Discuss Trans cultural Perspectives in Mental Health

Trans cultural Perspectives in Mental Health Nursing

Mental health nursing is a very complex and demanding areas of nursing. This area deals with people who have mental problems. Mental health nursing practice differs from that of the other members of the multidisciplinary team in a variety of ways. Mental health nursing involves nursing that cares for all people of all ages who have mental illness such as schizophrenia, psychosis, dementia and bipolar disorder. The nurses in this field receive more training in psychological therapy unlike the other members of the multidisciplinary team. This helps them build a therapeutic alliance that deals with challenging behavior and the administration of psychiatric medication. The members of the multidisciplinary team may be psychologists, social workers, occupational therapists, psychiatrists and support workers (Chang and Daly, 2007).Trans cultural Perspectives in Mental Health Nursing

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Discussion

The key challenge to these nurses is to form therapeutic relationships with mentally sick people and their families. The main tool for a mental health nurse is strengthening their own personality and communication skills. They need to empathize with the people they deal with and show care and warmth towards them. This branch of nursing is faced with danger of violence often. Therefore, it requires a special skill to recognize build up tension and suppress it.

Skillful mental health nursing requires more than a sound knowledge of human physiology, psychology, pharmacology and psychiatry. The mental health nurses need to understand both the theory and practice of the profession. Unlike the other members of the multidisciplinary team, the mental health nurses practice in inpatient and outpatient mental health clinics. They work with individuals, groups and families. They carry out assessment to patients who attend inpatient wards to understand their nursing needs. Each nurse is assigned a patient. The nurse is supposed to maintain a regular contact with the patient assessing progress and changes in their medical and daily needs. The nurse collaborates with the patient€™s family, friends and the psychiatrist responsible for the patient. The nurse also has the responsibility to coordinate and arrange for further care that may be needed when the patient has been discharged (Ball, 2000).Trans cultural Perspectives in Mental Health Nursing

The nurses talk to the patients whenever the patients feel to talk to them. The mental health nurses carry out counseling and psychotherapy with the mentally ill patients. This may be formal or informal. They have the responsibility of teaching the patients on how to cope with anxiety and relaxation techniques. A charge nurse is responsible for the entire mental health nursing staff and also the nursing care of patients.

A mental health nurse can request an urgent opinion from a psychiatrist when they are concerned with the condition of the patient. This is more so when the nurse feels that the patient may be at risk to himself or herself when he or she leaves the ward. They have the power to detain the patient up to six hours to enable the psychiatrist carry out an assessment on the patient.

The issue of professional boundaries arises because the nature of mental health practice necessitates the development of therapeutic relationships. The beginner nurses may get confused when navigating the complex issues that come along with professional boundaries.

Many areas within the relationship that mental health nurses share with consumers may constitute in to problematic behavior that may include physical contact, gift giving, and self disclosure, personal and social involvement in the work.

A multi disciplinary team is considered as routine in the provision of mental health care within the community. The multi disciplinary team is necessary in mental health care in order to provide a holistic treatment or approach to care. The different professional groups provide complementary approaches that honor the complexity that the consumer has. Each discipline has a body of knowledge and a framework for practice that emphasizes different aspects of how to work with patients and other consumers. A single discipline cannot prepare workers with the range of knowledge and skills required to offer help to the patients with diversification encompassed in mental health practice.Trans cultural Perspectives in Mental Health Nursing

A general practitioner is the first contact person for patients with depression. A general practitioner offers treatment to depressed patients. They offer advice and support to the depressed patient. The general practitioner may refer the patient to a counselor, psychologist or consultant psychiatrist.

Psychiatrists on the other hand works with the community mental team and have responsibility for a number of patients in a hospital ward. They use psychological treatments to help a patient who is depressed. Clinical psychologists see patients who are referred by general practitioners or the mental health team they carry out assessment of the mental health needs of the patient. They do psychological therapies with individuals and groups (Videbeck, 2010).

