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Foreword
Transcultural nursing and challenging the status quo
Olga Kanitsaki
Head and Professor of Transcultural Nursing, Department of Nursing and Midwifery, RMIT University, Melbourne VIC
Article Text
Nurses, locally and globally, are facing new and complex challenges on account of living in a culturally diverse and dynamic world. This special issue of Contemporary Nurse (the first Australian-based nursing journal to carry a special feature dedicated to transcultural nursing) provides a timely opportunity to reflect on some of these challenges and on the various ways in which nurses might respond effectively to them. This special issue also provides a timely reminder of the importance and moral imperatives of the theory and practice of transcultural nursing and its emphasis on care as a universal, but diverse culturally constructed phenomenon, that lies at – and must remain at – the heart of nursing research, education, and practice.
Background
Madeleine Leininger, worldwide founder and global leader of transcultural nursing, has long argued that care is the central and unifying domain that characterises nursing (Leininger 1967, 1978, 1984, 1990, 1991). In asserting this position, Leininger has been careful to clarify that although care has primacy in nursing, its practice is not universal, and that nurses need to be aware that how care is conceptualised, constructed and practiced varies across and even within different cultures. Leininger has repeatedly warned nurses that if they do not practice transcultural nursing then, no matter how well intended their practices of nursing are, they risk ‘cultural imposition’; that is, practising nursing in a way that imposes cultural (ethnocentric) expressions of care that may be nontherapeutic and even harmful. In other words, a failure to practice culturally informed nursing care could result in people receiving nursing that is ‘toxic service’, rather than therapeutic care (Kanitsaki 1996, 2000).
Discourse and Scholarship
In keeping with the dynamics and diversity of cultural expression, transcultural nursing has itself been conceptualised, developed and applied in diverse and different ways in different countries around the world. In some instances, the diverse ways in which transcultural nursing has been conceptualised and applied has given rise to controversy (see, for example: Bruni 1988; Swendson and Windsor 1996; and Ramsden 2002). This controversy was further advanced and countered by Kanitsaki (1996), Omeri (1996), a transcultural nurse specialist, and Leininger (1997, 2001). The controversy has not been detrimental to transcultural nursing, however. To the contrary; it has given rise to a dynamic dialectic that, in accordance with tenets of transcultural nursing theory and practice, has seen (and continues to see) the development of a still more dynamic theory of transcultural nursing, and to more dynamic and diverse ways of dealing with cultural complexity and the many challenges it poses to those working in nursing and health care domains.
Like other countries, Australia has its own distinctive history of the development of transcultural nursing. According to Leininger, (personal communication to Omeri 2003) the concepts of transcultural nursing were introduced to Australia sometime between the mid1950’s and 1960’s. The impact of the introduction of these concepts in nursing education and practice is, however, unknown. A search of the nursing literature for this period has not revealed publications or documents relating specifically to transcultural nursing in particular or to crosscultural nursing in general. Other more general literature searches, however, show that public and formal discourses during this period were related primarily to government inquiries into issues raised by Australia’s growing immigrant population, including the plight of immigrants (especially Italian, Greek and Eastern Europeans) and their children’s schooling and language problems. The concerns of Australian immigrants (that included concerns about health care access and services) were also voiced by a small number of select ethnic and mainstream individuals who had backgrounds in the respective disciplines of anthropology, sociology, medicine, psychiatry, psychology, pharmacology and teaching, and who were also often involved in various government inquiries.
In the Australian State of Victoria, concerns about the cultural (in)appropriateness of monocultural nursing care (or, to use Leininger’s term,‘unicultural’ care), and the harmful consequences this could have for patients of diverse cultural and language backgrounds, were first raised in the late 1970’s by a handful of immigrant nurses who were working in metropolitan hospitals at the time. These nurses observed directly the harmful effects of ‘normal’ (monocultural) professional nursing and health care, and the intense suffering and distress such care caused immigrant patients and their families. These nurses recognised that a key reason why immigrant patients and their families suffered was because they felt oppressed and disenfranchised on account of receiving care that although ‘professional’ was nevertheless culturally alien and hence alienating. This ‘care’, in turn, tended to be interpreted by the immigrant patients and their families as being uncaring, nontherapeutic and even toxic to their health and wellbeing.
