Contributors: Carol Bloch PhD, RN, CTN-A, CNS;
Carolyn Bloch, PhD, RN, CTN-A, CNS; and
Jacqueline Fawcett, RN: PhD; ScD (hon); FAAN; ANEF 

Jacqueline Fawcett:

I am very pleased to collaborate with Drs. Carol and Carolyn Bloch for this blog about culture, subcultures, and transcultural nursing. This blog is an extension of a previous blog about the evolution of my version of the metaparadigm (Fawcett, 2023) and an essay about culture as an addition to the metaparadigm concepts of human beings, global environment, planetary health, and nursologists’ activities (Fawcett, 2023, in press), as well as an essay about subcultures (O’Rourke & Fawcett, in press).

I added the concept of culture to the metaparadigm in response to recommendations from graduate students at St. Mary’s College School of Nursing in Kurame, Japan (Fawcett, in press). Among several definitions of culture found in an unabridged dictionary and published papers, the definitions given by Leininger (2006) are most relevant for this blog. These definitions are:

“[T]he learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular culture that guides thinking, decisions, and actions in patterned ways and often intergenerationally” (Leininger, 2006, p. 13).
“[C]ulture is usually viewed as a broad and most comprehensive means to know, explain, and predict people’s lifeways over time and in different geographic locations” (Leininger, 2006, p. 13).
“[C]ulture is more than social interactions and symbols. . . . [and] more than ethnicity or social relationships. . . . Culture can be viewed as the blueprint for guiding human actions and decisions and includes material and nonmaterial features of any group or individual. . . . Culture distinguishes human beings from nonhumans”.

Leininger, 2006, p. 13

Leininger (2002) recognized subcultures, which she defined as “closely related to culture, but refers to sub ups who deviate in certain ways from a dominant culture in values, beliefs, norms, moral code, and ways of living with some distinctive features that characterize their unique lifeway” (p. 47).

However, in the essay about subcultures, I joined Maria O’Rourke in rejecting the reality of subcultures. We explained:

“We reject the reality of subculture as this term places a group in a subordinate position, which is counter to the contemporary ideal of diversity and inclusion of all persons as equal members of society. We maintain that continuing to refer to groups as subcultures perpetuates racism, inequities, and inequalities. We are firmly committed to perpetuating the contemporary ideal that all person are equal members of society, a commitment even more important in light of recent United States Supreme Court rulings to the contrary”.

O’Rourke & Fawcett, in press

Carol Bloch and Carolyn Bloch:

So much has been written about cultures and subcultures that it becomes overwhelming. We maintain that culture must viewed as very broad and not defined only as race, religion, or ethnicity. Culture addresses, for example, multiple cultural perceptions, urban versus rural patients, patients with disabilities, and health care plans. Thus, by looking at the broadness of culture, patients and nursologists are multicultural and, therefore, care must be tailored to meet these diverse needs.

Culture and subcultures are personal. Regarding subcultures, we do not agree with O’Rourke and Fawcett’s (in press) contention of the lack of reality of subcultures. Instead, and in keeping with Leininger’s (2002) acceptance of subcultures, we contend that it is difficult to place any individual in any category in relation to the cultural or subcultural group one belongs to. It is the individual who will self-identify their own perception of their cultural and subcultural significance. It is the personal perception of who one is or to say their essence of being who one is. It is personal and has far-reaching implications for the individual.

One important aspect of one’s perception of cultural and subcultural identity is one’s level of acculturation into a society different from one’s original society. For us, there are predictors of acculturation that influence individuals on their perception of what culture and subculture they belong to, as well as their perception of health and illness. The predictors that we use are level of education, generational distance from immigration, level of encapsulation, experience with medical services, experience with particular diseases in the immediate family, and extent of contact with country of origin. (Hattar, 1990). For us, these predictors answered our questions of why one individual from a group could be so different from others in the same group. We can predict for a group but not for individuals.

Using these predictors helps individuals when we teach our classes on culture and health care so that not all people can be categorized into subcultures so easily (Hattar, 1990). Not all Hispanics are Catholic but can be other religions. There are many books written on different cultures. We know that many books and articles are based on qualitative and quantitative research, but the above predictors still play into how one identifies who one is. The books written should not be taken as gospel but working generalities that provide a road to understanding an individual. The books and articles are not to be taken as cookbooks to culturally provide sensitivity understanding and care but opening in understanding the patient perspective.