Community psychiatric nurses provide support to people through difficult periods in their illness. They see patients who are living in the community and not inpatients. They also see patients who have healed to check on their progress. They work with the patient`s family and care givers to cope with the patient and the illness. They receive patients from general practitioners, psychiatrists and inpatient wards (Elder, Evans and Nizette. 2009).Trans cultural Perspectives in Mental Health Nursing

Psychotherapists offer therapy to the patients who are referred to them. They liaise with the person who referred the patient to them and give updates of the patient€™s progress. Counselors offer counseling to the mentally ill patients and others who are in need of their service. They identify the problem that the patient has and help bring out measures of coping with those problems. They work in different places such as hospitals, and general practitioner surgery rooms.

In mental health practice, the nurses carry out almost all of the tasks and duties mentioned above that are carried out by the multidisciplinary team members.

Our knowledge, views, beliefs, attitudes, and approach inform our intervention and care for the consumer in various ways. Our knowledge is a very important device to the consumer in this case, the patient. For a patient to take intervention and care properly and with seriousness they should be educated about the intervention and care that they are to be given. This education should not come from other people but preferably from us, the people who are directly involved and dealing with them. Our knowledge comes in handy because we should provide them with the appropriate and relevant information they require. If we give them the correct information, they are likely to get healed because they will most likely follow what we tell them. However, if we provide them with the wrong information their condition is likely to get worse because we will have misled them.

Consumers who acquire knowledge from their doctors regarding intervention and care in most cases change their lifestyle and show awareness of risk rather than those who are uninformed. Our knowledge provides essential information on the benefits of intervention to the consumer. It guides the consumer in making well informed decisions about their health. Therefore we should ensure that our knowledge is relevant, appropriate and reaches the consumer in the best way they can understand.

Our views, beliefs and attitudes are also very vital in informing interventions and care for the consumer. Patients form their own views, beliefs and attitudes about intervention and care provisions basically from our beliefs, views and attitudes towards the same. The patient may either be positive or negative towards intervention and care based on the experience they get form us regarding the issue. Many depressed patients have negative beliefs and attitudes towards antidepressants. This has led to poor adherence to drugs, low perceived well being, poor role functioning, life quality and unfavorable depression outcome. This could however be rectified if doctors and other multidisciplinary team members develop a positive attitude and belief to the depressed patients through their views about antidepressants.Trans cultural Perspectives in Mental Health Nursing

Our views acts as important mediums of knowledge break down of intervention and care to the consumer in the same way as our knowledge. Consumers take our views regarding intervention as the most appropriate. From our views the patients learn and form their own. This is because they trust the medical practitioners and thus believe whatever views they get from the medical practitioners. If we have a view, belief and attitude that a patient will heal very fast by observing certain intervention measures and care and they know about this, the patient will form a positive attitude towards the care and intervention and this will help so much for instance in the therapeutic intervention and care.

Our beliefs for informing our intervention and care for the consumer can be looked at in two perspectives. Some of us take the dualism belief while others have belief in holism. Dualism originated from the Cartesian philosophy that there is a mind and body duality. The body is the passive agent or vehicle with an immortal soul that is separate and distinct from the body. The concept of dualism has made the body the channel for medication and the mind the domain for religion and philosophy. Those among us that believe in dualism look for only that which can be observed. Their focus is on the deficits within the functioning of the brain. To them the mind does not influence the physical body. They value the meaning of the symptom for the person and understand the impact of the symptom to the patient`s life. This belief if applied when offering intervention and care may be limited in the sense that patients who have lived with mental distress for a long period of time have not found symptoms and problems helpful.

Holistic practice in mental health nursing focuses on healing the whole person knowing the importance of the relationship between biological, psychological, social, and spiritual characteristics of the consumer. Those nurses who believe in the holistic approach state that it is meaningless to separate a person€™s body into parts as if they were discrete entities. They believe that the whole is better than putting together the parts (Barker, 2004).Trans cultural Perspectives in Mental Health Nursing

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They state that a person`s social life cannot be separated from treatment but must be considered putting in mind all aspects of the person. Holistic procedure attends to the patient`s relationship with their own self, others, the society, and their participation within the greater cultural context of the community. They follow certain principles that underlie this practice. These principles include trust, hope respect for individuality and individual freedom allowing people to exercise their rights even when they are sick.

