language for nursing practice all over the world and providing a holistic and cultural content care that respects social equality, justice and individual differences. There are 12 items in the manual given in the following:
Social Justice and Equality
Cultural Based Care
Cultural Based Health Care Systems and Organizations
Patient Advocacy and Empowerment
Cultural Based Care in Education and Training
7. The history of transcultural nursing
The foundations of transcultural nursing were laid in the mid-1950s. In nursing, Peplau first mentioned in 1950 that the cultures were an important variable affecting mental health. The growing interest in Leininger’s transcultural nursing model has begun with population changes and migration. Leininger tried to promote transcultural nursing movements. Much more attention was paid to the care of individuals from different cultures in the 1960s. Since 1960s, nurses have been carrying out studies aimed at providing particularly cultural care to people from all communities/cultures. In 1962, King stated that psychopathological behaviors differ from culture to culture. In 1969, the International Council of Nursing (ICN) began using cultural content in nursing. The Transcultural Nursing Society (TCNS) was established in 1974 to train nurses in this area.
This organization aims to provide the nurses and other health care professionals with the basic knowledge necessary to develop cultural skills in culturally sensitive practice, education, research and management .
Since 1989, “Journal of Transcultural Nursing” has been published, aiming to train nurses about transcultural care and improve their practice. Evidence-based studies have been conducted in this area. Today, there are about 25 books and over 800 articles covering research, theory and applications related to transcultural nursing .
This is a promising field of study with which Turkish nurses have recently started to be familiar. Now that globalization is inevitable, studies on transcultural care practices will broaden the horizons of Turkish nurses and the others all around the world.
In addition to Leininger, a pioneer model of transcultural nursing, many nurses worked in the field of cultural care including Boyle, Campinha-Bacote, Yahle Langenkamp, Giger and Davidhizar, Juntunen, Leuning, Swiggum et al., Purnell, Ryan, Carlton and Ali.
Among these, there are researchers arguing that the models and theories of two modelists (Giger and Davidhizar and Purnell) who do myriads of studies on cultural care are extremely simple, comprehensible and suitable for use in many different fields and cultures .
8. Transcultural nursing care models
8.1. Cultural competence models
Burchum JLR; Cultural competence: Evolutionary dimension.
Campinha-Bacote J; Cultural competence in providing health care services: Culturally adequate care model.
Cross T., Bazron B; Dennis K., Isaacs M.; Towards a culturally adequate care process: Effective services for minority children with emotionally serious illness.
Kim-Godwin YS; Clarke PN & Barton L.; Providing culturally adequate public care model.
Leininger MM; The differences in cultural care and the theory of universality.
Leininger M; Cultural care theory and ethnocentric research method.
Leininger M; Evaluation of culture care for appropriate and adequate practices.
Orque M.; Orque’s ethnic/cultural system: Conceptual framework for ethnic nursing care.
Pacquiao DF; Cultural competence in ethical decision making.
Papadopoulos I. & Lees S; Training culturally competent researchers.
Purnell LD. & Amp; Paulanka BJ; Ppur model for cultural competence.
Suh EE; Cultural competence model through evolutionary concept analysis.
8.2. Cultural assessment models
Giger JN. & Davidhizar RE; Transcultural nursing; Evaluation and intervention
Spector RE; Cultural difference in health and disease.
8.3. Cultural assessment guidelines
Andrews MM; Culturally adequate nursing care.
Andrews MM; History of health and cultural competence in physical examination.
Bloch B; Bloch’s assessment guide for ethnic/cultural diversity.
Boyle JS & Andrews MM; Andrews/Boyle assessment guide.
The conceptualization of the cultural competence model in nursing has emerged after 1989. Leininger, Campinha-Bacote, Giger and Davidhizar, Orque, Purnell and Paulanka, Spector, Andrews and Boyle are regarded as the pioneers contributing to the accumulation of the relevant data. Orque is a leading figure in developing a cultural model for nursing with “the conceptual framework of the ethnic system”. The use of nursing theories and models in nursing researches offers unparalleled contribution to the health care system through the practices of the nurse as a professional. Cultural competence models developed by nurse researchers can be transferred not only to nursing but also to other disciplines.
