Transcultural Nursing in relation to Holistic Nursing Practice

Transcultural Nursing in relation to Holistic Nursing Practice


Diversity of the world’s population has reached a point where it is vital to address and more importantly to understand, the ever growing challenge that transcultural nursing poses to the nursing profession. Addressing this issue avoids discrimination and promotes equality within holistic nursing practice in order to meet patients’ needs. Health care professionals should be qualified to deliver, on a daily basis, proficient care and sensitive skilled communication to culturally different individuals (Maier-Lorentz, 2008).

To exercise professional nursing in a conceptual way holistic nursing care focuses on physical, emotional, social, environmental and spiritual aspects as well as on the idea that any individual involved in treatment care should be treated as a whole and with dignity (Dossey & Guzzetta, 2005).

One of the areas to be discussed is Transcultural Nursing and Leininger’s Transcultural Theory of Culture Care Diversity and Universality and its research enablers: the Sunrise Enabler and the Ethnonursing Method.

Another area will be Holistic Nursing Practice and Nightingale’s Nursing Theory of Environmental Adaptation as well as the liaison between Transcultural Nursing and Holistic Nursing Practice.

Nightingale’s theory has been chosen over others because she was the first to acknowledge nurses’ work in a theoretical framework and also because she was considered to be the mother of nursing practices (Ellis, 2008).

The development of culture care theory introduced health care professionals into a new nursing dimension formed by issues such as culture background, spirituality, environment and others that demonstrated how culture and health care are linked (Leininger, 2002a).

Holistic Nursing Practice encourages active communication and reciprocal understanding, underlines the exercise of physiological and psychosocial awareness, it is based on logical thinking and supports values such as autonomy and patient wishes and tendencies (MacKinnon, 2010).

Transcultural Nursing

Transcultural nursing may be defined as a method to contrast and observe how individuals view health care, biased by their culture background. The principles of practising transcultural nursing are to provide complete nursing care to individuals or groups by treating them with respect and taking into account their cultural factors. It is all about nursing practice applied to cultural values and limitations (Leininger, 1991).

Definitions of transcultural nursing incorporate many factors that shape the individual’s cultural orientation. These include are age, sexual orientation and financial aspects. It has been suggested that by ignoring these culture background factors, health care professionals do not achieve enough cultural experience to be incorporated in holistic nursing practice (Barnes et al. 2000). This absence might lead to unsafe nursing care and both dissatisfied patients and professionals (Curren, 2006 cited in Leininger & McFarland, 2006, pp.159-160).

To promote transcultural nursing care, Narayan (2001) felt that there are four crucial attitudes to assume – caring, empathy, openness and flexibility. This shows the patients a cultural understanding, appreciation, consideration and willingness from health care professionals that are based on individual care.

Cultural education and the creation of culturally competent care professionals are one of the biggest challenges yet to tackle worldwide. For instance, in America, as the migrant population increases notably so it does the need for reducing inequalities and barriers such as language. Maier-Lorentz (2008) firmly understood that such a need could be met by the targeting of bilingual health care professionals coming from different backgrounds. Moreover, she suggested that in order to provide culturally competent nursing care, some knowledge of non-vocal communication signs could be of great value, as it is in eye contact, touch, silence, space and distance, and health care habits.

Green-Hernandez (2004) recommended that as a step towards multicultural competency, professionals that need to deal with farmers should familiarize themselves with their specific customs such as using animal medication for their own conditions as a consequence of living far away from the care institutions.

With the purpose of understanding culture, Andrews & Boyle (1997) gave out diverse illustrations. For example, they suggested that by understanding a people’s proverbs, professionals may grasp knowledge of the cultural values shared by that population. The authors also stressed the importance of culture knowledge when coming across two different ways to view stealing. For one culture it may not be acceptable whereas for another one, e.g. gipsy people, it may be ok, as long as it is coming from a better-off person. Furthermore, they also found, through researchers, that different cultures may think that by being a demanding patient, the treatment they receive may improve.

Riley (2004) reported that a foremost test for nurses in an ethnically different society is communication. Not just words but also tone and volume form spoken communication which in diverse cultures differs greatly. For example, Thai people are regarded as not talking too much as they believe it is a sign of idiocy whereas Cuban people are happy with talking vociferously. He also pointed out that Europeans are not afraid of talking about emotions whereas Asians are hesitant to do so.