The rights considered are civil, social, and personal rights including the right of choice and dignity of risk. The holistic belief has a well informed and richer nursing experience that validates the complexity of life and cultural and societal experience. Thus our belief in the holistic perspective seems to be very vital to the consumer than the dualism perspective. The belief in the holistic perspective helps us to offer intervention and care to the consumer considering their diverse and different aspects that may help us understand them well enough. Putting together these different aspects like age and gender and combining them to form a whole helps us give the consumer a more relevant care (Finch, 2004).

People who have had the experience of mental distress usually state that when a professional has helped them, it is very important to them and their self worth to respond to treatment. The approach of facilitating, intervention and care for a patient is essential to other fields. Some approaches informing intervention and care may operate at the level of individuals, groups, systems organizations or society. For instance the contract based interventions to improve adherence to treatment and health promotion may be directed to patients, family care givers and other practitioners providing these services.Trans cultural Perspectives in Mental Health Nursing

Psychological treatment of depression assists the patient in a number of ways. It helps take away the pain of depression and hopelessness that comes with depression. It changes the pessimistic ideologies and unrealistic expectations that encourage and sustain depression. This approach helps the patient know the problems that are critical and those that are minor. It helps the patient develop positive life objectives and self assessment.

Our approach must be at the level of patient care. The consumer must be able to understand the intervention and care approach that is being used on him or her. We should not prescribe an approach to a patient without letting them know what approach is being used on them, the benefits of the approach and how it works. A consumer should be told about the impacts of the intervention and care approach being used on them (Happell and Cowin 2008).

The information about the harm and the benefits should be readily availed to the patient. The patient should be included in the decision making concerning the intervention and care approach that will be applied on them. In cases where the patient cannot understand the approach, his or her family members or any other person responsible for them should be made aware on their behalf. As physicians we are supposed to be custodians of our patients. We should be trustworthy to our patients so that they develop a good rapport with us and be free to talk to us. This will help them to bring out issues that may be disturbing them (Burns, Purandare and Craig, 2002).Trans cultural Perspectives in Mental Health Nursing

Mental health promotion is a population based approach to mental health. This approach attends to the mental health status and the needs of the whole population. It emphasizes the need for continuum care from universal prevention to long term individual care with early intervention and treatment. Mentoring can also be used. This aims at promoting growth and development by means of partnerships with other health professionals. It involves problem solving, feedback, support and relationship building. This helps consumers to develop courage to face the problem that the have at hand (Park, Murray and Delaney, 2006).

Mentoring also helps in providing more information to consumers on the problem they are facing and the step that they can take to ensure that it becomes better for them. We could also use the normalization approach to informing on our intervention and care. This is a humanistic model of care for patients with an intellectual disability. They are given rights and opportunities in the same way and magnitude as any other person. This helps us to understand the consumer very well. It helps us know how the patient can act when given an opportunity to exercise his or her free will. This in turn will help us come up with proper intervention and care measures that will benefit the patient in the best way possible and in his situation (Sartorius and Schulze, 2005).

Conclusion

Health consumers and health providers have an interdependent relationship. For the patient to heal, he or she needs the health provider who will offer advice, treat, prescribe medicine or refer him or her to the relevant medical practitioner. The health providers need the health consumer for them to work with. They need people to treat and offer medication and advice to. Without the health consumers, the health providers have no work to do.

