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Transcultural Caring Dynamics in Nursing and Health Care 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page ii 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page iii
Transcultural Caring Dynamics in Nursing and Health Care By Marilyn A. Ray, RN, PhD, CTN-A Col. (Ret.), United States Air Force (USAF), Nurse Corps Professor Emeritus Florida Atlantic University The Christine E. Lynn College of Nursing Boca Raton, Florida 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page iv
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Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN Developmental Editor: Caryn Abramowitz Director of Content Development: Darlene Pedersen Project Editor: Kristin L. Kern Cover Design: Dr. H. Lea Barbato Gaydos
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Library of Congress Cataloging-in-Publication Data Ray, Marilyn Anne. Transcultural caring dynamics in nursing and health care / by Marilyn A. Ray. p. ; cm. Includes bibliographical references. ISBN-13: 978-0-8036-0809-2 ISBN-10: 0-8036-0809-8 1. Transcultural nursing. I. Title. [DNLM: 1. Nursing Care. 2. Transcultural Nursing—methods. 3. Cultural Competency. WY 107 R264t 2010] RT86.54.R39 2010 610.73—dc22 2009029450
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To the memory of my late husband, James L. Droesbeke Loving husband, devoted son, caring person
And To the memory of my late parents, Arthur and Elvera Ray Caring parents, great teachers, spiritual advisors
And To all of my family, teachers, colleagues, and students who have encouraged and supported me throughout my nursing career 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page vi
The Cover: Sunflower World Sunflower World By H. Lea Barbato Gaydos, PhD, RN Sunflower World is about the interconnectedness of all things. It is in the tradition of a mandala, the Sanskrit word for “whole world” or “healing circle.” Mandalas are usually very colorful and found in many spiritual traditions. The purpose of a mandala is to pro- vide a focus for meditation and reflection. There are three symbolic elements for reflec- tion in Sunflower World. First, in this work, the earth is encompassed by the sunflower, which is meant to sym- bolize the beauty and harmony of the world as it exists in nature. Second, the mosaic background represents the multiplicity of peoples and cultures that inhabit our world, different in color, shape, and tradition, but essentially the same in our humanity. Like the sunflower that follows the light, we must look to our intrinsic nature and compassionate caring to transcend our differences and find our wholeness as human beings in relation- ship with others. Third, the green bars that bisect the image horizontally and vertically represent the four directions; they resemble a ribbon, suggesting a gift, the gift of life. The aesthetic for this piece was inspired by the work of Lily Yeh, Founder and Director of Barefoot Artists, Inc. and her work with people in Africa who had experienced geno- cide. With the community of survivors, she created a healing garden memorial to the dead where before they had only had a mass grave of concrete.
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BIOSKETCH
Marilyn A. Ray, RN, PhD, CTN-A Colonel, Retired, USAF, Nurse Corps
arilyn A. Ray, RN, PhD, CTN-A is a economic, legal and humanistic and spiritual-ethical Professor Emeritus at Florida Atlantic caring. The research of Drs. Ray and Turkel earned M University, The Christine E. Lynn College the Federal Nursing Essay Award for research from of Nursing, Boca Raton, Florida where she has served the Association of Military Surgeons of the United for more than 20 years. Throughout her nursing States (AMSUS), and the coin for excellence in nurs- career, she has worked as a clinical nurse in different ing research from the TriService Nursing Research roles in various hospitals, held faculty positions at the Program of the Uniformed Services University of the University of California San Francisco, and the Health Sciences (USUHS). As an advanced certified University of San Francisco, the University of Colorado transcultural nurse (CTN-A), Dr. Ray has published Denver Anschutz Medical Campus, College of Nurs- widely on the subjects of caring in organizational ing, Denver, Colorado, and McMaster University, cultures, caring theory, and caring inquiry, transcul- Hamilton, Canada, and has served in two Eminent tural caring, transcultural ethics, technological car- Scholar positions at Florida Atlantic University and ing, political and economic caring, spiritual caring, Virginia Commonwealth University respectively. She complex caring dynamics, complexity sciences, and holds a diploma from St. Joseph Hospital, Hamilton, relational caring theory in the economics of the Canada, bachelor of science and master of science nurse-patient relationship. She also has published in degrees in nursing from the University of Colorado, the qualitative research area, specifically phenome- Denver, Colorado, a master of arts degree in cultural nology and hermeneutics, the grounded theory anthropology from McMaster University in Hamilton, method, caring inquiry, and critical social theory. Canada, and a doctor of philosophy degree in Dr. Ray’s Bureaucratic Caring Theory has been used transcultural nursing from the University of Utah. in many health-care organizations throughout the Dr. Ray also participated in the two ethics programs world. Dr. Ray contributed to the core curriculum de- of study at Georgetown University, Kennedy Institute velopment for certification of the Transcultural Nurs- of Ethics. She is a Fellow of the Society for Applied ing Society with her model of transcultural caring dy- Anthropology, and received the first honorary degree namics, and qualitative research methods. She is conferred by Nevada State College, Henderson, co-editing a book with Dr. Alice Davidson, Nursing, Nevada. As an officer in the United States Air Force Caring, and Complexity for Human-Environment Reserve, Nurse Corps, she retired as a Colonel after Well-Being. At Florida Atlantic University, Dr. Ray more than 30 years of service in flight nursing, clini- serves as a guest teacher, continues to work with cal practice, administration, education, research, and doctoral students, and is a faculty mentor. In addi- consultation in aerospace nursing. Dr. Ray was a tion, she is on the review boards of the Journal principal investigator on many federal grants with of Transcultural Nursing and Qualitative Health her colleague and co-principal investigator, Dr. Marian Research. Dr. Ray also presents at many national Turkel. Their research using both qualitative and and international conferences and will represent the quantitative methods involved the study of nurse discipline and profession of nursing as a speaker at and administrative caring in complex organizational the 2010 World Universities Forum in Davos, cultures with emphasis on technological, political, Switzerland. vii 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page viii 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page ix
FOREWORD
t no time in the history of humankind has professionals are often heard in the thinking, words, there been so many major and subtle and actions of many nurses. A changes in the world. Changes and the Over the past 50 years, a cadre of professional processes of change are occurring worldwide and in- nurse scholars have studied and documented human fluencing the values of human beings, and altering caring. Among these caring scholars has been the their environments, societies, economics, politics, and author of this book, Dr. Marilyn Ray, who has spiritual and ethical lifeways. These changes are focused on transcultural caring dynamics in nursing related to many factors but especially to new tech- and health care. Dr. Ray has interwoven the essence nologies, human innovations, rapid transportation, of caring, transcultural caring ethics, transcultural changing economic conditions, new kinds of intercul- context and universal sources (spirituality) into a tural relationships, geopolitical challenges, wars, cli- model for awareness, understanding, and choice for matic shifts in temperature, and major language and patients and families of diverse cultures regarding living changes. Granted some of these changes can health, healing, and well-being. occur rather quickly and others very slowly over time The essence of nursing as human care has been and geological locations. From an anthropological studied in many Western and non-Western societies perspective, many of the major geo-environmental from holistic, transcultural nursing perspectives, and changes have been occurring over millions of years frequently by using my Theory of Culture Care and documented by archaeologists, geologists, cli- Diversity and Universality with the Sunrise Enabler mate experts as well as by spiritual leaders and and other transcultural care