With regards to communication without words Riley (2004) explained that eye contact is not always expected. For instances, in Native America and Asian cultures it is offensive and among Muslim Arab women it is allowed only to their husbands. Therefore, he identified the importance for healthcare professionals to be culturally aware.

Phillimore (2011) explored the challenge of provision of diversity needs in the UK based on studies done on health care service provision to new migrants, during 2007/08 in Birmingham. She stated that with political forces wanting to reduce welfare support for new migrants, such provision becomes quite a challenge. She also believed that, in the long run, this disregarding of health care needs will lead to further issues for the health care system that otherwise could be avoided by just providing what is needed now: cultural and language services and health support.

It was also suggested that in today’s political climate offering of ethnically specific provision by the community and for the community, results in the local needs not being met, as the existing GP systems are already overstretched. She concluded that a number of migrants are condemned to an unwelcoming future since UK seems to embrace a tendency of anti-migrant sentiment and a move to community institution instead of multicultural provision (Phillimore, 2011).

The Culture Care Diversity and Universality Theory by Madeleine Leininger

In the 1950’s Madeleine Leininger, a nurse-anthropologist, realised that nursing practice was requiring a theory to allow people to transform nursing into a more advanced and beneficial discipline that challenges nurses to open up to cultural variety and universality (Leininger, 2006).

This was developed as a response to the demand for multicultural care which was immense and yet incomplete as many healthcare systems did not consider the need for bringing together culture and nursing care (Giger & Davidhizar, 2008).

The culture care diversity and universality theory developed by Leininger in 1991 (Leininger, 2002a) is unique in that it focuses on competent care, can be used upon any culture and is based not only on individuals but groups and families too.

The theory addresses the importance of a consistent cultural competence instrument to acquire cultural awareness through a constant learning attitude and approval towards human differences and rights by health care professionals (Burford, 2001, cited in Baxter, 2001, pp. 202-203).

Leininger (2002a) insisted on the importance of transcultural knowledge as a tool to avoid human acts such as the event of September 11, 2001. She then proposed the culture care theory as the most holistic approach to gradually transform the health system. This much needed transformation requires understanding of individuals in ways that identify and respect their cultural background and will lead us to understand such transcultural dismay.

The theory was used in a study among Hispanic home care patients in the US, 2007, in order to identify cultural needs. As a result, care delivery improved in some areas and there was a suggestion describing the use of the model as a tool to reduce costs in the health care system (Woerner et al. 2009).

Leininger’s theory applies not only to races from different backgrounds but also to today’s controversial groups such as transgendered people, disabled people , the youth, poverty and the homeless that may pose a certain degree of difficulty of understanding to healthcare professionals. There is also an agreement that, thanks to Leininger’s culture care theory, the nursing profession today knows how to allow for culture when looking after individuals and has a widely spread caring philosophy in hospitals (Clarke et al. 2009).

For this model to assist the health care professional to understand factors as important as management and policies, as well as being able to reflect on their decisions and actions, Leininger designed two tool assessments, The Sunrise Enabler and the Ethno Nursing research method, which are based on monitoring treatment care on a daily basis (Hubbert, 2006, cited in Leininger & McFarland, 2006, pp. 354-356).

The sunrise enabler focuses mainly on total life ways and caring factors influencing health and well-being, disabilities and death. It also identifies features influenced by the patient’s cultural background whereas ethnonursing finds ways in which multicultural care could be better. In doing so, the reflected culture becomes part of the holistic nursing practice (Leininger, 2006).

The Sunrise Enabler

The Sunrise Enabler is used as an assessment tool to enable multidisciplinary teams to deliver suitable and competent cultural assessments that impede intolerance and stereotype behaviour. This is to supply the healthcare system with a guide to cultural vicinities ranging from religious beliefs to economic factors (Giger & Davidhizar, 2008).

Wherever a healthcare professional starts the model either from the top or from the bottom, the most important feature is to listen to the individuals, trying to grasp ideas and concepts rather than enforcing them (Leininger, 2002a).