Therefore, mental health nursing practice puts nurses in that field on a very sensitive role. They are the ones who do much of the work that the patient requires. Our views, beliefs, attitudes and approaches informing our intervention measures for health consumers should fit the health consumers’ needs and requirements even in cases where the consumer does not know or understand the needs that re required for the condition they are in.Trans cultural Perspectives in Mental Health Nursing

Trans cultural nursing has been integrated into modern nursing education due to the increased heterogeneity of patient populations. As more people from a variety of cultures and with a variety of ethnicity now utilize healthcare facilities, nurses need to be aware of their varying perceptions and levels of tolerance for healthcare. This situation can lead to departures from the practice norms that would otherwise direct patient care, thus opening up a wide array of options regarding treatments and follow-ups. Decision making in patient care involves many important considerations, including patient’s attitudes and how they will react to treatment advice [1-3]. For these reasons, the adaptability of nursing professionals is crucial, particularly when it comes to cultural diversity, because this issue can affect the quality of service provided to patients.

Nurses should have sufficient information about different cultural backgrounds and customs to be able to conduct holistic patient assessments. For optimal care, the completion of a thorough assessment is particularly important when a patient comes from a different culture [4]. The provision of high-quality care builds patient’s comfort and confidence in the healthcare system while promoting patient satisfaction [5]. Therefore, the assessment process should be designed to be accurate, comprehensive, and systematic; in essence, it should assist nurses in reaching concrete conclusions regarding suitable patient interventions [6,7]. To this end, researchers have developed models to help nurses overcome challenges when caring for culturally diverse patients. These models were designed to encourage culturally appropriate and culturally competent care, and the developers of the models emphasize how nurses can use this skill to work effectively with any population [8]. Following an introduction to trans cultural nursing, this paper includes the comparison of four prominent models of cultural competence: Leininger, Giger and Davidhizar, Purnell and Campinha-Bacote [9-12]. It also discusses the application of these models with respect to the present literature and outlines the recommended standards for achieving best practices.Trans cultural Perspectives in Mental Health Nursing

Concepts and Definitions

Trans cultural nursing refers to various culture-related aspects of healthcare delivery that can affect disease management and the status of individual’s health and well-being [13]. The main objective of trans cultural nursing is to promote the delivery of culturally congruent, meaningful, high-quality, and safe healthcare to patients belonging to similar or diverse cultures [13]. Accordingly, when different cultures are studied, healthcare professional scan understand their similarities and differences. Culture affects an individual’s concepts and approaches to health and illness. Because nurses need to care for patients belonging to different cultures, cultural competence is essential for nursing [14].

Culture care emphasizes consideration of a patient’s beliefs and heritage when developing a healthcare plan. Moreover, it requires nurses to acknowledge that individuals belong to different cultures and races and, therefore, necessitating treatment that respects the uniqueness of each individual [15]. Trans cultural nursing employs the concepts of ethnicity, race, and culture in order to understand individual’s perceptions and behaviors. Nurses must consider these concepts in order to deliver culturally congruent healthcare. The nursing literature has developed a variety of applicable concepts, including acculturation, cultural awareness, and cultural competence.Trans cultural Perspectives in Mental Health Nursing

In addition, certain culture-related concepts are particularly relevant to healthcare and nursing [15]. These include culture, race, ethnicity, and cultural competence. Culture refers to a set of beliefs, assumptions, values, and norms that a group of individuals largely observe and transfer across generations [16]. Ingram defined culture as a learned worldview demonstrated by a group of individuals that is transferred socially [17]. Culture affects the beliefs, values, norms, and behaviors of individuals, and it is reflected in language, food, dress, and social institutions. Culture can significantly affect various aspects of human life, including health and preferences for managing health conditions. Multicultural trends are emerging in numerous countries due to globalization and mass immigration [17].

Each culture has distinct characteristics and therefore, individuals belonging to different cultures can differ considerably. These differences must be respected and each individual treated as a unique human being. Indeed, even people belonging to the same race may differ culturally. Race is a social classification based on physical characteristics like skin color [16]. It can also serve as an identifying trait of a culture. Similarly, ethnicity indicates cultural membership based on people having similar cultural characteristics that have led to a common history. Ethnicity tends to remain with people throughout their lives [16].