In one of the earliest articles on the subject published in The Australian Nurses Journal, the problem of monocultural nursing and the failure of the nursing profession to prepare its graduates to care for people from diverse cultural and linguistic backgrounds, was raised independently of knowledge about Madeleine Leininger’s foundational work. In this article, the nursing profession is challenged: Although our awareness of cultural diversity has increased in recent years, there has been little serious focus (if any) in our nursing curricula on the underlying concept of culture. The concept of culture must be understood as an integrated meaningful whole, for without this understanding no approach to nursing can be truly comprehensive (Kanitsaki 1983, p. 42).
After presenting a critical case study highlighting the difficulties that immigrant patients can face in a monocultural health care system, the article concludes by making a number of recommendations including one to ‘develop leadership in transcultural studies with the object of implementing educational changes on a national and State level’ (Kanitsaki 1983, p. 53).
Visibility
Shortly after this article was published, Kanitsaki and her immigrant colleagues discovered Madeleine Leininger’s (1978) influential and foundational work Transcultural nursing: concepts, theories and practices. This work, along with Leininger’s subsequent works, enabled the immigrant nurses to make sense of their nursing experiences and to help explain why, although being a part of the nursing profession and health care system in which they had chosen to work, they nevertheless felt that care as taught and practiced in nursing did not reflect crosscultural care and caring practices, and that at times nursing care practices could be perceived and interpreted as inhumane care. In addition, Leininger’s theory enabled this handful of immigrant nurses to make sense of their own experiences and help explain why they felt disconnected, marginalised, powerless and trapped, notably, by the ‘normalcy’ of the profession and the health care system which, in reality, was alien to them. Leininger’s theory enabled them, offered a ray of hope and validated their nursing and personal experiences in a powerful way. It helped the nurses to explain why the ‘care’ practices of the nursing and health care systems they had observed was providing care that was often contradictory to the care immigrant people wished to receive, and that it was oppressive to and discriminatory of immigrant patients. Importantly, it also provided a ‘tool’ to legitimate their (the nurses’) struggle to assert and promote the development and spread of transcultural nursing in Australia as well as the rights of culturally diverse peoples within a health care system that, at the time, was viewed as one of the best in the world – despite its discriminatory and culturally oppressive practices.
Leininger’s work became visible in Australia in the mid1980’s and marked the beginning of a new and unprecedented scholarship on crosscultural nursing (which Leininger contests is not focused on all cultures) and transcultural nursing in Australia. Notable among those nurse scholars who promoted and contributed to the expansion of crosscultural and transcultural nursing in Australia were Kanitsaki (1988, 1989) and Idrus (1988). In the 1990s, transcultural nursing was further promoted, and I believe advanced, by nurse scholars who studied cultural anthropology and ethics in the Australian context (see, for example, Kanitsaki 1992, 1993, 1994; Tham 1993; Johnstone 1994). This prodromal development was followed by further contributions to the advancement of transcultural nursing by transcultural nurse specialists who had been supervised and guided by Professor Leininger herself (for example: Omeri and CameronTraub 1995; Omeri 1996, 1997a, 1997b, 2000). Transcultural nursing theory and practice continues to develop in the new millennium, as the 16 feature articles and case studies, from many countries in the Asia Pacific region, in this special issue of Contemporary Nurse demonstrate.
