Transcultural Nursing Theory And Models: Cultural Factors Influencing Nursing Practice

Cultural factors influencing the nursing practice which affects the health of diverse groups in a community

Discuss about the Transcultural Nursing Theory and Models.

Culture is a significant determining factor in the healthcare practices and preferences. The prevalence of transcultural nursing is, therefore, undeniable. Transcultural nursing is all about the ability of planning, designing, implementing and evaluating care for the patients, their families and the community as a whole that represent the various cultures embedded in the society (Giger, 2016). In order to practice effectively in the health care domain, a nurse needs to have a strong understanding of the need to possess a high level of cultural competency. It is utmost pivotal that a nurse has the desire to remain culturally aware, culturally skilful and culturally knowledgeable for seeking cultural encounters. A number of cultural factors act as the stimulator of the process of cultural competence whereby nurses are effected by a vast range of such multi-dimensional factors, making the ultimate impact on their nursing practice (Wiechula et al., 2015). Nurses must have the motivation to be open to updated knowledge and accept changes in the society and must acknowledge that the process continues for lifelong. They, therefore, need to set aside their personal feelings and deliver optimal care services to all patients without any discriminations and judgements. Unique patients are to be treated equally and in a justified manner (Shambley-Ebron, 2015).

According to Shen (2015) nurses are found to be working in a society that is mostly multicultural and therefore they must have the understanding of other cultures other than their own. Individuals they are caring for must not be a victim of any kind of assumptions pertaining to conformation to a certain cultural pattern. It is crucial that nurses adequately consider the different cultural factors are making a profound impact and are aware of the intracultural variation. Intracultural variation signifies that all patients are to undergo an assessment by the nurses for their diverse cultural differences. The practice of nursing encompasses individuals from diverse groups and places like schools and prisons apart from the normal healthcare settings. The present paper discusses the cultural factors that influence the nursing practice that makes an impact on the health of the diverse groups in the community. The paper aims to highlight the extent to which cultural factors are significant in daily nursing practice and the implications for future in this field.

Ray (2016) opines that nursing care in the contemporary era has witnessed progression beyond treatment of illness with only diagnosis procedure and prescription of medical approaches. It has moved into a comprehensively holistic domain of care where transcultural nursing-patient care is highly advocated by the practice. Transcultural nursing is the formal area of practice grounded in need of delivering holistic care with respect to similarities and differences in the cultural beliefs, values and ways of leading lives. The aim of such nursing is to provide the patients with culturally compassionate, competent and congruent care. The nurses are to build up necessary skills for providing culturally competent services. This can be achieved through mentorship, training, education and continued professional development. The strategy of transcultral nursing is about the adequate address of cultural needs of the patients and respect for their cultural beliefs. When a nurse meets a patient, its a meeting of three cultures, that of the nurse, of the patient and the setting (Williams, 2017).

Molloy et al., (2015) highlight that communication is responsible for keeping the culture alive for keeping the culture alive through nonverbal and verbal means. However, this is the biggest obstacle in healthcare. Nurses are responsible for asking questions for determining the views of the patient on causes of illness and their potential treatment options. Moreover, nurses are to interact with the family of the patient for gathering more information. Communication may be varying from one culture to another, and this holds true for all settings across different communities. Some individuals mostly speak in the Standard English language, nevertheless, there may be variation based on differences in social class, ethnicity and region. A variety of nonverbal communication is often used by a section of the common population across the world. Eye contact has been thought to be a positive sign of honesty and trust between healthcare professionals and patients. Expression of patient’s emotions greatly varies in different culture. They use many gestures, body language and verbal language in combination while communicating with the nurse. In addition, they may be demanding. In contrast, some individuals do not complain much and withdrawal, and silence is the only indications of a condition wherein they are facing issues. They remain stoic in most of the cases (Almutairi et al., 2015).