Our major interest is in transcultural nursing, which was founded by Madeleine Leininger. Transcultural nursing is defined as “a substantive area of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices” (Leininger, 1995, as cited in Gonzalo, 2023). Hence, we regard transcultural nursing as an awareness, understanding, and skills that the cultures of the patients will influence their perception and understanding of their health and illness. These beliefs will have an impact on their treatment and care plans.

As nursologists, we are always in contact with diverse patients in practice. Thus, we need to sharpen our assessment skills from a cultural perspective to assist these patients in their health journey along the healthcare continuum. What happens in practice and knowing why the patient reacts the way they do can facilitate implementation of the plan of care. However, the patient may not agree to the nurse’s designated plan of care but instead simply following their health beliefs and practices generations old or performing additional alternative methods of health care in their plan of care. A strategy to understand diverse health care is by storytelling. Three stories we offer are given here.

Story 1

You are caring for a hospitalized Chinese patient, and the morning ritual in the hospital is to refresh all the water pitches with iced water. The doctor has ordered forced fluids, and the nurse comes into the patient’s room and states that the patient must drink the whole pitcher of water by 11:00 a.m. because the doctor has ordered forced fluids. The patient nods, and the nurse believes the patient has been informed and understands the medical order. The nurse returns two hours later and finds the water pitcher dripping on the outside of the pitcher and no water has been drunk by the patient. The nurse is frustrated and says, “Why did you not drink the water as I told you?” The patient tells the nurse that the illness is cold disease, and the cold water would only make the illness worse. It is the health belief of Ying and Yang – a hot and cold belief of health and illness. The nurse should have asked the patient from a cultural advocacy role, “How do you like the temperature of your water to drink? The doctor has ordered you to increase drinking water”. It is the assumption that all patients like ice cold water when in fact not all patients like cold water to drink. Some like room temperature water, warm water, or even hot water to drink when they are ill. Another aspect of this interaction is that a nurse is an honored figure in the Chinese culture and the nod simply was given out of respect and not for agreement of the treatment plan. Also, the patient may not understand English very well and is embarrassed to say so. This is where checking the patient’s medical chart and the use of an interpreter is imperative. The nurse needs to know the primary language of the patient before going in and rendering care. The nurse may have assumed that the patient speaks English.
This is just an example of an additional aspect of the nursing role of becoming a cultural broker. The nurse role has expanded to blending patient advocacy and cultural brokerage to meet the patient’s needs in clinical practice. In 1990 Dr. Mary Ann Jezewski defined cultural brokering as “the act of bridging, linking, or mediating between groups or persons of different cultural backgrounds for the purpose of reducing conflict or producing change”. In nursing the role cultural brokering is connecting the patient’s cultural health beliefs with the clinical health care plan by negotiating, sharing, informing, and empowering the patient to understand the plan of care.

Story 2

In caring for a pregnant Hispanic patient in the hospital, it was noted that she had a safety pin fastened to her underwear near her umbilicus. When she was asked, “Why do you wear the safety pin?” The patient stated, “It was to protect her unborn child from cleft lip and palate.” She further revealed that her other child had been born with a cleft lip and palate and she wanted to protect her unborn child from this birth anomaly. This preventative measure for her unborn child is practiced in the Mexican culture. This is an Aztec belief that if a pregnant mother should come in contact with an eclipse, the safety pin would divert the ray of the eclipse from her uterus thus preventing this birth anomaly.

Story 3

Recently in the Olympics, Gold Medalist Swimmer, Michael Phelps, had circular markings on his back. This alternative method of healing called “cupping” was introduced to many Americans for the first time by the pictures in the news. It made headlines throughout the world. It is a Chinese traditional medical therapy, thousands of years old. This therapy helps relieve muscle tension by enhancing blood flow created by vacuum suction of glass cylinders. This method of treatment can be used to relieve other illnesses as well. This is common in many other cultural groups; it is gaining recognition in this country as an alternative to mainstream medical care.