enablers, and the Ethno- human life specialists. These changes are of major nursing research method. It was in the late 1950s concern to most humans locally and globally, but es- that I began this movement to study care and caring pecially to professional nurses. from transcultural theoretical and research perspec- In the process of such changes and their conse- tives. At that time, I discovered in nursing and in quences, the phenomenon of human caring and its institutional care settings that cultural factors were affect on the health and well-being of people is im- woefully missing to understand and help people of portant to study and reflect upon through time and diverse cultures. This was, indeed, a major shock to in different geographical environments. Political, me so I took steps to prepare nurses in transcultural economic, social, cultural, spiritual, moral-ethical, nursing and to incorporate cultural care meanings and environmental factors play a key role in one’s and research findings into nursing practice. While health and well-being. Unquestionably, changes and this was a slow process, my theory gradually became especially cultural care changes do alter or affect the an integral part of many nurses’ thinking and nurs- thinking activities and health status of human be- ing practice by the late 1970s. It was during this time ings. In the field of nursing, human life changes have period as Dean and Professor at the University of been clearly evident in the care of people in most Utah that I had the opportunity and special privilege cultures. Many people struggle to understand and to know and help prepare Dr. Ray in transcultural respond to such changes in their daily lives. Amidst care research and theory. As one of the first nurses to these changes the importance of caring for and with pursue graduate study and research in transcultural humans in order to receive quality health care nursing, Dr. Ray obtained her doctor of philosophy and/or to survive; grow; be healed; and face death, degree focusing on the study of the meaning of car- disabilities, or handicaps are foremost in the minds ing within institutional contexts. Through her re- of professional nurses. Two frequent questions, search, she discovered the Theory of Bureaucratic Who cares for whom, and who cares for health Caring within complex organizations. She is well ix 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page x
known and recognized for major research contribu- or misunderstood. Today, research-based practice tions to human caring, organizational caring, and using or developing explicit theories and models has transcultural nursing. facilitated the advancement of transcultural under- In this book, it was most encouraging to find that standing and culturally congruent care. Unquestion- Dr. Ray focused on the complex phenomena of hu- ably, transcultural care knowledge has become a man caring dynamics and processes from transcul- major national and global trend in the study of hu- tural nursing viewpoints. This book is truly a break- man cultures. through not only to understand the dynamics of Since the purpose of a Foreword is to open the human caring, but to understand how local and door to all who are interested to explore ideas pre- global cultural and organizational processes and sented in a book, I believe that the above points contexts influence and shape care meanings and ex- should greatly stimulate and encourage readers to pressions that affect choices for health, healing, and read this book, and to discover a true scholar and well-being. To achieve this goal, Dr. Ray’s research leader of transcultural nursing. Dr. Ray is to be com- and observations provide new and fresh insights mended for this milestone contribution and excellent about human caring dynamics and the complexities book, Transcultural Caring Dynamics in Nursing and of transcultural relationships within changing local Health Care. I recommend it to teachers, beginning and global cultural contexts. students, graduate students, administrators, and prac- As I reflect on Dr. Ray’s creative work, several titioners and the many in the health professions who factors come to mind in addition to her intellectual desire to continue to learn about human caring and astuteness and research abilities. Dr. Ray has had the multiple factors that influence transcultural nurs- 50 years of professional nursing practice, educa- ing care. Dr. Ray has discussed the “rough diamond” tion, and research, and more than 30 years as an of- and has polished and made it shine as a brilliant gem ficer culminating with the rank of Colonel in the for nurses and other professionals. I wholeheartedly United States Air Force Reserve. She gained valu- endorse this scholarly publication that advances hu- able experience in aerospace nursing service and re- man caring and the complexities of transcultural care search, which gave her unique insights to explore knowledge to improve the health of and help people complex, sometimes invisible, and multifaceted of diverse cultures worldwide. care phenomena. Most importantly, Dr. Ray had Madeleine M. Leininger, PhD, LHD, DS, RN, the love and compassion of her parents and family, CTN-A, FAAN, FRCNA along with many spiritual advisors who instilled in Founder and Leader of Transcultural Nursing her faith and the love of God’s creation and the uni- and Human Care, the Theory of Culture Care Diver- verse. Moreover, her beloved husband, Jim, and sity and University, and the Ethnonursing Research many caring teachers and colleagues over the years Method were important role models and mentors to dis- cover and know caring. Professor Emeritus, Wayne State University, and Today, transcultural nursing with a human care Clinical Professor, University of Nebraska, Omaha focus has become a major and essential academic Distinguished Lecturer and Global Consultant area of study and practice. Many transcultural nurs- ing practitioners, faculty, administrators, and other Collection on Human Caring and Transcultural nursing leaders have contributed to the growth of Nursing and Anthropology, Archives of Caring, transcultural nursing as a discipline. This positive Christine E. Lynn College of Nursing Museum change is remarkable when contrasted with the fact Archives at Florida Atlantic University, Boca Raton, that specific cultures were often neglected, avoided, Florida
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PREFACE
n the last few decades, the rapidly changing ways of encountering all people in the world. As we world around us has produced enormous chal- begin to recognize the complexity of the universe, we Ilenges. Changes in science, technology, trans- can see culture as transcultural or intercultural and as portation, economics, and health care, and expanded dynamic and complex. Culture as dynamic complex- knowledge of the meaning of spirituality and religion ity mirrors complexity sciences that highlight the have affected all cultures at local and global levels. meaning of interconnectedness; it shows how we Advancement in the different disciplines of knowl- must work together to enact our caring natures, to edge shows how closely we are interconnected. Sci- be ethically responsible for each other and the envi- ence has illuminated new paradigm thinking, the new ronment, to find meaning in transcultural contexts— sciences of complexity that consider the profound re- understanding of the person in family, community, lationship between the mind and nature, the mutual organizations, and societies, and to appreciate the human-environment process. New thinking about spiritual and religious values, beliefs, and creativity of human values, societies, the environment, cultural di- one another. “We are whole and unique. We are versity, geopolitical communities, health, and our diverse but communal. We are in the midst of a re- common future are transforming societies. The search markable transition to building the global civic cul- for the relationships between nature and conscious- ture, to understanding a global civilization that will ness, matter, and mind have helped to illuminate the work for each inhabitant of the universe and for the fertile link among quantum science, art, different universe itself.” worldviews, psychology, language, creativity, theol- In nursing, we are fortunate to experience the joy ogy, and the social-cultural world. Technology has and sorrow of life in our everyday work. Even provided the opportunity to learn how we are linked though we often may feel that our caring efforts are together by information and communication. Tech- in vain or our good intentions are not appreciated or nology and transportation are helping us understand rewarded, we know that when in an authentic rela- the meaning of history, environments, location, space, tionship with another person, family, or community immigration, affluence, and poverty while seeing the who rely upon us for compassion and help, we affect world, people, and cultures in new