Healthcare professionals struggled to understand the meaning of factors influencing the care practice so crucial when applying the culture care theory. Such factors as culture beliefs, environment and religion were to be included in the nursing care, therefore Leininger (1997) built the Sunrise Enabler to illustrate such aspects.

The Ethno-nursing Method

This method was developed to fit the purposes of qualitative research methods. It is a systematic method for studying multiple cultures and care factors within a familiar environment of people and to focus on the interrelationships of care and culture to arrive at the goal of culturally congruent care. Ethnonursing is a particular research method developed by Leininger to inspect the theory. It was developed to allow health care professionals to discover new ways of helping different cultural groups distinguish features of nursing care (Leininger, 2006).

Leininger (2006, p.6) stated that the ethnonursing method “…was new and unknown in nursing and was different from other qualitative methods including ethnography”.

Holistic Nursing Practice

The exercise of modern nursing is based on the view of holism that underlines the individual’s wholeness. Healing viewed as an indication of nursing practice that treats people as whole, developed in the late 20th and early 21st century into a popular subject in nursing in order to clarify the meaning of wholeness and holism. As a result, alternative therapies surfaced as approaches of practice in holistic nursing (Locsin, 2002).

The definition of holistic came into effect in the 20th century. Then the word holism included the physical, emotional, mental, social, cultural, and spiritual view. This view of holism was envisioned by Florence Nightingale who is seen today as an example to follow, although many of her studies are not used in today’s nursing practice (Beck, 2010).

“Holistic nursing care embraces the mind, body and spirit of the patient, in a culture that supports a therapeutic nurse/patient relationship, resulting in wholeness, harmony and healing. Holistic care is patient led and patient focused in order to provide individualised care, thereby, caring for the patient as a whole person rather than in fragmented parts” (McEvoy & Duffy, 2008, Vol.8, p. 418).

Furthermore, it addressed the expansion of multidisciplinary and collaborative teams as a way to applying holistic care into practice and asserted that the practice of holistic care by health professionals should avoid intrusion and, when really needed, as it is the case of unconscious patients, should use skills that include aspects such as consideration, disciplined criticism and liability in order to exercise nursing in a holistic approach (McEvoy & Duffy, 2008).

Since individuals from different culture backgrounds may appreciate holistic nursing practice and care choices in different ways so is the healthcare provided in different ways (Locsin, 2001). It may also be the case that some individuals may feel embarrassed to mention alternative remedies used in the past, therefore the assessment should be supportive rather than disapproving (Maddalena, 2009).

Pearcey (2007) ran a study on clinical practices amongst student nurses to draw on a few key points related to holistic nursing practice. It was found that the notion of holistic care was not clear within nursing practice. Some students claimed not to know the right meaning of holistic nursing practice and also claimed that tasks and routines are what nursing is all about. The study showed an evident lack of professionalism and knowledge amongst care professionals as well as a huge gap between what is taught and what is really applied at work. The author concluded that there is a real risk of inconsistency within the profession.

Within the practice of holistic care there has been lately a huge influence of alternative or complementary medicine which care experts have tried to professionalise by setting certain values to be met. A study amongst nurses and midwives accomplished in England, 2008, revealed this but also the lack of initiative from the NHS to incorporate such practices, even though it was demonstrated that a huge variety of them were successfully applied on patients where biomedicine seemed not to work. Such practices included reflexology, aromatherapy, acupuncture and massage that actually underlined biomedicine rather than substituted (Cant et al. 2011).

Whilst carrying out an interview on medical students in the UK, a student suggested that it is actually a catch-22-situation when looking after patients from diverse races as they have diverse predominance of whatever conditions that eventually will require different treatment, a world apart from what is being taught in medical schools with regards to treating everyone in the same way (Roberts et al. 2008).

A quick look to Harrison (2008) for a concluding comment on multicultural nursing in relation to holistic care, offers us this brief view: a Western health care organism that has not managed to treat minority communities in a holistic manner is a system that claims to care for one and all identically.

The Theory of Environmental Adaptation by Florence Nightingale

According to Nightingale’s Theory of Environmental Adaptation, an individual’s health is improved by looking after the surrounding environment. It goes further than this and asks for the environment to be operated by the health care professionals as an approach to healing (Howett et al. 2010).