We also offer guidelines for the care of culturally diverse patients. These guidelines are:

1. When caring for patients with medals of icons, bracelets, or safety pins, prior to removing the article if it is so indicated, the nurse needs to ask why. Removal of these articles could cause unneeded distress and anxiety in the patient. If the article must be removed for surgical or medical reasons, clear explanations and discussion of other alternative measures should be considered with the patient to allay any suffering or misfortune.
2. Based on predictors of acculturation ranging from levels of education to generational distance from immigration, not all from the same cultural group will recognize the same beliefs, practices, and/or customs. Cultural books have provided working generalities about a certain culture which means we can predict for a group but not an individual based on the above predictors. These working generalities provide basic knowledge, but it is the encounters with the patient that provide us the essence of each individual in understanding their own health care beliefs.
3. Always review the patient documentation prior to assuming a patient is from a particular ethnic, cultural group based on name only. For example, assuming that all Hispanics are Catholic, and they are not. Hispanics are diverse in religious beliefs and would feel quite offended if the Hispanic patient who is a Seventh Day Adventist would have the Catholic priest called to assist this patient requesting Chaplain Services.
4. There are physiological variations in cultural groups, such as a Mongolian Spots in children. When skin variations are noted, it is best to check with a cultural informant from that cultural group to clarify the significance of the variation to distinguish from a normal physiologic variation from abuse. Mongolian spots are hereditary and are bluish, dark color spots usually seen in upper part of buttock but can be noted in other parts of the body that often are confused with bruises.
5. The concept of culture is very broad and not ethnicity or race only; it is how each individual looks and interprets their “lived experiences.” No two individuals from the same ethnic group will respond exactly the same way in the same circumstances.

An additional guideline we developed is the BLOCH TWINS’ (BLOCHTWINS) APPROACH TO CULTURAL COMPETENCE

• B = Biculturalism leads to Multiculturalism – Learn about other cultures focusing on their cultural health beliefs and practices
• L = Linguistically Competence assuring accurate and culturally sensitive language assistance and care is provided
• O = Open Mindedness leads to Cultural Mindedness
• C = Cultural Competence is a lifelong journey
• H = Harmony – Balance in life and work

• T = Transculturalism is transcending to another’s way of thinking. Take a risk for a cultural experience/exchange.
• W = Wholism – mind, body, spirit concept in one’s life experience and health care
• I = Intercultural variations; Predict for a group but not for an individual
• N = Negotiate – Be a Cultural Broker and Advocate
• S = Synergy Sensitive – Working together with understanding and caring

Given their strategic role in patient contact, nurses must be the cultural advocates and cultural brokers for patients in the continuum of care. Nurses become cultural advocates/brokers by listening to patient stories and providing care within the context of patients’ cultural perceptions. Advocacy and nursing must be in tandem as the diversity of patient populations increases. As more diverse nurses enter practice and better reflect patient population diversity, the opportunity becomes even greater for nurses to be the leaders and providers of cultural caring.

References

Fawcett, J. (2023, January 17). Evolution of One Version of Our Disciplinary Metaparadigm. nursology.net. https://nursology.net/2023/01/17/evolution-of-one-version-of-our-disciplinary-metaparadigm/

Fawcett, J. (in press). More thoughts about the evolution of the metaparadigm of nursing: Addition of culture as another metaparadigm concept and definitions of all the concepts. Nursing Science Quarterly. (Scheduled for 37(2), April 2024)

Gonzalo, A. (2023, July 2). Madeleine Leininger: Transcultural Nursing Theory. Nurseslabs. https://nurseslabs.com/madeleine-leininger-transcultural-nursing-theory/

Hattar, M. (1990). Ethnic diversity and health care providers: The integration of Hispanic and Asian health care providers in California’s health care system. Keynote address presented at the 2nd Annual Conference of Rancho Los Amigos Medical Center. Long Beach, CA.

Leininger, M. M. (2002). Essential transcultural nursing care concepts, principles, examples, and policy statements. In M. M. Leininger & M. R. McFarland (Eds.), Culture care diversity and universality: A worldwide nursing theory (pp. 45-98). Jones and Bartlett.

Leininger, M. M. (2006). Culture care diversity and universality theory and evolution of the ethnonursing method. In M. M. Leininger & M. R. McFarland (Eds.), Culture care diversity and universality: A worldwide nursing theory (2nd ed., pp. 1-41). Jones and Bartlett.

O’Rourke, M. & Fawcett, J. (in press). More thoughts about culture as a metaparadigm concept: Rejection of the reality of subcultures. Nursing Science Quarterly. (Scheduled for 37(3), July 2024)

Note: Portions of this blog are taken from Bloch, C., & Bloch, C. (n.d.) Role of Transcultural Nursing in Today’s Healthcare. Unpublished manuscript. 4 pages.