Cultural competence refers to a set of culturally congruent practices, behaviors, and policies that allow nursing professionals to deliver high-quality services in a variety of cross-cultural scenarios [16]. Cultural competence is an essential requirement in nursing. Culturally congruent healthcare does not aim to facilitate patient care for ethnic or racial minority groups only; rather, the objective is to improve healthcare delivery by considering differences in age, gender, religion, and socioeconomic status [18].

Healthcare professionals, especially nurses, should make an effort to understand and learn about different cultures. Understanding a patient’s religious and cultural background can be highly beneficial in delivering healthcare. This understanding may cause healthcare professionals to evaluate their own cultural and religious beliefs, which may in turn influence their practices [19]. Such cultural awareness denotes an individual’s self-awareness of his or her own cultural background, differences, and biases. Acculturation, on the other hand, signifies the process of learning about a new culture. Nurses should adapt to different cultures by making modifications to their nursing practices [20].Trans cultural Perspectives in Mental Health Nursing

Evolution of Trans cultural Nursing

Lingering uncovered a core concept of care during her early education; this concept later became her motivation to specialize in trans cultural nursing specifically [9]. She explained this concept as a fundamental nursing component based on her experience and positive feedback from patients. During her work at a child-guidance home, she experienced a cultural shock, leading her to realize that a lack of understanding regarding cultural diversity could explain recurrent behavioral patterns in some children. She recognized a major deficit in understanding differential patient demands in the context of care and wellness. She maintained that the quality of nursing education suffered due to the absence of training in cultural diversity, the result being a disconnect between patient and nurse.

The theorist’s identification of this problem shaped a new paradigm in nursing care, leading to the advent of trans cultural nursing [9]. Lingering defined trans cultural nursing as an area of study that focuses on comparative cultural care based on the beliefs, practices, and values of care-seeking patients. Its main purpose is to provide both universal and culture-based nursing practices that promote well-being and health. Additionally, it aims to help patients overcome illness in a culturally intelligent and responsive manner [16].

Models of Trans cultural Nursing

Trans cultural nursing models provide nurses with the foundation required for gaining knowledge about different cultures during healthcare delivery. The models are under continual development and they guide nursing practice all over the world. Hence, this paper focuses on the four particularly significant models.Lingering Sunrise Model Trans cultural Perspectives in Mental Health Nursing

The Leininger Sunrise Model represents the structure of culture care theory by describing the relationship between anthropological and nursing beliefs and principles [9]. Nurses use this model when making cultural evaluations of patients. The model connects the concepts of the theory with actual clinical practices, while offering a systemic approach to identifying values, beliefs, behaviors, and community customs. The model encompasses numerous aspects of culture: religious, financial, social, technological, educational, legal, political, and philosophical dimensions. These factors, along with language and social environment, significantly affect the services delivered by systems, whether traditional or professional. Traditional healthcare systems are based on conventional beliefs related to health, whereas professional systems rely on learned knowledge, evidence-based practice, and research [13]. The nursing profession considers patients’ physical, spiritual, and cultural needs. A thorough understanding of these needs facilitates the achievement of desired clinical outcomes. Moreover, Leininger’s model helps healthcare professionals to avoid the stereotyping of patients [13]. To accomplish such goals, the model utilizes three concepts: culture care maintenance/preservation, culture care negotiation/accommodation, and culture care restructuring/re patterning. Cultural preservation refers to nurse’s provision of support for cultural practices, such as employing acupressure or acupuncture for anxiety and pain relief prior to medical interventions. Similarly, cultural negotiation refers to the support provided to the patients and their family members in carrying out cultural activities that do not pose threats to the health of the patients or any other individual in the healthcare setting. Finally, cultural restructuring refers to nurse’s efforts to deliver patient-centered care by helping patients modify or change their cultural activities. Cultural restructuring is suggested only when certain cultural practices may cause harm to the patient or those in the surrounding environment. These concepts can inform nurses in achieving their ultimate goals [16].Trans cultural Perspectives in Mental Health Nursing