ways. Economics the healing, health, and well-being of those whom illustrates the importance of resources and how being we serve. The conceptual model identified in this stewards of resources worldwide, we can assist with book, Transcultural Caring Dynamics in Nursing complex human, social, environmental, health, and and Health Care with its dimensions: the Essence political problems in every nation and in space. Reli- of Caring, Transcultural Caring Ethics, Transcultural gions, while often divisive continue to help us under- Context for Transcultural Nursing, Universal Sources, stand the true meaning of spirituality and its illumi- and Transcultural Caring Inquiry: Awareness, Un- nation of love and compassion and social justice for derstanding, and Choice enables us to explore and all people of the world. Health-care research and understand nursing as a transcultural caring dynam- practice illuminates ways in which we should and ical process, specifically a transcultural communica- can provide improved health care for all. From a tive spiritual-ethical caring way of being, knowing, nursing perspective, by virtue of our understanding of and doing. The central phenomena of the dimensions human caring, awareness of the importance of rela- of this conceptual framework are processes used by tionships, holism (i.e., body, mind, and spirit), and in- each of us when we become aware, seek understand- tegration of the holistic nature of the mutual human- ing, and make choices affecting our health, healing, environment process, we show how the scientist and and well-being. Participating in the processes of artist in us, engage the cultural other and explore new awareness, understanding, and choice helps us to xi 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page xii
become more transculturally competent to provide The book, Transcultural Caring Dynamics in culturally relevant or congruent care to patients, Nursing and Health Care includes a presentation of families, communities, and citizens of the globe. transcultural caring experiences (stories/case stud- The Essence of Caring highlights the history of ies) at the end of each chapter in Section 1 where the caring and its importance in human relationships conceptual model and dimensions are featured, and and various disciplines. Caring in contemporary in Section 2 where many transcultural caring expe- nursing is illuminated from the commitment of nurs- riences illuminate the diversity and dynamics of cul- ing to relationships and the human-environment ture and transcultural nursing in a global world. process beginning first with Florence Nightingale The content of the book helps to reveal information and including Jeanne Mance of Canada through to and wisdom that is embedded in each one of us as Martha Rogers and the caring theorists of the last cultural/multicultural beings. Illuminating informa- 3 decades, such as Roach, Watson, and Leininger. tion in the conceptual framework presented in this Leininger, the “mother” of transcultural nursing, was book provides a means to deal with both details and instrumental in advancing caring as the essence of difficulties that nurses as transcultural professionals nursing and the concept is foundational to her the- may encounter each day. ory of Culture Care Diversity and Universality: A Having devoted my attention to exploring the Worldwide Theory of Nursing (Leininger, 1991; complexities of nursing from a transcultural per- Leininger & McFarland, 2006). Transcultural Car- spective has been a great pleasure for me. I have ing Ethics illuminates essentially how we ought to learned so much from my experiences in nursing live when we share a common world. Ethics deals practice, education and research, traveling, and my with issues and theories of “serving the good” and deep relationships with family, friends, and col- how cultures have values in common but with con- leagues. I am pleased to have this opportunity to tending ideas, theories, and ways of expressing the share with you not only my ideas and experiences understanding of morality and what is required of us but also some ideas and experiences of other people in professional nursing when examining culture and who have contributed to and enriched this book. its diversity and commonality. The ideas that are discussed in this book are Transcultural Context for Transcultural Nursing important in an interconnected and global society. identifies the centrality of the human-environment They have arisen in the course of exploring nursing process, the unity of persons within their cultural through education, research, administration, and contexts. Transcultural context highlights the hu- practice over time, and observing and studying man-environment integral relationship, the person changes in the contemporary world. They have arisen (race and identity), and the person in family (kinship through teaching and learning opportunities in the system, group, or community), and illuminates eth- classroom and in many countries of our world. They nicity, panethnicity, societal and organizational sys- have arisen through my many interactions with peo- tems in local and global communities. As such, the ple of diverse cultures, including three children I have transcultural context also examines multicultural- the privilege to sponsor from Nicaragua, Guatemala, ism, interculturality, and transculturality in the and India. Moreover, the ideas expressed have arisen changing world culture and nursing. from the opportunities for service, education, and Universal Sources outlines the importance of spiri- travel during my career in the United States Air Force tuality and/or religion in all choice making processes Reserve, Nurse Corps. These ideas would not come to in conjunction with the understanding of caring as life, however, without the participation of each of the transcultural ethics and within a transcultural con- readers of this book. For me, the evolution of this text. Some of the dominant religions or spiritual tra- book came to fruition only because of love and help ditions in the world are presented. from God, the devotion of my late husband and sup- Transcultural Caring Inquiry: Awareness, Under- port from my remarkable family, and the many cre- standing, Choice highlights how nurses use the model ative students, colleagues, friends, and the publisher, and its components and the assessment tools for in- and editors whom I have had the privilege to know. quiry—knowledge and evidence for awareness, un- This book evolved also with my hope in the future derstanding, and the facilitation of choice for the pa- and to the possibilities that may emerge from the tient, community, and sociocultural healing, health, readers who are committed to transcultural nursing well-being, or a peaceful death. and caring. The contributions of each one of you will xii 0809_FM_i-xxiv.qxd 11/2/09 6:15 PM Page xiii
improve the healing, health, well-being, and peaceful have wondered when I would ever complete this deaths of our patients who, although may be differ- work, to my colleagues and production team at ent, share a common humanity. F. A. Davis Company who always gave me hope and I wish to mention those who have been particu- encouragement, and to the many wonderful contrib- larly connected with this work and the activities that utors who made this work a living history and a have led to its completion. As I mentioned in my ded- road map for possibilities, for a truly transcultural ication, I am deeply grateful to my parents and late caring future in a complex world. To Lea, for her husband for their enduring belief in me as a person Sunflower World cover painting and narrative that is and as a transcultural nursing professional, to my an inspiration for all transcultural caring nurses. family who did not give up on me when they may M. A.R
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CONTRIBUTORS