Florence Nightingale defined nursing as “…the act of utilising the environment of the patient to assist him in his recovery” (Funnell et al. 2009). She determined that the deficiency of factors such as uncontaminated air, clean water, sanitation, hygiene and sunlight is unhealthy to the human being. Furthermore, she reasoned that temperature, environment and nutrition affect the patient (Kozier, et al. 2008).

This theory of nursing includes inspection, recognition of environment changes and their execution and supporting the patient health care by allowing the environment to benefit the patient (Neils, 2010).

Selanders (2010) reviewed and compared this theory’s aspects with modern day practice and reported that Nightingale’s concept, such as air, light, noise and cleanliness is equal to today’s concept of physical environment; health recommendations to psychological environment; food to nutritional status and observation to nursing management. The author also estimated that the theory has been used in several qualitative works and some studies on the childbirth process.

Transcultural Nursing vs. Holistic Nursing Practice

According to Leininger (2002b) patients are not provided full holistic care by health professionals. Factors such as kinship, religion, environment and culture are largely missing. For that reason, care professionals should avoid being judgmental when delivering holistic care and rather provide an all-inclusive care that respects the individual’s cultural background (Maddalena, 2009).

As a student nurse, it is vital to value the development of cultural awareness and competency within the profession in order to encourage and address all stages of holistic nursing practice as it is meaningful to today’s multicultural society. Leininger (1997) also claimed that essential practice is needed to create a regulation of multicultural nursing that could be of use to much ignored cultures.

For example, acute medical treatment, medication, and patient fulfilment can be improved by understanding care beliefs when bringing in nursing care which, in turn, could save the health care system financially and also have a desired positive outcome on patients (Woerner et al. 2009).

Individuals or groups may clash with health professionals if they are not showing respect for each other’s cultural beliefs resulting in poor treatment and patients losing hope in the health care system. Hogg (2010a) also underpinned this understanding as crucial to delivering accurate holistic nursing practice. However, not only patients may lose faith in the system. Hogg (2010b) also affirmed that nurses from black and minority ethnic have suffered, at some point, racial harassment as well as lack of opportunities according to their numbers in the nursing profession.

As holistic nursing practice centres on recognition of patients’ rights and choices (Potter, 2005 cited in Dossey et al. 2005, p.347), it is subsequently supporting the meaning behind multicultural care. The association of both precepts confirms an ongoing engagement to pursue equality and diversity as promoted by the Nursing & Midwifery Council (2008).

“Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status” (The International Council for Nurses, 2005).

When assessing, planning, implementing and evaluating a patient’s needs as to medication, health professionals should take into account culture’s physiologic traits, as it can seriously impact the treatment. For instances, due to genetics, for one patient a normal given dose may develop a reaction whereas for another it may not work at all (Anon, 2005).


It is obvious that cultural competency is a must when performing holistic nursing practice, in order to deliver a responsive and high quality care system. It is therefore recommended that specific cultural training should be given to all health care professionals so as to not overlook the great multi-cultural society we all are in.

As society becomes more diverse, health care professionals should expand guiding principles that sponsor cultural skills as a way to deliver enhanced holistic healthcare.

By carrying out this essay, the author realises the significance of treating people in a holistic way and not making assumptions just because they are from different cultures. This is something that seems yet not to be well implemented in my workplace (NHS since 2007). The author will, from now on, be more aware of his practice when caring for individuals from different culture backgrounds.

It can be considered that nursing as a profession is also an example of human culture so indispensable for a in peak condition community, as seen looking through the theories of nursing and its tools presented in this paper, which if not recognized may affect the execution of holistic practice and its results, i.e. it is a profession whose culture needs to be elastic if it is to fulfil its function.


Andrews, M., M., & Boyle, J., S., (1997) Competence in Transcultural Nursing Care. American Journal of Nursing. [Online]. 97 (8), pp.16AAA-16DDD. Available from:|1|sl_10 [accessed 20th March 2011].

Anonymous, (2005). Understanding transcultural nursing. Nursing 2005. [Online]. 35 (1) p. 21. Available from: [accessed 20th March 2011].

Barnes, D., M., Craig, K., K., & Chambers, K., B., (2000). A review of the concept of culture in holistic nursing literature. Journal of holistic nursing. [Online]. 18 (3), p. 209, Available from: [accessed 11th February 2011].