Darnell and Hickson (2015) in this regard states that Asians do not engage in eye contact with health care professionals. Asians are known to speak in around 100 different languages, and these vary as per the geographic locations they hail from. In Arab countries, the patients mostly cooperate with the nurses and answer their questions, listen carefully and follow directions. They believe that a quick response is to be given to their suffering. On the contrary, Hispanics are emotionally expressive, and communication with these people is not founded solely on the basis of speaking their language. Rather, cultural rules permit certain discussions taking place between the patient and the nurses. Nurses, therefore, speak in a manner that is polite, concise, slow and is filled with simplicity and pantomime (Grady, 2014)

Bedi and Devins (2016) state that there may be differences between different groups of patients who may be having more need of personal space in comparison to others. When friends and family are near, one section of the patient population may be feeling relaxed, and the presence of an acquaintance or a stranger may invade space, making the patient uncomfortable. Research has indicated that Asians are in the favour of social distance. Many have the preferences for minimal physical contact with the healthcare professionals, and excessive contact is very much inappropriate in their viewpoint. In contrast individuals in other parts of the world who perceive touching to be a sign of friendliness, Asians are not comfortable with touching. It is common to stand and sit close to a professional while conversing, however, gender plays an important role in here.  Women show signs of becoming distraught when a male healthcare professional sits or stands nearby. In addition, it is desired that a patient is treated by a professional of the same gender. This implies that nurses are to take the patient’s lead. If the patient descends towards the nurse, the nurse must have the similar approach. But if the patient does not gravitate towards the nurses, it is the duty of the nurse to remain at a distance from the patient. The boundaries of communicating and interacting with the patient are not to be crossed by the nurse at any cost (Frey et al., 2014).

When patients are from diverse backgrounds are to be dealt with, nurses must consider the role that culture plays in the life of the patient. Family members have a pivotal role in the patient’s habits of eating, medication regime and sick role behaviour. Many patients view their family to be a vital element of healthcare plans. It is common for some patients to have the full support from the family and have frequent visits by the family at the time of being admitted at a healthcare setting. Open discussions are held with the family members regarding any incorporation of inputs and suggestions. They place family interference over self-dependence in matters of health. Complete assistance is provided by the family members in care provision (Son et al., 2014). In some cultures, a certain group of family members, mainly elderly and men, may be exercising dominating power over women and children, considering them to be inferior. They are commonly found to be taking all major decisions in life and giving consent. Nurses must, therefore, be accommodating to the families of the patients and involve them in the making of care plans. The members of the family demonstrating a greater role in care are to be given importance while considering the wishes of the patient on a simultaneous basis (Potter et al., 2016).

In this context Douglas et al., (2014) state that some section of the society, like the Hispanics, have larger families and demonstrate  genuine concern and love and affection. Spiritual and religious beliefs are crucial during disease, illness and death. A majority of the population of the world are Christians. Within this religion, division is based on Protestants and Catholics. The religious practitioners within this religion are ministers, priests and rabbis along with non-traditional leaders at the time of health complications. They include religious objects, like the Bible, to have a contribution in healthcare and rituals like communion to make an impact on care practices. Religious practices influence end of life choices and death to a considerable extent. Asians are an amalgamation of different religions; Hindu, Christian, Muslim and Buddism to name a few. A major section of the society in Asia believe in the evil spirit and their relation with untimely death. In cases where it is perceived that spirits are the cause of ill health, healers are sought after in many communities. Spirituality is revived in many religions in order to remain free from ill health and diseases. In many middle eastern communities, the holy and sacred religious books are read for getting free from ill health. In Hispanic community, religious objects and shrines are related with recovery from health issues. Against this background, nurses are to be sensitive to the religious practices and religious beliefs of the patients they are caring for. Seeking vast knowledge on religions and customs of different parts of the world is essential. Exposure to different cultures is also a good learning mechanism (Sagar, 2011).

