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Where culture meets care

The goal of embedding transcultural nursing within modern practice continues to make steady progress, to the benefit of patients around the world.

Australia’s shift towards multiculturalism was signalled with the adoption of a multicultural policy in the 1970s by the Whitlam government. Few at the time were aware of the implications for nursing practice and education that a culturally and linguistically diverse population would bring, or of the changes in healthcare services that would be required to provide meaningful and culturally competent care.

The nursing profession, embedded as it was in a mono-cultural approach to healthcare, was slow to come to terms with the implications for nursing practice and the education of nurses that the changing circumstances required. There was no means of understanding, let alone addressing, the issues that nurses met daily in their practice with people of diverse linguistic and cultural backgrounds.

With the launch of the National Agenda for a Multicultural Australia, Sharing our Future by the Australian government in July 1989 and the transfer of nursing education to the tertiary sector in 1985, the time was right for changes in education and the preparation of nurses. Factors such as: the growing multiculturalism of the client population as a result of immigration policies and the increasing numbers of refugees and asylum seekers arriving in the community; the pressing need to address social justice and human rights issues that ensued including equality of opportunity and equal access to healthcare, also prompted change.

Personal experience as an immigrant and practising nurse makes one aware of the difficulties other nurses face. I had developed a global perspective prior to coming to Australia, drawn from my experiences working in culturally diverse countries (Iran, Lebanon, the UK and the US). In 1974, I took the position of team leader at the Newtown Community Health Care Centre in the Central Sydney Area Health Service. The community centre provided multidisciplinary healthcare services including physical, mental and social welfare services to a multicultural community. During these years in community health in this culturally diverse part of Sydney, I soon realised that there was a missing dimension in nursing education and in practice that needed to be addressed; I saw the need for reform in nursing education to transform nursing care practices in culturally meaningful ways.

Transcultural Nursing’s Impact

In the early 1950s, Madeleine Leininger worked as a clinical mental health specialist in a child guidance centre for mildly disturbed children of diverse cultural backgrounds. It was during this time she saw challenges and non-caring actions in the care of children and realised that only limited research had been conducted in relation to care within specific cultures and in health institutions. It was evident to her that nurses and other health professionals had failed to recognise and appreciate the important role of culture in healing, in caring processes, and in healthcare treatment practices.

Leininger identified culture and care as major dimensions missing in nursing and healthcare services. She asserted that understanding and responding appropriately and therapeutically to clients from different cultures was a critical need that merited theoretical explanations and research investigations to discover beneficial outcomes.

Leininger envisaged a new field – transcultural nursing (TCN) – as an important discipline for study and practice in the mid-1950s. She stated that culture and care were embedded in each other and that care needed to be teased out and understood within a cultural context. Most importantly, she predicted this knowledge would contribute to transcultural nursing as a discipline and field of practice. Leininger’s Theory of Culture Care Diversity and Universality brings culture and care together in a conceptual and theoretical relationship to discover caring ways to help people. Her approach involved recognising the diversity and ways of knowing in nursing, alternative therapies and also realising and accommodating diverse world views. Transcultural caring dynamics in nursing include equal opportunity, the right to equal access to services and the provision of culturally competent nursing care.

The reading was persuasive. Nursing and nurses needed specific preparation in transcultural nursing as a means to guide change and as a discipline to provide culturally meaningful care beyond multicultural and ethno-specific services. The need to include transcultural nursing in Australia was clear and it became important to explore what preparation students were receiving.

I was in a position to provide some insight into student preparation in 1991 as a lecturer in Cumberland College of Health Sciences, University of Sydney. In 1991, guided by Leininger’s transcultural nursing and human care view, I undertook a national survey of 47 schools of nursing. The aim was to establish the need for undergraduate and graduate education in transcultural nursing care by understanding the extent to which nursing students were being prepared in the discipline.

Preliminary analysis of responses revealed that formal preparation in TCN was not available. The results also showed a lack of faculty prepared in it, as well as minimal commitment by nursing faculties to initiate such educational programs. Nurses were graduating from universities and schools of nursing with inadequate and minimal preparation in TCN and were thus unprepared for nursing practice within intensely multicultural communities.

I introduced and began teaching TCN in 1991 at the School of Nursing, Cumberland College of Health Sciences. The courses attracted large numbers of BN, BRN students. In 1996, I became the first nurse in Australia with a doctorate in TCN.

The survey showed some action was needed to promote TCN. I wrote to RCNA (now the Australian College of Nursing) proposing a plan to establish a TCN Society with the aim of placing TCN on the national nursing agenda. The society launched in 1994.

Cumberland School of Nursing amalgamated with the Faculty of Nursing at University of Sydney. That led to teaching TCN in the faculty in 1998, revising and strengthening the content of subjects with evidence-based research studies of diverse populations in Australia – including Iranian immigrants, Afghan refugees, immigrant nurses and Indigenous Australians.

The courses attracted increasing numbers of students, including six doctoral candidates. The first PhD and the first honours students completed their TCN studies at Cumberland College and the Faculty of Nursing; both have made significant contributions since.

Leininger’s impact has gone far beyond Australia. She established the international TCN society in 1974 and continued to promote and strengthen the society to the end of her life in August 2012. It has become the leading global organisation in setting up standards of excellence in transcultural nursing worldwide. These include: certification in transcultural nursing; promoting standards of excellence for scholars in research and publication; and the promotion of TCN worldwide through the development of regional branches.

On October 22–25, 2014, the Transcultural Nursing Society (Global) will celebrate its 40th Annual Conference in Charleston, South Carolina, in the US. The theme: 40 Years of Transcultural Nursing: Living Our Mission in a Changing World.

I joined TCN Society in 1993 and have continued involvement and commitment, supporting the aims and objectives of the society in promoting nursing care informed by TCN research and publication in an atmosphere of sharing and attempting to improve care in culturally meaningful ways in Australia and elsewhere. I became and remain the first certified transcultural nurse in Australia.

state of play

It would be of great interest to all nurses in Australia to undertake another national survey to determine what is being offered in TCN and where.

It is my heartfelt hope that schools of nursing will adopt TCN to encourage the application of culture care theory and ethnonursing research findings and to encourage further studies in TCN to be used wherever nurses may be practising.

Nurse academics and educators should inform their teaching practices with evidence-based, culture-specific care knowledge, the better to prepare their students during their studies for practice in multicultural Australia. We now have a theoretical base and model with an increasing body of evidence on which to build.

Dedicated to Madeleine M. Leininger.

Dr Akram Omeri is a consultant and educator.


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