Leininger describes transcultural nursing as a branch of nursing or nursing school based on comparative research and analysis of different cultures which provides cultural universalism and cultural independence in nursing care and focuses on comparative studies and analyzing differences in cultures around the world in a respectful manner in view of health, illness, care, beliefs and values [3, 5, 13].
The aims of transcultural nursing are to provide sensitive and effective nursing care to meet the cultural needs of individuals, families and groups, to integrate transcultural concepts, theories and practices into nursing education, research and clinical applications, to improve transcultural nursing knowledge, and to incorporate this knowledge into nursing practice.
The International Nurses Association (ICN) invited the nurses from the World Health Organization (WHO) member countries to work on adaptable models to their communities at the 1989 Seoul Conference. The studies conducted in Turkey show that the nurses need to have classification lists and guidelines to be used in care, and thus a more systematic care will be provided in less time for individual patients and more data will be collected. In Turkey internationally developed models and classification systems in nursing care are translated into Turkish, or new guidelines specific to clinics are developed and used. These include NANDA’s diagnosis, Gordon’s Functional Health Patterns, NIC, NOC and Daily Living Activities and the OMAHA system .
The use of transcultural nursing models, classification systems and guidelines is becoming widespread. These models focus on the relationship of nursing to concepts and theories related to life, health, disease and society, facilitate organizing their thoughts, and provide a common language among professional members.
While there has been an increased awareness of the importance of cultural care and collecting cultural data in recent years in Turkey, no models or guides have been developed in Turkey .
8.4. Some of these models
8.4.1. Leininger’s sunrise model
The “Culture Care Diversity and Universality” theory developed by Leininger in 1960, the first nurse who made the first work in this field and received the title of anthropologist, is the first theory developed in the field of transcultural nursing and still used worldwide. This theory focuses on exploring different and universal cultures and providing comparative care. It adopts a multi-factorial approach affecting health and care such as environmental conditions, ethnography, language, gender, class, racism, social structuring, belief, politics, economics, kinship, technology, culture and philosophy. This model includes technological, religious and philosophical, kinship and social factors, cultural values and lifestyle, political and legal, economic and social factors , which have been used in many studies in the west and in other countries since 1960 (Figure 1).
8.4.2. Narayanasamy’s ACCESS model
Narayanasamy described the model in 1998 with the letters ACCESS (Assessment, Communication, Cultural negotiations and Compromise, Establishing respect, Sensitivity and Safety) to form the framework of cultural care practices  (Table 1).
|Assessment||Culturally focusing on the patient’s life style, beliefs and practices related to health|
|Communication||Awareness of the variety of verbal and nonverbal reactions|
|Cultural Negotiation and Compromise||Becoming more aware of the other people’s cultures and exploring their problems as well as understanding the patient’s opinion,|
|Respect||Describing therapeutic relationship relevant to the patient’s cultural beliefs and consensus values|
|Sensitivity||Applying the sensitive care model to culturally different groups|
|Safety||Making the patient feel safe in the culturally sensitive care|
8.4.3. Giger and Davidhizar’s transcultural assessment model
8.4.4. Purnell’s cultural competence model
This ethnographic model created to promote cultural understanding of people’s status in the context of health promotion and illness is based on ethical perspectives of individual, family and community. It can be used in primary, secondary and tertiary protection stages  (Figure 3).
8.5. Nurses’ competences to provide transcultural care
Having the ability to understand complex cultural dimensions,
Assuming a holistic approach to care instead of biophysical approach,
Showing efforts to reach rapidly increasing cultural beliefs and activities that are unique to distinct groups and individuals
Being able to change the idea of believing that individuals’ own race is superior to others,
Being able to make cultural evaluations,
Developing communicative and scientific language skills,
Being able to deal with cultural differences in real terms and make interpretations,
Being able to use appropriate cultural teaching techniques
Compromising cultural beliefs and studies with the general state of provision of health care,
9. Transcultural nursing education
The ability of nurses to change their current and future nursing practices through transcultural nursing care approach in the nursing care system can be achieved through cultural specific transcultural nursing education programs [22, 58].