Saleh Al Mutair et al., (2014) researches on the topic of the impact of culture on nursing practices and concludes that having knowledge of the cultural notion of specific periods is required to promote healthcare. Cultures are often time oriented, encompassing past, present and future. Care is often expected to be delivered at the appropriate time and within a certain suitable time frame. A section of the society are future oriented, and they have the belief that they have the ability to manipulate and influence the future through implementation of the certain action. On the other hand, a section of the society may be proactive, with the prime focus on optimism and positive outlooks. The coping strategies, as well as preventive  measures, are guided by such approaches. This kind of orientation is often demonstrated through check-ups, self examinations and being informed about the recent advancements in healthcare practices. It has also been found that individuals in some parts of the world have a past orientation. The preference they have are in support of adherence to conventional and traditional treatments and methods. The approach towards innovations is rather apprehensive. They may show the desire to shift gradually towards future orientation, but such signs are negligible when quantified. Some section of the population are more present oriented, and the approach towards preventive measures is often neglectful. They are often late, and missing appointments is often noticed. They have the notion that the future is to arrive in its own pace and therefore one is never late. Nurses, therefore, have the duty to explain the relevance and importance of time in the context of health care practices to the patients when they come for taking services. This is to be done while respecting the cultural views of the patients. They are to remain mindful of the preferences for care choices. Time-oriented commitments are not to be made by the nurses that are usually difficult to fulfil (Hart & Mareno 2014).

McClimens et al., (2014)  throw light on the fact that efforts to control the nature or attempts to control the environment have a deep effect on the health practices and values and health and illness’s definition. While in some culture it is believed that nature can be easily controlled by different means, people in other cultures have the strong opinion that human bodies are like machiene and if they are broken, then it is the responsibility of the healthcare professionals to fix it. Patients may not be conforming to the Western biomedical model that is famous for defining health to be the absence of any signs of diseases. A much criticised holistic paradigm is prevalent in many cultures that covenants with the concept of yin and yan. In such concept, the forces of nature are to be maintained in alignment and balanced state for producing harmony. Individuals are an integral element of nature. The earth is the pool of resources that is to be used for treating diseases. One common resource is the herbal medicines, used for treating a wide range of diseases and illness in an effective and safe manner. Nurses are to remain familiar with the above mentioned factors and must not dismiss any arising views of the patients in relation to their accountability or power. Patients often believe that a healthy diet and personal hygiene is the key to good health. Such people have confidence and trust in the medical profession and want to utilise western medicines for their treatment and getting relieve from pain. Hispanics may be believing that natural forces cannot be controlled and therefore it is better to consider applying preventive measures. They are more fatalistic about health, nature and death. In their system, medical uses encompass scientific, homoeopathic and spiritualistic elements. Holistic healers are utilised for getting rid of the illness. Information is to be provided to them is a non-judgemental way. Patients who have the belief that they cannot do much for bringing improvements in their health condition are to be taught more about how medications and diet can fulfil this purpose. Reinforcing positive beliefs act wonders for achieving better health outcomes (Purnell, 2012).

Rundle et al., (2016) give a brief overview of the idea that biological variations are present between different racial origins. Some groups of people may be sensitive to particular types of medications and may possess metabolic differences. They may also be sensitive to particular diseases and socio-economic factors of health. For example, African populations have three times more chances of getting tuberculosis in comparison to whites. A higher rate of hypertension is also found among this population. Asians are more sensitive to cardiovascular impacts of Propranolol in comparison to whites. HIV rates are higher in ethnic minorities. The variations among different populations across the globe make up an exhaustive list that is extensive and broad. This range of variation is to be recognised by the nurses working in diverse settings. It is pivotal that accurate evaluation and assessment of the clients is done. Nurses must take up the initiative for having adequate knowledge of the biocultural variations. Nurses need to have their focus on the recovery and well-being of the patients. No two individuals are the same, and this fact is to be acknowledged. Treatment and health status of a patient is influenced in a direct manner by the cultural beliefs they have, and different theories have gone on to explain this stance. Human diversity gives tolerance more importance than that of a virtue and makes tolerance a need for survival. Healthcare cannot be complete without adjustment, negotiation and respect. Transcultural nursing makes cultural competency a standard for all nurses to maintain and propagate. It is the duty of the nurses to uphold the standard and preach it to their fellow nurses in the different setting they work in. 