Development and Acceptance
The expansion and acceptance of transcultural nursing is reflected in other areas as well. For example, peak nursing organisations such as the Royal College of Nursing, Australia (RCNA), the Australian Nursing Federations (ANF), and the Australian Council of Nursing (ANC) all recognise the importance of culturally congruent care in nursing and have developed conduct standards and guidelines that reflect such recognition. In addition, many nursing curricula in Australia have given recognition to the nature and importance of culture (although not necessarily culturally congruent care) in nursing, by incorporating core and/or elective subjects/ courses (eg on crosscultural or transcultural nursing) in both undergraduate and postgraduate nursing programs.
The development of transcultural nursing in Australia and elsewhere stands as testimony to the futuristic and moral thinking of an ever increasing number of nurse researchers, theorists, ethicists and social scholars who have dedicated attention to questioning the cultural assumptions underpinning nursing and its care practices. They have been prepared to challenge the status quo embedded in the monocultural nursing and health care systems around the world. In acknowledging the contribution of these researchers and scholars, and the enormous progress that has been made in advancing transcultural nursing over the past several decades, it is important not to lose sight of other new challenges that are emerging.
One such challenge relates to the new tension that is emerging in culture care domains, notably between ‘local’ and ‘global’ cultural care practices.
Global vs Local Domains in Cultural Care
Health care systems around the world are becoming increasingly ‘globalised’ as internet connections and as ward/unit desktop and handheld computers facilitate the immediate transfer of information from global into local nursing and health care contexts and domains which, in turn, influence nursing care and treatment practices in those domains. The advent of new global information technology (IT) and its capacity for the rapid transfer of information into local nursing and health care domains is undeniably impressive. However, it also needs to be acknowledged that this new capacity for the rapid transfer of information has brought with it a new and insidious form of (IT) ‘cultural imposition’ and ‘cultural imperialism’.
This new IT cultural imposition/imperialism threatens to impose global (‘universal’) frames of care on local domains which, in turn, promote a rationalisation of nursing and health care services at the expense of ‘local’ and diverse culturally congruent (and therapeutically effective) care practices.
Transcultural nursing promotes congruent culture care practices at all local levels around the world as well as at the global level. It is important to understand, however, that these culturally congruent care practices are under threat. This is because diverse and universal congruent cultural care practices are not necessarily reflected in the new global care practices (eg corporatised health care services) as prescribed and rationalised (economically and now technologically) by dominant and vocal health practitioners, organizations, and more recently globalised computer software packages. In light of this threat, it is morally imperative that nursing care practices locally and globally are examined continually and critically to ensure that they are culturally meaningful, therapeutically effective and moral, and not beholden to imperialist (and possibly alienating) values imported through IT and other imposed frameworks for care. This is extremely important, particularly when we speak about care practices in contexts where imperialistic ideologies and economic, social, political and IT processes influence not just the distribution of resources, but also the caring roles and practices in a given (local) health care domain.
Transcultural nursing theory and practices provide a powerful culturecare lens through which caring and healing knowledge and practices can be discovered, developed and applied in nursing education, research and practice. The articles in this special issue of Contemporary Nurse provide a powerful testimony to the practical value, moral importance and significance for the future of the discovery, development and application of transcultural nursing knowledge of caring, health and healing in local as well as global domains.
Looking Forward
What is required now is to develop further and apply a critical transcultural nursing theory that:
- Openly and critically brings to light, and advances debate, on how diverse culture care and care practices are positively or negatively impacted upon by the ‘normality’ of a dominant group in a given health care context, as well as by social, class, educational, IT, technological and political processes;
- Examines the diversity of care and caring practices amongst indigenous peoples that take into account their own cultural, social, class and gender issues as well as how colonisation and the dominant culture’s ‘normality’ has mediated the care they receive;
- Examines and builds transcultural care theory (ie, via education, research, and practice) to contribute continuously to the dynamic transformation of the nursing profession and its managerial and IT developments worldwide.
By advancing a systematic and critical use of transcultural nursing theory, the profession will continue to promote the development of fairer, kinder, competent, ethical and effective nursing services as well as culturally and socially equitable health care systems world wide.
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