In addition, registered nurses should be aware of these issues and develop their knowledge and competence. Educators and administrators need to know, understand and believe in the importance of intercultural nursing care in order to be role models for students. The first step in the development and implementation of intercultural nursing education programs in nursing institutions is to evaluate the curriculum. It is recommended that the review in nursing schools be started with an examination of the mission statement. It should be examined whether the significance of cultural differences, care and education are explained in the mission statement [58, 59].
The multicultural education approach and educational program should replace the dominant cultures in nursing schools. With the help of this approach, school administrators and academics should observe whether content issues are appropriate and adequate in terms of multicultural education in current educational programs .
In terms of multiculturalism, important main subjects, concepts, theories should be defined and integrated into the curriculum .
The terms such as cultural competence, multiculturalism, cultural diversity, cultural awareness, cultural safety should be intertwined with other professional subjects into the curriculum.
An educational environment should be created in which racial differences are accepted and respected in nursing education. Within the scope of the program, generalizations and conceptualizations specific to different cultural groups should be introduced in theoretical and practical courses. During the courses social problems, experiences brought about by different racetracks such as racism, prejudicial discrimination, language problems, communicative difficulties, lack of obtaining information, health services that do not meet the needs, lack of recognition or determination of diagnosis, and incorrect nursing diagnosis should be discussed [58, 59, 60, 61].
Students can examine and evaluate their racial characteristics in the communication and skills lab. In addition, similarities and differences between ethnic groups should be emphasized in all lectures [58, 59].
In intercultural nursing education, the students’ ethnocentric worldview “just like me” should be replaced by the view “not like me”. It is stated in the nursing education that it is very useful for the student to assume some duties and responsibilities in community services and health education programs to develop cultural competence .
In addition, it has been shown that the exchange of national and international students and teaching staff in nursing schools is a very useful way to build cultural awareness and sensitivity by experiencing, working, and living in another culture, in order for students to find intercultural opportunities in different cultural settings [58, 62, 63].
It is stated that it is a useful teaching method for nurses to teach nursing diagnoses with case studies involving different cultural items in education programs. In nursing programs focusing on intercultural education, nursing educators use methods and tools such as critical reflection, discussion groups, role playing, observations, simulation exercises, clinical scenarios as well as written materials, videos, film monitoring and audio tapes .
10. Criticisms of transcultural nursing
Although transcultural nursing has an important role in the holistic approach, it is criticized at some points and is also mentioned in opposing views.
In the case of launching nationalist initiatives in intercultural care, it has been stated that stereotyped images may emerge, and that particular attention may be paid to certain cultural individuals in the caring process. Given the presence of some 3000 cultures around the world, it is impossible for healthcare professionals to have knowledge of all cultures. It also requires the specialization of health personnel in order to provide qualified, culturally specific care. Despite the desire to create multicultural societies in the world in which there are liberal immigrant policies, it cannot be argued that there is an accepted standard in health care, in terms of the socioeconomic status, ethnic characteristics, sexual behavior and lifestyle preferences. There is a cultural crisis in health care services. Individualized intercultural care is a nurse’s responsibility as both a human and a professional. However, it is noted that nurses may be ethnocentric with cultural knowledge, understanding, awareness, education, cultural competence and lack of faith .
It is argued that extraordinary endeavors in cultural sensitivity can result in the classification of cultures, thereby leading to stereotyped behaviors in certain cultures, races and religions. Another criticism is that paying particular attention to the patient of a particular culture, and focusing on that side can cause limitations in care. It is emphasized that the patient may feel “special”, “needing protection” or “patronized”. In addition, it has been pointed out that concerns about transcultural care in the field of health will only lead to formation of specialization in transcultural care that could increase responsibilities for nurses, which in turn will put a burden on them .
Conflict of interest
The authors declare that they have no conflict of interest.
No outside funding was received for this study.