Charlotte Barry, RN, PhD, NCSN Mary Enzman Hines, Associate Professor and Associate Director FNP, AHN-BC, RN, PhD Center for School and Community Well-Being Professor and DNP Program Coordinator Florida Atlantic University University of Colorado, Colorado Springs The Christine E. Lynn College of Nursing Beth-El College of Nursing and Health Sciences Boca Raton, Florida Colorado Springs, Colorado Chapter 17 Haitian Family’s Health Experience Chapter 23 American Nurses and the Native People and the Public School System of Ecuador: The Transcultural Experience of Shamanism Anita Beckerman, EdD, ARNP Associate Professor Emeritus Florence Keane, Florida Atlantic University DNS, MBA, ARNP-NPC The Christine E. Lynn College of Nursing Assistant Professor Boca Raton, Florida Florida International University Chapter 20 The Heart of Suffering, Mourning, and College of Nursing and Health Sciences Healing in the Jewish Spiritual Culture: A University Park Campus Mother’s Story Miami, Florida Chapter 13 Transcultural Diversity Within Unity in A. Judith Czerenda, Jamaica: Out of Many, One People RN, DNS, ARNP, LNHA Consultant Sandra Lovering, RN, DHSc, CTN Joint Commission Resources Chief Nursing Officer Oakbrook, Illinois King Faisal Specialist Hospital and Research Center Chapter 11 The Transcultural Social and Health (General Organization) Jeddah Experience of an Asian Indian Widow Jeddah, Saudi Arabia Chapter 22 with Dr. Marilyn Ray: Extending Susana Fortun, PhD Hands: Transcultural Caring in Saudi Arabia Program Dean—Technology Marilyn A. Ray, RN, PhD, CTN DeVry University Professor Emeritus Miami, Florida Florida Atlantic University Chapter 14 with Dr. Marilyn Ray: Cuban American The Christine E. Lynn College of Nursing Transcultural Experiences and the Quest for Boca Raton, Florida Freedom in the United States Chapters 8, 10, 15, 16, 21, 25, 26 Agnes Hay, RN, MSN(c) Francelyn Reeder, RN, CNM, PhD Associate Chief Nursing Officer Associate Professor Emeritus Boca Raton Community Hospital University of Colorado, Anschutz Medical Center Boca Raton, Florida Campus Chapter 12 with Dr. Marilyn Ray: The Cultural, Denver, Colorado Health Care, and Intermigration Experience of Chapter 19 with Dr. Marilyn Ray: The Elderly a Filipino Nurse Navajo Native American’s Health Experience in the Nursing Home Culture
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M. Christopher Saslo, ARNP, DNS Josie A. Weiss, ARNP, PhD Infectious Diseases/Hepatology Associate Professor Veterans’ Affairs Medical Center Florida Atlantic University West Palm Beach, Florida The Christine E. Lynn College of Nursing Chapter 24 The Culture of Physical, Mental, Boca Raton, Florida Spiritual, and Political/Sociocultural Illness: Chapter 19 The Transcultural Caring Experience Healing Through Education and Love of a Haitian Girl and a Nurse Practitioner in an Adolescent Correctional Facility The 49ers of Booker T. Washington High School: Harold L. Braynon, JD Sara (Faye) Summons Bullard Effie R. Fortson Whittington B. Johnson, PhD Moses Jones, Jr., Maj. (Ret.), United States Army Percy L. Oliver Cortell H. Owens Chapter 9 with Dr. Marilyn Ray: A Vibrant African America Community: The 49ers and the Quest for Justice
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REVIEWERS
Sara Fuller, PhD, APRN, CPNP Joyce M. Varner, Associate Professor RN, MSN, GNP-BC, GCNS, DNPc University of South Carolina Clinical Assistant Professor College of Nursing University of South Alabama Columbia, South Carolina College of Nursing Springhill Campus Nelma B. Shearer, PhD, RN Mobile, Alabama Associate Professor Arizona State University College of Nursing and Healthcare Innovation Phoenix, Arizona
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ACKNOWLEDGMENTS
wish to acknowledge and thank my teacher, and the sacred, how nursing as a science and art mentor, colleague and friend, Dr. Madeleine embraces holism, human caring, ethical responsi- ILeininger, the first nurse anthropologist, bility, transcultural awareness, and spirituality. I “mother” of transcultural nursing, and inspiration wish to acknowledge all of those who have encour- for the development of nursing as a human science, aged me not only to reach for the stars in my per- and caring as the essence of nursing. Dr. Leininger sonal life but also to find deep meaning in a career guided me through my bachelor and master of sci- dedicated to the study and practice of human car- ence in nursing, supported me through my master of ing, human science, and transcultural nursing. arts in anthropology, and directed my efforts to I wish to thank all the contributors to this book. achieve the doctor of philosophy in transcultural I thank Dr. H. Lea Barbato Gaydos for her cover nursing. painting. I am grateful to all of the nurses who I wish to acknowledge all of the people who have shared their stories of transcultural caring at helped me begin to understand myself as a cul- home and around the world in the second section tural, multicultural, caring, and spiritual being, be- of this book. I wish to thank Joanne DaCunha, ginning first with my family; the aboriginal, Publisher, F.A. Davis Company for her belief in me French Canadian and immigrant people of my na- and transcultural caring, and her constant encour- tive land, Canada; and, after coming to the United agement and patience to complete this work. I States as an immigrant myself, the many people of would not have been able to accomplish this book diverse cultures who also have made their home in without the commitment, perseverance, and assis- the United States. All have enriched my life with tance of my editor, Caryn Abramowitz. I am so ap- their fascinating histories, stories of the Diaspora, preciative of the talent and skill my co-author of immigration, and the struggle and joy in finding the Instructor Guide, Dr. Anne Vitale who, with meaning in new diverse and exciting communities. her knowledge of both in-class and online educa- I am also grateful to all the people whom I met tion will help to make this work accessible to through my commission as an officer and affilia- many faculty and students around the world. tion with the United States Air Force, Nurse Corps. Lastly, I am indeed grateful to my copy editor, Julie With nurturing from my loving husband and Vitale, Lisa Thompson, and the production team at family, and many wonderful friends—in particular F. A. Davis Company. Drs. Francelyn Reeder, Carolyn Brown, and May this book inspire students as Dr. Leininger in- Marian Turkel, my Deans, and colleagues—I was spired me. May this book help professionals seek un- able to achieve the goals in my life: the ability to derstanding of the meaning of professional nursing explore the interrelationship among science, art, as a transcultural caring discipline and practice.
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LIST OF FIGURES
1-1 Transcultural Caring Dynamics in Nursing and Health Care, 4 2-1 Dimensions of the Model: Essence of Caring, 33 2-2 Classification System of Caring, 46 2-3 Process of Spiritual-Ethical Caring, 46 2-4 Meaning of Spiritual-Ethical Caring, 46 2-5 Ray’s Transcultural Communicative Spiritual-Ethical CARING Tool for Cultural Competency, 47 3-1 Dimension of the Model: Transcultural Caring Ethics, 63 4-1 Dimension of the Model: Transcultural Context, 94 5-1 Dimension of the Model: Universal Sources, 122 6-1 Center of the Transcultural Caring Dynamics Model for Nursing and Health Care, 155 6-2 Transcultural Spiritual-Ethical CARING Action of Nursing, 163 6-3 Transcultural Caring Dynamics, 164 6-4 Ray’s Transcultural Communicative Spiritual-Ethical CARING Tool for Cultural Competency, 166 6-5 Culture-Value Conflict Assessment Tool, 167 6-6 Dynamics of Transcultural Caring Tool for Choice, 174 6-7 Transcultural Caring Negotiation Tool, 176
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TABLE OF CONTENTS
SECTION 1 CHAPTER 8 The Border and Pueblo: Conceptual Model and An American Mexican Applications 1 Cultural Experience 200 By Marilyn A. Ray
CHAPTER 1 Transcultural Caring CHAPTER 9 A Vibrant African American Dynamics in Nursing Community: The 49ers and and Health Care 3 the Quest for Justice 206 By Marilyn A. Ray By The Community of 49ers with Marilyn A. Ray CHAPTER 2 The Essence of Caring 32 By Marilyn A. Ray CHAPTER 10 The Story of a Guatemalan Mayan Farmworker 212 CHAPTER 3 Transcultural Caring By Marilyn A. Ray Ethics 62 By Marilyn A. Ray CHAPTER 11 The Transcultural Social and Health Experience of CHAPTER 4 Transcultural Context an Asian Indian Widow 217 for Transcultural By A. Judith Czerenda Nursing 93 By Marilyn A. Ray CHAPTER 12 The Cultural, Health Care, and Intermigration CHAPTER 5 Universal Sources 121 Experience of a Filipino By Marilyn A. Ray Nurse 221 By Marilyn A. Ray with Agnes Hay CHAPTER 6 Transcultural Caring Inquiry: Awareness, CHAPTER 13 Transcultural Diversity Understanding, and Within Unity in Jamaica: Choice 154 Out of Many, One By Marilyn A. Ray People 226 By Florence Keane SECTION 2 Transcultural Caring CHAPTER 14 Cuban American Experiences 185 Transcultural Experiences and the Quest for Freedom in the United CHAPTER 7 Transcultural Caring States 232 Competency in By Susana Fortun Transculturally Dynamic Communities 187 By Marilyn A. Ray
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CHAPTER 15 Puerto Rican Transcultural CHAPTER 21 The American Chinese and Health Beliefs in a Transcultural Maternal- Western New York Child and Family Community 237 Experience in China 269 By Marilyn A. Ray in memory of By Marilyn A. Ray Barbara Higgins CHAPTER 22 Extending Hands: CHAPTER 16 The Nurse Manager in a Transcultural Caring in Cardiovascular Intensive Saudi Arabia 275 Care Unit and the By Marilyn A. Ray and Sandra Organizational Complexity Lovering of a Hospital Culture 241 By Marilyn A. Ray CHAPTER 23 American Nurses and the Native People of Ecuador: CHAPTER 17 Haitian Family’s Health The Transcultural Experience and the Public Experience of School System 247 Shamanism 284 By Charlotte Barry By Mary Enzman Hines