Jennings et al., (2015) has the viewpoint that cultural values are the enduring belief systems and ideals to which a society shows commitment. Many cultures put the emphasis on individualism and self-reliance. Within the scope of individualism, the focus is given to individual rights and inputs. In certain cultures, heath decisions are made by a group, like the family and society. Nurses have the ethical dilemma of whether to care for such patients in a manner they want or to go by their own moral choices. Ethical concerns revolve around the cultural values. Harding (2013) argues that acquaintance of cultural diversity at all levels of nursing practice is important. Ethnocentric approaches are often not efficient enough to meet health needs of clients who are from diverse groups. Cultural diversity can address ethnic and racial differences. Skills related to such diversity broadens and strengthen care delivery. Other cultures can provide important sources of alternatives of care services. Different concepts of health, wellness and illness emerge from a mixture of varied cultural perspectives. These concepts then make up the elements of a complete belief system.

People from different cultures celebrate religious and civil holidays. Getting familiar with the important holidays of different cultural groups nurses serve helps in providing facilities. More about the religious celebrations can be found out from the patients, religious organisations and hospital chaplains. Routine health check-ups, surgery, diagnostic tests and other medical procedures are to be avoided on holidays. In there is no contradiction between the holiday rituals and medical procedures, they can be accommodated (Blais, 2015).

The cultural variations associated with food are multi-dimensional. For instance, having preferences for a certain food may be linked with the celebration of life events, good health and validation of cultural and social aspects. Culture goes on to determine what food patients would consider eating and at what time of the day. Culture determines how the food is cooked and how they are to be served. The frequency of basic meals and the choicest portions are also determined by cultural beliefs to a large extent. Religious practices include abstaining from certain foods, avoiding particular medicines and fasting. Cultural practices also influence the ritualistic use of beverages and food. Some individuals consume more high-calorie and high-fat foods than others. Hindusim restricts the consumption of certain meat products while Islamic religion prohibits animal shortenings and gelatin made from marshmallow and pork. Judaism restricts consumption of predatory fowl, scavenger fish and shellfish though scales and fins of fish are allowed. Some individuals have the tendency to eat heavy dinners or skip breakfast. The above mentioned factors are vital for nurses while caring for patients with special needs like hypertension, diabetes and gastrointestinal disorders. Medical conditions in which dietary modifications play a key role are to be dealt carefully by the nurses. Nurses need to consult with dieticians while making the diet plan for the patients so that there is no compromise on a diet required for the patients while respecting the food culture of the individual (Burnard & Gill, 2014).

Christensen (2014) has highlighted enhancement of nurse’s ability to deliver care within the context of the culture of incarceration. According to the authors, incarcerated women form a highly vulnerable population, having extreme adverse life experiences. Nurses working in correction homes face a number of challenges while attempting to care in the setting focused on punishment. It is interesting to look at the cultural factors that underpin nursing care in correction homes. At many times, the altruistic nature of the nursing profession and punitive environment puts up a major challenge. Lives of the individuals may be revolving around recidivism. Poor decisions are lives have led the individuals to reach a point where negativities influence more in their lives against all positivities. Patients in a correction home may be victims of abuse, physical and mental and may have terrible experiences. They have witnessed violence that has hampered the state of mind and mental stability. Incarceration leads to numerous losses, encompassing loss of autonomy, freedom, self-control, hope and possessions. Prisoners are often found to be a depressed and disturbed mood. Trust issues exist among the women in correction homes due to the abuse they have gone through. Low education levels are prevalent among the inmates of correction homes. Low health literacy leads to poor health outcomes. Due to low educational levels, inmates are not in the state of understanding the technological advancements in relation to healthcare. Personal technology is not used within such settings, and therefore the individuals are not exposed to such assistive techniques. Limited access to advanced technologies and equipment compels the individuals to have an old-fashioned mindset when it comes to access adequate health resources. In addition, the awareness about the recent trends in disease prevention and management is also lacking among this population.

The cultural ways in which the individuals live in the incarceration settings greatly impacts the nursing care given to them. Nurses are to be aware of the live experiences of each patient they are taking care of as each patient has his own set of unique experiences, influencing the advent of care. The complex pre-existing experiences warrant nursing methods that consider holistic care for the patients. The author analyses that nursing care in correction homes must provide culturally congruent care. If the patients are assessed in the context of their cultures, nursing care would be of the highest level as a trusting relationship between the patient and the nurse can be established. Nurses are to take the time to understand the background of the patients before initiating care. The social, religious and ethnic backgrounds are also to be checked for in this connection. Even if the patients show anger and grievance, in the beginning, respect, concern and sympathy can break the ice and establish a god framework for care delivery. Through the model of spirituality, education, social factors, legal factors and technology ability to care for these patients can be enhanced. Together, they would affect the heath of the patients in the incarceration homes (Andrews & Boyle, 2008).