Giger and Davidhizar Trans cultural Assessment Model

This model emphasizes the importance of considering every person as unique in his or her culture [10]. According to Giger and Davidhizar, there are six dimensions common to every culture: communication, space, social organization, time, environmental control, and biological variation [10]. The first dimension is communication, which is the holistic process of human interaction and conduct. The use and preservation of communication takes several forms – verbal, nonverbal, and written – and differs in terms of expression, language and dialect, voice tone and volume, context, emotional implication, facial expression, gestures, and body language. Language can become a barrier to quality healthcare due to simple misunderstandings and failure to communicate as intended. The second dimension is space, which is the distance maintained between interacting individuals; this “personal space” differs according to individual’s cultural backgrounds. The concept of space involves three other behavioral patterns: attachment with objects in the environment, body posture, and movement in the setting [10]. It is important to observe tact and to avoid overstepping boundaries with respect to these aspects of interaction, because doing so can cause patients unnecessary anxiety. The third dimension is social organization, which is how certain cultures group themselves in accordance with family, beliefs, and duties. This dimension requires nurses to remain aware that patient conduct can be influenced by factors like sexual orientation, acknowledgement and utilization of titles, and decision-making regulations. An awareness of this dimension can help nurses avoid being perceived as being derogatory or disrespectful. The fourth dimension is time, which is similar to social organization in terms of influence. Time is subdivided into whether the group is clock-oriented, like most Westerners, or socially oriented. The clock-oriented group is fixated on time itself, and individuals with this orientation seek to keep appointments so as not to be seen as ill-mannered or offensive. The behavior of socially oriented groups emphasizes the here and now. Such individuals understand time as a flexible spectrum defined by the duration of activities; an activity does not begin until the preceding event has ended. The fifth dimension is environmental control, which implicates how the person perceives society and its internal and external factors, such as beliefs and understandings regarding how illness occurs, how it should be treated, and how health is uplifted and maintained. The sixth and last dimension is biological orientation. Races vary biologically due to differences in DNA, and some races are more prone to certain diseases than others. Other notable elements of this model are a deeper understanding of pain tolerance and deficiencies and predilections in nutrition [21,22].Trans cultural Perspectives in Mental Health Nursing

Parnell Model for Cultural Competence

The Parnell model focuses on providing a foundation for understanding the various attributes of a different culture, allowing nurses to adequately view patient attributes, such as incitement, experiences, and notions about healthcare and illness [11]. This model is presented in a diagram with parallel circles that represent aspects of global society as well as the community, family, and person. The Parnell model includes twelve domains: overview or heritage, communication, family roles and organization, workforce issues, bio-cultural ecology, high-risk behaviors, nutrition, pregnancy, death rituals, spirituality, healthcare practices, and healthcare professionals [11]. Purnell considered these domains to be important in evaluating the traits and characteristics of various ethnic groups. The model can be depicted with a frame representing global society and an outer circle signifying community. The second circle signifies family, and the innermost circle depicts the individual [23].Trans cultural Perspectives in Mental Health Nursing

The first domain is culture and heritage, which includes the country of derivation, the geographical influence of the original and present home, political affairs, economics, educational status, and profession. The second domain comprises important notions relevant to communication, such as primary language and dialects, circumstantial effectiveness and convenience of the language, para linguistic differences, and nonverbal communication. The third domain, family roles and organization, involves who heads the household in terms of gender and age. The organization of the family is affected by goals and priorities, developmental tasks, social status, and alternative lifestyles. The fourth domain is workforce issues, including acculturation, autonomy, and the presence of language barriers. The fifth domain includes factors of bio-cultural ecology, which encompass observable differences with respect to ethnic and racial origins, like skin color and other physical variations. The sixth domain is high-risk behaviors, such as using tobacco, alcohol, or recreational drugs. This domain also includes physical activity and levels of safety or precautions taken. The seventh domain is nutrition. Depending on their place of origin, individuals or groups are accustomed to certain foods and draw meaning from the foods they eat. Food consumption associated with certain rituals may affect health. Some ethnic groups suffer from certain nutritional limitations and deficiencies. The eighth domain is pregnancy. Pregnancy is viewed differently, because there are a myriad of beliefs accompanying this life phase. The act of birthing and the postpartum period involve certain practices that need to be taken into consideration when dealing with a particular ethnology-cultural group. The ninth domain is death rituals. Perceptions of death differ from culture to culture in terms of how death is accepted, what rituals are performed, and how one should behave following a death. The tenth domain is spirituality, which includes religious practice, use of prayer, individual strength, the meaning of life, and how spirituality relates to health. The eleventh domain reflects healthcare practices. This domain includes the responsibility for health and the barriers that must be overcome to achieve successful health outcomes. Healthcare practices include traditional practices, magical religious practices, chronic-disease treatment and rehabilitation, mental-health practices, and the roles of the sick. The twelfth and final domain, healthcare professionals, involves the perceptions and roles of traditional and folk healthcare practices [24].Trans cultural Perspectives in Mental Health Nursing