CHAPTER 18 Elderly Native American CHAPTER 24 The Culture of Physical, Navajo’s Health Experience Mental, Spiritual, and in the Nursing Home Political/Sociocultural Culture 251 Illness: Healing Through By Marilyn A. Ray with Francelyn Education and Love 289 Reeder By M. Christopher Saslo
CHAPTER 19 The Transcultural Caring CHAPTER 25 The Political-Legal Culture Experience of a Haitian of Multiculturalism and Girl and a Nurse Interculturality: The Story Practitioner in an of Canada 296 Adolescent Correctional By Marilyn A. Ray Facility 256 By Josie A. Weiss CHAPTER 26 Cocreating the Future Culture of Nursing: CHAPTER 20 The Heart of Suffering, Transcultural Caring at Mourning, and Healing in Home and Around the the Jewish Spiritual World, and in Space 304 Culture: A Mother’s By Marilyn A. Ray Story 261 By Anita Beckerman INDEX 316
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Section 1 Conceptual Model and Applications
Objectives
1. To present an introduction to the Transcultural Caring 9. To understand concepts, such as, identity, ethnicity, Dynamics in Nursing and Health Care book and model, panethnicity, interculturality/transculturality. and each dimensions of the model (i.e., the essence of 10. To appreciate the concept of universal sources—the caring, transcultural caring ethics, transcultural context roles of religion and spirituality in the choice-making for transcultural nursing, and universal sources) to process in transcultural nursing. develop an awareness of, assess, guide, and evaluate To identify major dimensions of the major religions nursing from transcultural, multicultural, and global 11. and beliefs in world culture. perspectives. (See Section 2 for application of the dimensions of this book in diverse transcultural caring 12. To present transcultural caring inquiry that integrates experiences [i.e., case studies/stories] to facilitate the dimensions of the model for awareness, under- health, healing, well-being, or a peaceful death.) standing, and choice in transcultural nursing practice. 2. To illuminate the processes of globalization and its effect 13. To identify for purposes of application a variety of tools on nursing and the meaning of nursing as transcultural for inquiry and culturological assessment, planning, caring. and evaluation to enhance the Transcultural Caring Dynamics for Nursing and Health-Care model. The To understand the meaning of culture as dynamic com- 3. tools include: Transcultural Caring Dynamics Assess- plexity that incorporates traditional views of culture and ment Tool, Ray’s Transcultural Spiritual-Ethical the new sciences of complexity. Communicative Caring (CARING) Tool, Transcultural 4.To appreciate the notions of cultural diversity and Caring Culture Value Conflict Assessment Tool, and cultural universality in co-creating a common humanity. Negotiation Tools for Choice—the Dynamics of 5. To present the history and emergence of caring in Transcultural Caring Tool for Choice and the human culture. Transcultural Caring Negotiation Tool. 6. To appreciate the emergence of caring in the discipline 14. To present transcultural caring experiences (i.e., and profession of transcultural nursing. case studies/stories) at the end of each chapter in 7. To identify transcultural caring ethics in relation to the Section 1 to highlight the discussions of each chapter history of ethical theories (primarily Western) that has dimensions (i.e., essence of caring, transcultural influenced the discipline and profession of transcultural caring ethics, transcultural context for transcultural nursing. nursing, and universal sources) for teaching-learning and reflection. 8. To appreciate the person, family, community, and organi- zations within a transcultural context for transcultural nursing.
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CHAPTER 1 Transcultural Caring Dynamics in Nursing and Health Care
Our era lures us to create the first global civilazation on earth. We are the generation that begins the creative transformation of the whole world into a single community out of the diverse peoples of the planet. (Fox & Swimme, 1982, p. 6)
Chapter Objectives KEY WORDS 1. Develop awareness of nursing from transcultural, Globalization • culture • multicultural, and global worldviews. multiculturalism • culture as dynamic complexity • cultural 2. Examine the concepts of caring, transcultural caring, caring sensitivity • health-care for self and self-reflection, ways of knowing, and culture as issues • alternative therapies dynamic complexity. • caring • transcultural 3. Identify issues in globalization—diversity, cultural identity, worldview • transcultural economics, multiculturalism, and immigration. nursing • transcultural caring 4. Apply the concepts of the multicultural self and transcultural • ways of knowing in nursing consciousness. • Transcultural Caring 5. Conceptualize the conceptual model of Transcultural Caring Dynamics in Nursing and Dynamics in Nursing and Health Care. Health-Care Model 6. Analyze the transcultural caring experiences of Monique, Kathleen, and Lian to appreciate the concepts in transcultural caring in nursing practice and enhance awareness and understanding of transcultural caring dynamics in nursing and health care.
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4 Conceptual Model and Applications
variety of tools for inquiry, culturological assess- he purpose of this book is to teach nurses ment, planning, and evaluation, the Transcultural Ttranscultural caring dynamics, to under- Caring Dynamics Assessment Tool, Ray’s Trans- stand and care for people of different cultures as cultural Spiritual-Ethical Communicative Caring they interact with each other locally, nationally, (CARING) Tool, Transcultural Caring Culture and transglobally. Readers will explore each di- Value Conflict Assessment Tool, and Negotiation mension of the Transcultural Caring Dynamics in Tools for Choice—the Dynamics of Transcultural Nursing and Health-Care Model (Fig. 1-1)—the Caring Tool for Choice and the Transcultural Car- essence of caring, transcultural caring ethics, tran- ing Negotiation Tool. The final part of the book scultural context, and universal sources—as the will present a variety of transcultural caring expe- foundation for awareness, understanding, and riences to discuss and analyze using the Transcul- choice. The chapters outlining each dimension of tural Caring Based Learning (TCCBL) model, the the model will be followed by case studies that Transcultural Caring Dynamics in Nursing and illustrate the dimension being explored. The book Health-Care Model, and the assessment tools. will then delve into use and application of a These practical applications will guide students
Transcultural Caring Dynamics in Nursing and Health Care
Essence of Caring Transcultural Caring Ethics (Love, Empathy, Authenticity, (The Good, Commitment/Trust, Respect, Compassion, Co-Presence, Availability, Fidelity, Integrity, Beneficence/Nonmaleficence, Attendance, Communication) Justice/Truth, Autonomy, Human Rights, The action of compassion/love as the Cultural Rights, Rights of Nature) mediating force to guide moral caring The knowledge shaping moral caring behavior and facilitate right action experience that facilitates (justice or fairness) within the transcultural ethical caring dynamics of culture
Transcultural Caring Awareness, Understanding and Choice
Transcultural Context Universal Sources (Person in Family/Society/Culture–Political, Economic, Educational, Legal, (Religion-Spirtuality (God, Christ, Technological, Ecological, Health-Care Systems) Buddha, The Absolute, Allah, Power, Force, Energy, Creativity, The diverse identities and personal/ethnic/ Healing, Mythology) cultural/multicultural values, beliefs and attitudes about relationships, symbols, The standards of spiritual/religious rituals guiding transcultural experience traditions shaping transcultural in social, communal, health-care and caring experience global cultural systems
Figure 1–1: Transcultural caring dynamics in nursing and health-care model. 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 5