About the authors:

Carol Bloch, PhD, RN, CTN-A, CNS

Dr. Carol Bloch is a Transcultural Nurse Scholar, Transcultural/Diversity Consultant, and Nurse Educator. She is a Neuman Systems Model Practice Center Fellow. She has worked internationally in both the private and public sectors. Her experiences included educational and advisory roles in Mexico and Venezuela. She has created programs and lectured extensively on cultural issues for health care providers in various healthcare settings, including healthcare organizations to academic venues. Dr. Bloch has developed programs and taught in various nursing educational levels from entry, graduate, to staff development. She has written and been interviewed on topics of cultural diversity and cultural competence in addition to nursing content and theory.

She received her diploma in Nursing from Queen of Angels School of Nursing, a B.A. at Pepperdine University and from Azusa Pacific University received both an M.A. in Education and an M.S. in Nursing, and a Doctor of Philosophy in Nursing. Her dissertation research study was on the concepts of cultural competence in clinical practice. She is certified as Transcultural Nurse Specialists Advanced and in Diversity Management and Customer Service. She holds a license in California from the Board of Registered Nursing as Clinical Nurse Specialists.

In October 2015 the Transcultural Nursing Society inducted her as Transcultural Nurse Scholar in Portland, Oregon. She is a recipient of the 2009 La Opinion’s Mujer Destacada for the Health Category. (La Opinion is America’s #1 Spanish-language Daily Newspaper). She received a Certificate of Congressional Recognition for Education Excellence by U.S. Congresswoman Grace F. Napolitano, 38th District of California for Outstanding Commitment to Nursing Education, Research, and Distinguished Clinical Expertise in April 2009. Dr. Bloch was honoree of the 2009 Dr. Murillo-Rhode Award by the National Association of Hispanic Nurses. Other recognitions for her were Congratulatory Scroll from the Honorable Supervisor Don Knabe, 4th District, County of Los Angeles Board of Supervisors for receiving a Doctorate in Nursing, 2013, the Multimedia Electronic Award, Region I for “Nurses in Action – Transcultural Nursing,” Sigma Theta Tau International, Inc. in November 1992, Outstanding Nurse of the Year from MAHEC (Multicultural Area Health Education Center), May 1991, and proclaimed Hispanic Nurses of the Year by the Honorable Supervisor Gloria Molina, District 1, Los Angeles County Board of Supervisors, October 1991.

Carolyn Bloch, PhD, RN, CTN-A, CNS

Dr. Carolyn Bloch is a Transcultural Nurse Scholar, Transcultural/Diversity Consultant, and Nurse Educator. She is a Neuman Systems Model Practice Center Fellow. She has worked internationally in both the private and public sectors. Her experiences included educational and advisory roles in Mexico and Venezuela. She has created programs and lectured extensively on cultural issues for health care providers in various healthcare settings, including healthcare organizations to academic venues. Dr. Bloch has developed programs and taught in various nursing educational levels from entry, graduate, to staff development. She has written and been interviewed on topics of cultural diversity and cultural competence in addition to nursing content and theory.

She received her diploma in Nursing from Queen of Angels School of Nursing, a B.A. at Pepperdine University and from Azusa Pacific University received both an M.A. in Education and an M.S. in Nursing, and a Doctor of Philosophy in Nursing. Her dissertation research study was on the concepts of cultural competence in clinical practice. She is certified as Transcultural Nurse Specialists Advanced and in Diversity Management and Customer Service. She holds a license in California from the Board of Registered Nursing as Clinical Nurse Specialists.

In October 2015 the Transcultural Nursing Society inducted her as Transcultural Nurse Scholar in Portland, Oregon. She is a recipient of the 2009 La Opinion’s Mujer Destacada for the Health Category. (La Opinion is America’s #1 Spanish-language Daily Newspaper). She received a Certificate of Congressional Recognition for Education Excellence by U.S. Congresswoman Grace F. Napolitano, 38th District of California for Outstanding Commitment to Nursing Education, Research, and Distinguished Clinical Expertise in April 2009. Dr. Bloch was honoree of the 2009 Dr. Murillo-Rhode Award by the National Association of Hispanic Nurses. Other recognitions for her were Congratulatory Scroll from the Honorable Supervisor Don Knabe, 4th District, County of Los Angeles Board of Supervisors for receiving a Doctorate in Nursing, 2013, the Multimedia Electronic Award, Region I for “Nurses in Action – Transcultural Nursing,” Sigma Theta Tau International, Inc. in November 1992, Outstanding Nurse of the Year from MAHEC (Multicultural Area Health Education Center), May 1991, and proclaimed Hispanic Nurses of the Year by the Honorable Supervisor Gloria Molina, District 1, Los Angeles County Board of Supervisors, October 1991.