Almutairi (2015) explored the culture and language differences as major barriers to provision of quality care by the health workforce of Saudi Arabia. The authors identified, and summarised challenges and issues related to cultural factors that influence health care in Saudi Arabia. As per the authors, the uniqueness and distinct features of Saudi culture together with large number of emigrant health professionals with limited knowledge of Saudi culture exacerbate the issue of providing high quality care. The country has an unique set of culture linked with religion that all nurses are to know about. Lack of knowledge regarding different cultural aspects in Saudi Arabia is a major concern for nurses in order to meet the diverse needs of the patients. It is vital that if a care giver has adequate knowledge of different cultures, the care given can be patient centric. Nurses in Saudi Arabia would be more eligible for working  with patients if they know their customes, culture and are well versed with the common socioeconomic problems.

Zimmerman et al., (2014) have written an article on the role of the family in the lives of the indigenous population across the globe in respect to healthcare. For some people, their family is the main caregiver, holding more importance than a nurse or any other healthcare professional. The caregiving experience thus needs to be positive, though it might impose an additional burden. Individuals may be suffering from trauma, poverty, cultural traumatisation and substance abuse. The normative dependence on families is underpinned by the desire to have a reciprocation of care given by family members. Therefore nurses caring for indigenous adults in clinics, hospitals and care homes must be cognizant of fulfilling the requests of the patients for support and information. Such patients want their families to be present at the time of emotional support, and this request is to be fulfilled by the nurse. Some patients may feel shy and timid when the physicians are present and engage in a conversation with them. Difficulty in understanding medical terms is also an issue. The correct meaning of the prescribed interventions the potential complications of the interventional plans are to explained to the patients in a simple language. The concept of health and diseases for these patients is more broad in dimension and includes a wide spectrum of life, encompassing mental, physical, emotional and spiritual dimensions. The holistic perspective of the individuals indicates that life has a synergistic balance and this balance is crucial for supporting a healthy person, and any imbalance can result in illness. Nurses, therefore, are in the pressure of supporting the choices of the patients and make way for an environment that permits privacy of the patients for healing purposes.

Qin et al., (2015) have contributed to a rich literature that discusses the cultural aspects of caring for refugees. Cultural barriers exiting between a refugee patient and a nurse an have a deep impact on the outcome of the medical encounter. In certain cultures, it may not be permissible to ask any authoritative figure, like a nurse, any question. Refugee patients may nod their heads and smile for creating the impression of having understood a certain aspect while they have not. In other culture, maintaining eye contact while engaging in a communication with the nurse may be inappropriate, and therefore some patients may not make eye contact while communicating. Though the behavioural differences may be linked to cultural differences, there may be a link with the fear of assigning a heath issue to the status of any nation. Problems may arise while assessing the patients and undertaking medical procedures. Many individuals from certain cultures may dignify certain body parts to be sacred. Sickness is believed to be due to physical and supernatural and metaphysical agents. Thus, it is worth undertaking a complete exploration of the belief system of the patient regarding illness on the nurse’s part. 

Aklöf et al., (2015) pinpoint the challenges nurses face in the due course of caring for immigrant patients. The cultural differences that influence care delivery encompass perception of hygiene, nutritional habits, religious practices, the perception of illness, stigmatised diseases, emotional expression, social identities, truth-telling and lack of knowledge of diseases. Communication is the sole way of breaking the religious and cultural barriers and reaching to the patients so that their needs can be addressed. Nurses while working with immigrants must know the background of the patient before approaching them for care.  This would ideally include political and humanitarian situations and family history. The attitude of the nurses are to be positive, and patients are to be treated with sincerity, empathy, compassion and patience. Probing into the root cause of the cultural differences would be advantageous.