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and professionals in developing culturally sensi- globalization by reflecting upon creative ways to tive, creative transcultural caring practice skills handle complex problems, and cultural differences when working with individuals and families from while sharing worldwide resources (Bar-Yam, 2004; diverse cultures, communities, and nations. Boulding, 2000; Eisler, 2007; Lindberg, Nash, & Before going into details, we must first grasp the Lindberg, 2008; Sachs, 2005). Individual cultures basics, which is the purpose of this chapter.Transcul- need to be aware of how they will change and grow tural caring in nursing is a culmination of a number as cultures interact. Technology, communication of forces, each of which we will review and define in technology, travel, and immigration especially have this chapter: globalization, caring, nursing para- joined people together. Such challenges present ex- digms and ways of knowing, culture, transcultural traordinary opportunities for health-care profession- consciousness, transcultural caring, health, and mul- als, such as nurses. Different cultures perceive wealth ticulturalism and transculturality. Only after exam- and health, disease and illness, caring and death ining these basic components will we turn to a dis- in very different ways. But there is a force toward cussion of the Transcultural Caring Dynamics in understanding the universality of what it means to be Nursing and Health-Care Model and its application human in the world, and the practice of securing to transcultural nursing practice. competency and human rights in health and cultural care (Giger, Davidhizar, Purnell, Harden, Globalization Phillips, & Strickland, 2007; Miller, Leininger, Globalization is causing a worldwide reformation, Leuning, Pacquiao, Andrews, Ludwig-Beymer, & transformation, and integration of cultures, and it is Papadopoulous, 2008; Journal of Transcultural here to stay. Science is manifesting that “this universe is Nursing, 2007, Special Issue, Vol. 18, No. 1). As a single, multiform energetic unfolding of matter, more cultures seek access to health resources, nurses mind, intelligence and life” (Swimme, 1996). New will be the ones responsible for understanding, facil- technologies including transportation, space, and com- itating, and integrating traditional culture into mod- munication infrastructures, and changing ideological, ern approaches to health and nursing care. Transcul- economic, environmental, and social forces have thrust tural caring-based nursing practice can improve the countries around the world toward globalization, quality of care and health for diverse and vulnerable causing shifts in every sector from economics to tech- populations. nology, politics to military, and entertainment to health In 21st century North America, individuals are (Friedman, 2006; Gutierrez & Kendall, 2000; Pensky, challenged with globalization and identity (Brush, 2005; Rogers, 2003; Sachs, 2005; Zwingle, 1999). This 2008). Different cultures are assimilating less and worldwide shift toward globalization intimately affects blending more. More frequently, individuals of dif- our encounters with, and our perception of, culture, ferent cultures are preserving their cultural diversity cultural diversity, and cultural universality (Leininger, by choice and in symbol and rituals, and adding 1991; Leininger & McFarland, 2006). East is meeting their diversity to the ever-changing mix of values, west and south is meeting north, so it is our responsi- customs, lifeways, norms, and artifacts already in bility to be mindful of the differences and not take for place. Out of this mix emerges a new understanding granted the similarities. and an interconnectedness that will open humans to As the world is becoming more dynamic and emotional and intellectual cultural innovation. One complex, new patterns of relationships are emerging. common feature to all cultures and people is the Each nation and culture, with its unique values and human capacity to care deeply for people, and now, perspectives, must rise to the challenges presented by the environment, regardless of origins.
Learn More The racial and ethnic populations of North American countries are growing differently than they have in the past. Immigration is having a greater impact on population growth. According to U.S. Census Bureau (2008), the population is expected to grow from 296 million in 2005 to 438 million in 2020 to 500 million in 2050 (http://www.census.gov/population/www/pop-profile/natproj.html). A good portion of the increase will be attributable to immigrants of non-English speaking countries. The Pew Continued 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 6
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Learn More—cont’d Research Report (Passel & Cohn, 2008) projected that 82% of the increase will be due to immigrants arriving (67 million), and their U.S.-born descendants (50 million) during this period. By 2042, the minority population will be the majority (Winslow, 2008). One in five Americans (19%) will be an immigrant in 2050. The Latino/Hispanic population is the nation’s largest minority (15% in 2008 and projected to be 30% by the year 2050). Population growth of the black population in 2050 is projected to rise to 15% at 65.7 million from 14% in 2008. Asian American population growth is expected to rise in 2050 to 9% from 5 % in 2008. Population growth of American Indians/Alaska Natives is expected to rise from 1.6% to 2% (4.9 million to 8.6 million). Native Hawaiians and Pacific Islanders are projected to double from 1.1 million to 2.6 million. The white population is expected to decrease from 67% to 47% in 2050. (U.S. Census Report 2008. http://www.census.gov./ press-release/www/releases/archives/population/012496.html;).
Learn More caring in different ways and it is incumbent upon nurses in North America and around the world to The population of Canada is more than understand, acknowledge, and incorporate innovative 33 million people. Seventy percent of ethnic and varied transcultural caring expressions into their groups are visible minorities (a term used in practice. Canada) and were born outside the country. Ironically, for a profession charged with the obliga- One hundred languages are represented. In tion to learn about and effectively care for many dif- 2017, one in five Canadians is projected to be ferent cultures, nursing is not very representative of a visible minority or between 19% to 25% of the country’s cultural diversity. Despite the fact that by the population (2006 Canadian Census, the year 2042, the U.S. Census Bureau projects that Statistics Canada, 2006). The Daily (Statistics the nation will become much more diverse and mi- Canada, March 22, 2005) reported that norities will become the majority (Winslow, 2008), the currently, most minorities, about 58% are from majority of registered nurses are Caucasian (Findings China, South Asia, Korea and Japan, and of the Registered Nurse Population, 2004; National the Middle East (West Asia). The remaining Coalition of Ethnic Minority Nurse Associations immigrants are from the United States, Latin [NCEMNA], 2008). In American baccalaureate nurs- America, and Europe. In 2017, Canada’s ing education, the dominant racial group continues First Nations’ and Inuit peoples (aboriginals) to be white, followed distantly by black/African will represent 4.1% of the population, up Americans, Hispanics/Latinos, Asian Americans, and from 3.4% in 2001, a rise from 1.39 million to American Indians (Fang, Wilsey, & Bednash, 2007). 1.43 million (2006 Canadian Census, Statistics The registered nurse minority population in the Canada. www.statcan.ca). United States, Canada and other countries has in- creased in the last few decades largely due to the scope and magnitude of global migration to fulfill staff nurse GLOBALIZATION IN NURSING And this brings us to the heart of nursing—caring for others. Nursing is becoming increasingly dedicated to Nursing Reflection holism, healing the split among body, mind, and spirit, Why Must Nurses Become More and renewing a commitment to the focus of nursing as Transculturally Caring? global health, and caring in the human health experi- Technology, economics, class structure, ence (Gennaro, 2008; Leininger & McFarland, 2006; immigration, increasing needs of vulnerable Newman, 2003; Newman, Smith, Pharris & Jones, populations, and changing views of the mean- 2008; Watson, 1999, 2005, 2008a, 2008b). In these ing of race, ethnicity, and gender are altering times of cultural intermixing, this central phenome- the face of North America, the world, and the non of caring, although a universal value, becomes delivery of health and nursing care. more complex. Different cultures express care and 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 7
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shortages in hospitals and elsewhere (Brush, 2008). In Learn More the United States, there are more than 350,000 minor- One example of the way that ethnic and ity nurses (NCEMNA, 2008). Organizations, such as professional cultures can change and merge is the American Association of Colleges of Nursing illustrated by the recent surge in the use of (AACN), the Canadian Association of University complementary or alternative therapies. Such Schools of Nursing (CAUSN), and the American Acad- therapies—acupuncture, meditation, therapeutic emy of Nursing (Giger et al, 2007) have recognized touch, Reiki, massage, Ayurvedic, Chinese, and that respect for cultural diversity must be a core value other herbal remedies—generally come from of the nursing profession and of institutions that hire nonwestern cultures and are gaining not only in nurses. Moreover, nursing education and research rec- popularity, but also acceptance in some nursing ognize the importance of teaching and learning about and medical circles (Dossey & Keegan, 2008; cultural diversity and initiating culturally competent National Center for Complementary and care (Journal of Transcultural Nursing, 2007, Special Alternative Medicine [www.nccam.nih.gov]). Issue, Vol. 18, No. 1; Pacquiao, 2007). What was once shunned as “quack medicine” Madeleine Leininger, the first nurse-anthropologist is now viewed by some western health-care and mother of transcultural nursing (1970, 1991; practitioners as viable and meaningful. Western Leininger & McFarland, 2006) advocated for the in- healing is beginning to take on a new holistic corporation of transcultural nursing content in educa- light, as a combination of traditional and tion and has promoted research for culturally focused modern practices. practice for more than 50 years. In 1970, Leininger stated the following:
The cultural context approach [for nursing] GLOBALIZATION YIELDS HEALTH ISSUES strives for specificity in the consideration of patient problems and for reducing ambiguity With the benefits of globalization come the short- in nursing goals. . . . Each cultural group in comings. Health issues emerging from diverse view- various places in the world has its own life points about health and illness, geopolitical strife, style, patterns of living, and its own special war, communicable and infectious diseases, poverty, way of viewing the world about it. Its special nutrition deficiencies, global spread due to travel, or world view is the essential basis of a people’s characteristics of genetic engineering, biotechnol- modes of acting and thinking, and its world ogy, and environmental pollution all pose serious view serves as the basic framework for their health concerns that are exacerbated by globaliza- unique cultural context of behavior.” tion. “...[T]he health of one affects the health of all” Leininger (1970, p. 111) (Simpson, 1989, p. 196). The extent to which scien- tists should interfere with nature to develop new More and more, schools and clinical agencies are products or inventions creates ethical dilemmas responding to the demand and are incorporating for health-care practitioners and governments. A content and teaching-learning processes related to greater divide exists now between the world’s afflu- culture and transcultural nursing (Dougherty & ent and the world’s poor, creating responsibility on Tripp-Reimer, 1991; Giddens, 2008; Pacquiao, the part of the affluent to care for the disenfran- 2007; Ryan, Carlton, & Ali; 2000; Simpson, 1989). chised (Chamberlin, 1999; Eisler, 2007; Sachs, Building on the educational organizations in nurs- 2005). Global changes and monetary regulation is- ing, and the Transcultural Nursing Society (TCNS) sues have led to insecurities and uncertainty about there is a call for more action on the part of the the world’s financial markets. Moreover, political nurse accrediting agencies to require transcultural instability in many regions of the world affects education as part of curricula and the accreditation all nations, and presses many to seek asylum in criteria. By acknowledging the importance of trans- North America and Western Europe. This influx of cultural knowledge development in nursing educa- immigrants often leads to additional poverty and tion, administration, and research, nursing practice substandard access to health care. Often, immi- gradually will become more culturally aware, car- grants, both documented and undocumented, and ing, sensitive, and competent. others such as the working poor with different 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 8
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ethnic and racial identities are prevented from avail- 1994b; Turkel & Ray, 2000, 2001; Watson, 1999, ing themselves of quality health care. Globalization 2005, 2008a, 2008b). Newman et al (1991) viewed also has led to local job losses in varied industries. caring in the human health experience as the central The general accelerated costs in health care, not phenomenon of nursing that facilitates health only in North America but also in the world com- and healing. Roach defined caring as compassion, munity over the past decades, have made health- commitment, conscience, confidence, competence, care costs and access prohibitive in many nations and comportment (1987/2002). Mayeroff (1971) (Hannerz, 1993, 1999; Mander & Goldsmith, 1996; focused on caring as helping others grow. Watson: Ray, Turkel & Marino, 2002; Sorbello, 2008a, (1) advanced the idea of nursing as a sacred science, 2008b). and knowledgeable caring intended to protect Globalization has affected society and nurses feel and enhance human dignity (1985, 1999, 2005). its effects when they provide health care. Understand- Ray (1981a, 1981b, 1989a, 1989b, 1997a, 1997b) ing oneself in the context of diverse cultures helps the (2) explicated the meaning of caring as love and co- nurse to evaluate the affect of globalization on cul- presence, and (3) in practice illuminated spiritual- ture and health. Self-reflection and awareness propels ethical caring as interrelated with political, eco- nurses to engage in transcultural caring practices that nomic, legal, and technological dimensions of the demonstrate moral responsibility, cultural relevancy, organizational environment. and innovation in the care to people within complex Over the course of 30 years of scholarship in organizational systems and nation-states. Consider caring, new ideas and multiple meanings of caring the case study, Monique, and its accompanying ques- have been advanced. Although there are many dif- tions at the end of the chapter to further your under- ferent ways of caring and definitions of caring, standing of issues presented by globalization. there are several common threads. Every human being is in need of and capable of caring (Boykin The Concept of Caring & Schoenhofer, 2001). Furthermore, “the human Caring, for many nurse theorists, is considered to be expression of caring may be shown through the foundation of the discipline and practice of love or compassion, sorrow or joy, sadness or nursing (Bishop & Scudder, 1991; Boykin & despair....” (Roach, 1987, p. 2). Caring is an art, a Schoenhofer, 2001; Coffman, 2006; Leininger, science, and a philosophy. Thus, caring is an ontol- 1991; Leininger & McFarland, 2006; Newman, ogy (a way of being), an epistemology (a body of Sime, & Corcoran-Perry, 1991; Newman et al, knowledge and way of knowing), an ethic (a moral 2008; Ray, 2006; Roach, 2002; Watson, 1985; ideal), an aesthetic (an artful practice), and a soci- 2005). However, it is not a simple concept. Dispar- ocultural phenomenon. Caring is central to the aged as too illusive, vague, and ambiguous (Paley, notion of well-being; self-care (Brown, 2009); 2001), caring remains the most important concept growing into wholeness, body, mind, and spirit for illuminating what happens in the nurse-patient (Nouwen, 1979); cultural competence (Pacquiao, relationship and the mutual human-environment 2007); and quality nursing care practices nursing process. Caring is a complex, relational con- (Leininger, 1991; Leininger & McFarland, 2006; cept that relies on the intricate interactions between Ray, 1989a, 1989b, 1997b; 2006; Turkel & Ray, individuals and others in their life world (Ray, 2000, 2001, 2004a,b, 2009; Turkel, 2007; Watson, 1985, 2005). Through the efforts of 30 years of scholarship, the International Association for Nursing Reflection Human Caring (www.humancaring.org), and the Understanding oneself as a cultural or International Journal for Human Caring have dis- multicultural being in relationship to other diverse seminated knowledge, held conferences, and pub- culture groups helps the nurse to evaluate lished articles on caring that have reached count- the effect of globalization—potential poverty, less numbers of nurses and others interested in inequality, commercialism, conflict or war, and human caring, including caring in educational, environmental degradation—on culture and political, economic, legal, and technological health. Subsequently, there is a call to action in spheres (Barnard & Locsin, 2007; Eggenberger & developing a more caring and just global society. Keller, 2008; Ray, 2006; Touhy & Boykin, 2008; Turkel & Ray, 2000, 2001, 2004a; Watson, 2005). 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 9