Beck, D., (2010) Remembering Florence Nightingale’s Panorama: 21st-Century Nursing?At a Critical Crossroads. Journal of Holistic Nursing. [Online]. 28 (4), pp. 293-295. Available from: [accessed 21st March 2011].

Burford, B., (2001). The cultural competence model. In: Baxter, C., (2001) Managing Diversity & Inequality in Health Care. Edinburgh: Harcourt Publishers, pp. 202-203.

Cant, S., Watts, P., & Ruston, A., (2011). Negotiating competency, professionalism and risk: The integration of complementary and alternative medicine by nurses and midwives in NHS hospitals. Social and Science Medicine. [Online]. 72 (4), pp. 529-533. Available from: [accessed 31st March 2011].

Clarke, P., N., McFarland, M., R., Andrews, M., M., &Leininger, M., (2009). Caring: Some Reflections on the Impact of the Culture Care Theory by McFarland & Andrews and Conversation with Leininger. Nursing Science Quarterly. [Online]. 22 (3), pp.234-237. Available from: [accessed 2nd April 2011].

Curren, D., A., (2006). Culture Care Needs in the Clinical Setting. In: Leininger, M., & McFarland, M.,R., (2006) Culture Care Diversity and Universality: A worldwide nursing theory (2nd ed.). Sudbury, MA: Jones & Bartlett, pp. 159-160.

Dossey, B. M., & Guzzetta, C., E., (2005) Holistic Nursing Practice. In: Dossey, B. M., Keegan, L., & Guzzetta, C., E., (2005) Holistic Nursing: A handbook for practice. (4th ed). Sudbury, MA: Jones & Bartlett Publishers, pp. 32-33.

Ellis, H. (2008) Florence Nightingale: creator of modern nursing and public health pioneer. Journal of Perioperative Practice. [Online] 18 (9), pp. 404-406. Available from:[accessed 18th February 2011].

Funnell, R., Koutoukidis, G., & Lawrence, K., (2009). Tabbner’s Nursing Care: Theory and Practice. (5th ed). Chatswood, N.S.W.: Elsevier Australia.

Giger, J., N., & Davidhizar, R., E., (2008). Transcultural Nursing: Assessment and Intervention. (5th ed). Missouri: Mosby Elsevier.

Green-Hernandez, C., Quinn, A., A., Denman-Vitale, S., Falkenstern, S., & Judge-Ellis, T., (2004). Making Primary Care Culturally Competent. The Nurse Practitioner. [Online]. 29 (6), p. 51. Available from: [accessed 30th March 2011].

Harrison, P., (2008). Thinking holistic, thinking integratedJournal of Integrated Care. [Online]. 16 (2) p.44. Available from: [accessed 31st March 2011].

Hogg, C., (2010a). Understanding the theory of health and illness beliefs. In: Holland, K., & Hogg, C., (2010). Cultural awareness in nursing and health care. London: Hodder Arnold, p.16.

Hogg, C., (2010b). Cultural Diversity and Professional Practice. In: Holland, K., & Hogg, C., (2010). Cultural awareness in nursing and health care. London: Hodder Arnold, pp. 203-205.

Howett, M., Connor, A., & Downes, E., (2010).Nightingale Theory and Intentional Comfort Touch in Management of Tinea Pedis in Vulnerable Populations. Journal of Holistic Nursing. [Online]. 28 (4) p. 244. Available from: [accessed 15the March 2011].

Hubbert, A., O., (2006) Application of the Culture Care Theory for Clinical Nurse Administrators and Managers. In: Leininger, M., & McFarland, M., R., (2006) Culture Care Diversity and Universality: A worldwide nursing theory (2nd ed.). Sudbury, MA: Jones & Bartlett, pp. 354-356.

Kozier, B., Erb, G., Berman, A., Snyder, S., Lake, R., & Harvey, S., (2008). Fundamentals of nursing. Concepts, process and practice. Harlow: Pearson Education Limited.

Leininger, M., (1991). Culture care diversity and universality: a theory of nursing. New York: National League for Nursing Press. In: Leininger, M., (1997). Transcultural Nursing Research to Transform Nursing Education and Practice: 40 Years. Journal of Nursing Scholarship. [Online]. 29 (4), p. 344. Available from: [accessed 30th March 2011].