O’Mahony et al., (2013) have advised that regardless of the cultural differences among the patients who are refugees, the respect for the patient is to be maintained and healthcare is to be provided by the nurses as per the standards of the host society. Refugees may be expecting the western physicians and therapeutic approaches to cure the complications immediately in a rapid manner. Others may think that illness cannot be avoided in life and therefore delay may be caused in contacting a healthcare professional. They may not feel the urgency to have a prescribed medication regime and the importance of adhering to it. It might be difficult for them to come in terms with Western medical culture. Non compliance to treatment protocol and medication may often be a problem. While explaining the medication plan to the patient, the nurses must explain the refugee patient to need of finishing the complete course of the medicine especially when the general custom is to have medicine only until the symptom or pain has gone. Time is to be given to the patient to understand the drifts that the modern society has witnessed in the recent past pertaining to medical arena and they are to be politely educated about differences between their host country and the country in which they are getting heathcare. Caring for children refugees may be also an issue as disciplining of children tends to vary greatly among cultures. Nurses must recognise the possibility of abuse and violence in refugee families for assisting care.

Conclusion

A cultural competent nurse thrives to combat and prevent stereotypes and prejudices through culturally inclusive and holistic practice through a clear articulation of guideline policies regarding prevention of inequalities and stereotypes. Nurses have the need of implementing the knowledge they have regarding cultural diversity for developing a caring process that is exclusively culturally sensitive. This can enable the nurses to successfully fulfil the role the patient’s advocate and initiate nursing assessments. When nurses have adequate knowledge of cultures of different people, they are in the position of influencing the professional policies. Cultural sensitivity, competence and sensitivity are crucial for nursing practice. Nurses who are culturally competent bring benefits for the patient through better outlook towards health care. Unsafe cultural practises lead to undesirable circumstances. The influence culture makes as a causative impact on the interpretations, perceptions and behaviours exhibited by individuals. Issues like cultural differences in designing treatment methods are important. When knowledge of different cultures is gained, the cross cultural comparison often gives rise to appreciation of probable widespread characteristics as well.

Nurses are to know how cultural groups consider life processes, how they define illness and health, how they maintain wellness and what they believe are the causes of ill health. Nurses consider the cultural factors and recognise the cultural variations impacting individual clients. Nurses take pride on themselves if they can deliver care that reaches the satisfactory level set by the clients. Since the aim of the nursing practice is better patient outcomes, their feedback is crucial. If nurses are sensitive to the various needs of the patients, they can plan interventions accordingly. Nurses bring their own cultural heritage and philosophical and cultural views into their diverse professional settings. They must know that nurse-patient encounters include the interaction of the culture of the nurse, the patient and the setting. Care delivery can be improved and evolved through culturally relevant and responsive services. A nurse administer is to foster procedures and policies helping to make sure that care accommodates the different cultural beliefs. Through an extensive research and exploration of different cultures practitioners can find innovative ways of catering to the patients.

References

Almutairi, A. F., McCarthy, A., & Gardner, G. E. (2015). Understanding cultural competence in a multicultural nursing workforce: registered nurses’ experience in Saudi Arabia. Journal of Transcultural Nursing, 26(1), 16-23.

Almutairi, K. M. (2015). Culture and language differences as a barrier to provision of quality care by the health workforce in Saudi Arabia. Saudi Medical Journal, 36(4), 425-431.

Andrews, M. M., & Boyle, J. S. (Eds.). (2008). Transcultural concepts in nursing care. Lippincott Williams & Wilkins.

Bedi, M., & Devins, G. M. (2016). Cultural considerations for South Asian women with breast cancer. Journal of Cancer Survivorship, 10(1), 31-50.

Blais, K. (2015). Professional nursing practice: Concepts and perspectives. Pearson.

Burnard, P., & Gill, P. (2014). Culture, communication and nursing. Routledge

Christensen, S. (2014). Enhancing Nurses’ Ability to Care Within the Culture of Incarceration. Journal of Transcultural Nursing, 25(3), 223-231.