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CARING THROUGH SELF-REFLECTION process (Rogers, 1970; Davidson & Ray, 1991). Because every individual is unique, caring also is Love should transcend religious, cultural, or ethnic unique in terms of how to care for self and each in- differences. Caring requires compassion because it dividual (Boykin & Schoenhofer, 2001). Caring is a embodies a loving, empathic response, a deeply felt learned art and science (see International Journal for awareness of the human race with recognition that Human Caring, Vol. 12, 2008). Self-reflection is one we are all bound together by the human condition way to learn this art (Brown, 2009; Johns & Fresh- (Nouwen, 1977). Caring involves empathy because water, 1998; Johns, 2007). Not only does caring for empathy entails seeing the other as our self and self through reflection offer solitude, inspiration, and treating the other as we would want to be treated lessons for self-growth, caring also enhances human (The New American Bible, 1970). Justice and fair- understanding and human awareness in general ness are implicit in caring because they speak to the (Lauterbach & Becker, 1996; Johns, 2007). Self- societal need for everyone to be treated equitably reflection focuses on the meaning and interpretation and with respect (Rachels, 2003). Cultural dynam- of one’s living as a person with multiple worlds— ics involves relating to the complexity and ever- personal, social, cultural, spiritual, and professional. changing process of complex human interactions in Strategies for nurses to reflect inwardly include med- nursing situations, and moral responsibility, and fa- itating, journaling, and dialoguing about values, cilitation of choice for wholeness, well-being, beliefs, attitudes, and human experiences. This type health, healing, and a peaceful death (Ray, 1994a,b; of multifaceted internal exploration can help prepare 1997a,b). nurses to understand themselves as cultural beings or Transcultural caring as compassion and justice even multicultural beings, and the complex meanings for people of diverse cultures is a worldview and a in the human health and sociocultural experience philosophy, but it also is a practical approach. ultimately to care effectively across cultures. Transcultural caring as a way of practicing encour- ages nurses to be mindful of themselves as TRANSCULTURAL CARING cultural/multicultural beings, and work carefully Caring, for purposes of this text, means transcultural and ethically to communicate and interpret the caring. Transcultural caring is defined as “the rela- multiple meanings of cultural expressions, and of tionship between charity and right action—between diverse health and illness practices. Nurses practic- love as compassion and response to suffering and ing transcultural caring recognize the influence of need, and justice or fairness of doing what ought to diverse cultural aspects like spirituality and/or reli- be done within the [dynamics] of culture [nursing sit- gion on choice-making. Transcultural nurses con- uations, organizations], or society” (Ray, 1989a, sider values, beliefs, and attitudes of others within p. 19). This definition contains several components cultural, environmental, political, technological, of caring and culture: and economic contexts (Ray, 1989b). By concen- trating on the changing nature and meaning of pop- • Love ulation groups, cultural diversity, panethnic identi- • Compassion ties, and multiculturalism, nurses can care more • Empathy competently for culturally complex patients. • Justice or fairness • Dynamics of culture Panethnicity • Nursing situations/organizational cultures/society Panethnicity refers to the dynamic interrelationship Caring integrates love and compassion because between culture and identity that reflects the notion of its unity of purpose, agape love, that is express- of many intersecting “coethnics” and evolving inter- ing limitless or unconditional altruism for its own cultural patterns or multicultural/postmulticultural sake and for the benefit of others without expecting frames of reference of people who share complex anything in return (Templeton, 1999). In essence, transcultural and sociopolitical experiences in the agape love is working for the good of others and so- emerging global community, especially the dynamic ciety (Eriksson, 1997, 2006; Ray, 1981a, 1981b, community in postmulticultural North and South 1997b; Templeton, 1999). The good in nursing is America, and Europe (Postero, 2007; Tuan, 1998). holistic, facilitating the integration of body, mind, [Panethnicity, multiculturalism, or the newer terms spirit, and choice in the mutual human-environment postmulticulturalism, interculturality or transculturality 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 10
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supercede the concepts of ethnicity and even race. Race progressive; as information because culture is com- in the sense of classification, in the anthropological municated and transmitted through acquired lan- literature is considered controversial and difficult to guages; as problem-solving because people develop define and in the United States, to a large extent has systems to deal with human and environmental chal- been rejected academically and viewed as negative in lenges; and as everywhere because culture is the the study of human variation (Kaszycka, Strkalj, & complex whole (Tylor, 1871). Culture has been de- Strzalko, 2009)]. fined in various ways since Tylor. Although contro- versies exist in its meaning from the superorganic to The Concept of Culture the material, from the empirical to the interpretive, Culture, like caring, is a term and concept with mul- and from the diverse to the universal (Freilich, 1989, tiple definitions and meanings (Andrews & Boyle, Kroeber, 1917), some dominant ways that culture 2007; Frelich, 1989; Smircich, 1985). Historical has been defined include: social habits of people conceptions of culture ground contemporary ones. (Boas, 1928); designs for living (Kluckhohn & Kelly, Different culture groups view the concept of culture 1945); the way of life of a people (Leininger, 1970); in different ways. Yet, there is a growing commit- ideas and perception or cognitive and behavioral ment to recognition of our common humanity, a elements like values, beliefs and attitudes that are sense of interconnectedness and belongingness in a transmitted from one group to another (Leininger, complex universe (Bar-Yam, 2004; Capra, Steindl- 1995); and shared systems of meaning that are Rast, & Matus, 1991). Through this knowledge of socially constructed, interpreted, and reproduced interconnectedness and the living history behind the through interaction (Geertz, 1973). concept of culture, we can begin to appreciate the Helman (1994) defined culture as a set of guide- process of the complexity and dynamics of an lines that individuals inherit as members of a emerging world culture in the 21st century that in- group. These guidelines are a moral compass corporates global change and transcultural caring. and direct individuals how to view and experience the world, and how to behave in relation to others, HISTORICAL MEANINGS supernatural forces, and the environment. Culture Culture generally has been part of the parlance of includes most social structural elements in society, anthropology, a human science discipline dedicated such as kinship, religion, politics, law, economics, to the study of the meaning of culture. In its simplest technology, ecology, and health care (Leininger, form, culture refers to humankind, tribes of human- 1991; Leininger & McFarland, 2006; Ray, 1989b). ity from a common ancestry of races, and a family Moreover, culture today includes complex adaptive of languages from one ancestral tongue (Tylor, systems, social norms, creative ideas, complex 1930, pp. 4–5). Culture equals race, ethnicity, or problem-solving processes, explanatory models, panethnicity (integrating multiple identities and and action (Bar-Yam, 2004; Brown, 1998). With practices as people interact with one another) the continuation of exploration and advent of com- (Tuan, 1998). The concept of culture, emerging puters, culture includes the exploration of outer from the Latin, cultura, was originally associated space and the cultures interfacing in the interna- with cultivation or agriculture—cultivation of the tional space station (Duggins, 2007; Furniss, 2006); soil. Over time, however, culture became associated the MySpace culture (Platt & Platt, 2007), thumb with humanitas (humanity), society, and civiliza- culture (cell phones and text messaging etc.) (Glotz tion. The first professional anthropologist, Sir & Bertsch, 2005), the culture of place making Edward Tylor (1871), stated the following: (Zúñiga & Pellow, 2008) and biltechnology (soci- ocultural behavior and the built environment), sim- Culture, or civilization, taken in its wide ulation and robotics (Barnard & Locsin, 2007), ethnographic [descriptive] sense, is that and more recently, the culture of cyberterrorism complex whole which includes knowledge, and extremist tyranny (Libicki, 2007). In his book, belief, art, moral, law, custom, and any other The Predicament of Culture, Clifford (1988) wrote capabilities and habits acquired by man as a that in many ways, “culture is a deeply compro- member of society (p. 1). mised idea...it comprises local and global perspec- Tylor presented culture in a number of ways: tives” (p. 10), and permeates every aspect of life. as creative because people create culture and it is Culture is in a constant state of unfolding and 0809_Ch01_001-031.qxd 10/29/09 12:01 PM Page 11
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