Leininger, M., (1997) Overview of the Theory of Culture Care with the Ethnonursing Research Method. Journal of Transcultural Nursing. [Online] 8 (2), p. 32-51. Available from: [accessed 16th February 2011].

Leininger, M., (2002a). Culture Care Theory: A Major Contribution to Advance Transcultural Nursing Knowledge and Practices. Journal of Transcultural Nursing. [Online]. 13 (3), pp.189-190. Available from: [accessed 25th February 2011].

Leininger, M., (2002b) Founder’s Focus: Linguistic Cliches and Buzzwords in the Culture of Nursing. Journal of Transcultural Nursing. [Online]. 13 (4), p. 334, Available from: [accessed 25th February 2001].

Leininger, M., (2006) Culture care diversity and universality theory and evolution of the ethnonursing method. In: Leininger, M., & McFarland M., R. (2006). Culture care diversity and universality. A worldwide nursing theory. (2nd ed). Sudbury, MA: Jones & Bartlett Publishers. p. 20-22.

Locsin, R., C., (2002). Culture Perspectives. Holistic Healing: A Practice of Nursing. Holistic Nursing Practice. {Online]. 16 (5), pp. ix-x. Available from: [accessed 30th March 2011].

MacKinnon, F., (2010). Holistic Nursing Practice. Available from: [accessed 30th March 2011].

Maddalena, V., (2009). Cultural Competence and Holistic Practice: implications for nursing education, practice, and research. . Holistic Nursing Practice. 23 (3) pp.156-157. Available from:|1|sl_10 [accesed 30th March 2011].

Maier-Lorentz, M., M., (2008). Transcultural nursing: its importance in nursing practice. Journal of Cultural Diversity. [Online]. 15 (1), pp.37-43. Available from: [accessed 30th March 2011].

McEvoy, L., & Duffy, A., (2008). Holistic practice- A concept analysis. Nursing Education in Practice. [Online]. 8 (6), pp. 416-418. Available from: [accessed 30th March 2011].

Narayan, M., C., (2001). Six steps toward cultural competency: a clinician’s guide. Home Health Care Management and Practice. [Online]. 14 (1), p. 41. Available from: [accessed 30th March 2011].

Neils, P., E., (2010). The influence of nightingale rounding by the liaison nurse on surgical patient families with attention to differing cultural needs. Journal of Holistic Nursing. 28 (4) p. 242. Available from: [accessed 26th March 2011].

Nursing & Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. Available from: [accessed 14th February 2011].

Pearcey, P., (2007). Tasks and routines in 21ST century nursing: student nurse’s perceptions. British Journal of Nursing. [Online]. 16 (5), pp. 296-300. Available from: [accessed 31st March 2011].

Phillimore, J., (2011). Approaches to health provision in the age of super-diversity: accessing the NHS in Britain’s most diverse city. Critical Social Policy. [Online]. 31 (1), pp. 5-25. Available from: [accessed 30th March 2011].

Potter, P., J., (2005) The holistic caring process. In: Dossey, B. M., Keegan, L., & Guzzetta, C., E., (2005) Holistic Nursing: A handbook for practice. (4th ed). Sudbury, MA: Jones & Bartlett, p. 347.

Riley, J., B., (2004). Communication in Nursing. (5th ed). St Louis: Mosby.

Roberts, J., H., Sanders, T., & Wass, V., (2008) Students’ perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study. Medical Education. [Online]. 42 (1), p.50. Available from: [accessed 31st March 2011].

Selanders, L., C., (2010). The Power of Environmental Adaptation: Florence Nightingale’s Original Theory for Nursing Practice. Journal of Holistic Nursing. [Online]. 28 (1), p. 84. Available from: [accessed 2nd April 2010].

The International Council for Nurses, (2005). The ICN Code of Ethics for Nurses. Available from: [accessed 20th March 2011].

Woerner, L., Espinosa, J., Bourne, S., O’toole, M., & Ingerson, G., L., (2009). Project Exito!: Success through diversity and universality for outcomes improvement among Hispanic home care patients. [Online]. Nursing Outlook. 57 (5), p.271. Available from: [accessed 30th March 2011].