Darnell, L. K., & Hickson, S. V. (2015). Cultural competent patient-centered nursing care. Nursing Clinics of North America, 50(1), 99-108.

Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., … & Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109-121.

Eklöf, N., Hupli, M., & Leino?Kilpi, H. (2015). Nurses’ perceptions of working with immigrant patients and interpreters in Finland. Public health nursing, 32(2), 143-150.

Frey, R., Raphael, D., Bellamy, G., & Gott, M. (2014). Advance care planning for M?ori, Pacific and Asian people: the views of New Zealand healthcare professionals. Health & social care in the community, 22(3), 290-299.

Giger, J. N. (2016). Transcultural nursing: Assessment and intervention. Elsevier Health Sciences.

Grady, A. M. (2014). Enhancing cultural competency in home care nurses caring for Hispanic/Latino patients. Home Healthcare Now, 32(1), 24-30.

Harding, T. (2013). Cultural safety: A vital element for nursing ethics. Nursing Praxis in New Zealand, 29(1), 4-12.

Hart, P. L., & Mareno, N. (2014). Cultural challenges and barriers through the voices of nurses. Journal of clinical nursing, 23(15-16), 2223-2233.

Jennings, K. S., Cheung, J. H., Britt, T. W., Goguen, K. N., Jeffirs, S. M., Peasley, A. L., & Lee, A. C. (2015). How are perceived stigma, self-stigma, and self-reliance related to treatment-seeking? A three-path model. Psychiatric rehabilitation journal, 38(2), 109.

McClimens, A., Brewster, J., & Lewis, R. (2014). Recognising and respecting patients’ cultural diversity. Nursing Standard, 28(28), 45-52.

Molloy, L., Walker, K., Lakeman, R., & Skinner, I. (2015). Ethnonursing and the ethnographic approach in nursing. Nurse researcher, 23(2), 17-21.

O’Mahony, J. M., Donnelly, T. T., Bouchal, S. R., & Este, D. (2013). Cultural background and socioeconomic influence of immigrant and refugee women coping with postpartum depression. Journal of immigrant and minority health, 15(2), 300-314.

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of nursing. Elsevier Health Sciences.

Purnell, L. D. (2012). Transcultural health care: A culturally competent approach. FA Davis

Qin, D. B., Saltarelli, A., Rana, M., Bates, L., Lee, J. A., & Johnson, D. J. (2015). “My Culture Helps Me Make Good Decisions” Cultural Adaptation of Sudanese Refugee Emerging Adults. Journal of Adolescent Research, 30(2), 213-243.

Ray, M. A. (2016). Transcultural caring dynamics in nursing and health care. FA Davis.

Rundle, A., Carvalho, M., & Robinson, M. (2016). Cultural Competence in Health Care. Jossey Bass Wiley.

Sagar, P. L. (2011). Transcultural nursing theory and models: application in nursing education, practice, and administration. Springer Publishing Company.

Saleh Al Mutair, A., Plummer, V., Paul O’Brien, A., & Clerehan, R. (2014). Providing culturally congruent care for Saudi patients and their families. Contemporary nurse, 46(2), 254-258.

Shambley-Ebron, D. Z. (2015). Transcultural nursing promoting peace through practice and scholarship. Journal of Transcultural Nursing, 26(5), 529-530.

Shen, Z. (2015). Cultural competence models and cultural competence assessment instruments in nursing: a literature review. Journal of Transcultural Nursing, 26(3), 308-321.

Son, H. M., Je, M. J., & Lee, B. J. (2014). Integrative review on cultural competence of nurse. Korean Journal of Culture and Arts Education Studies, 9(4), 25-47

Wiechula, R., Conroy, T., Kitson, A. L., Marshall, R. J., Whitaker, N., & Rasmussen, P. (2015). Umbrella review of the evidence: what factors influence the caring relationship between a nurse and patient?. Journal of advanced nursing.

Williams, P. A. (2017). deWit’s Fundamental Concepts and Skills for Nursing. Elsevier Health Sciences.

Zimmerman, S., Shier, V., & Saliba, D. (2014). Transforming nursing home culture: Evidence for practice and policy. The Gerontologist, 54(Suppl 1), S1-S5.