Camping-Bacote Model of Cultural Competence in Healthcare Delivery

Campinha-Bacote first developed her model, known as “cultural competency in the delivery of healthcare services,” in 1998, revising it in 2002 [12]. The model considers cultural competence not as a consequence brought about by certain factors, but as a process. The concept of cultural competence can be defined as a process in which the nurse attempts to achieve greater efficiency and the ability to work in a culturally diverse environment while caring for the patient, whether an individual, a family, or a group [12]. To achieve cultural competence, a nurse must undertake a process of developing the capacity to deliver efficient and high-quality care, a process that encompasses five components. The first involves cultural awareness, a process in which healthcare professionals consciously acknowledge their own cultural backgrounds, which helps them avoid biases toward other cultures. The second component is cultural skill, defined as the ability to obtain the necessary information from patients via culturally-appropriate conduct and physical assessment. The third component is cultural knowledge, a process in which healthcare professionals open their minds to understand variations in cultural and ethnic traits as they relate to patient attitudes toward illness and health. The fourth component is cultural encounter during which stereotyping is avoided through the interaction between healthcare professionals and members of different cultures. During this process, over reliance on conventional views is discouraged. The fifth and last component is cultural desire, which is the driving force for becoming educated, skilled, competent, and aware of culture; it also presumes a willingness to have trans cultural interactions [25].

Discussion across Models

Trans cultural nursing models have played a significant role in forming the basic foundations of nursing practice. Despite their positive contributions, the trans cultural models have been criticized for their limitations and failure to acknowledge certain issues related to the educational and practical components of trans cultural nursing [8]. For example, the Leininger model has been critiqued for failing to acknowledge political and structural processes. Critics have argued that it focuses exclusively on cultural diversity, biases, conventional views, and the inequity between nurses and patients. According to these critiques, the model also fails to acknowledge that cultural diversity needs to go beyond between group differences and be understood from the perspective of differences among individuals from the same culture, due to varying socioeconomic backgrounds, age groups, and types of communities. Conversely, the model has been praised for its clear and simple way of evaluating professional and societal cultures [3].Trans cultural Perspectives in Mental Health Nursing

Integrating cultural competence models are a beneficial addition to nursing curricula and clinical training in undergraduate and graduate nursing programs [26-28]. Numerous studies have investigated how these models can be integrated effectively into nursing curricula. Kardong-Edgren and Campinha-Bacote assessed the effectiveness of four nursing programs’ curricula in producing culturally competent graduates [29]. Two of these programs had adopted models advocated by trans cultural-nursing theorists, such as Campinha-Bacote and Leininger. One of the other programs used an approach that integrated concepts from various models. The remaining program involves a free-standing course with no specific model used. According to the study’s results, graduating nursing students scored in the culturally aware range, as measured by the Campinha-Bacote’s Inventory for Assessing the Process of Cultural Competency among Healthcare Professionals-Revised (IAPCC-R) questionnaire, regardless of which program they attended [29].

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This finding is consistent with Noble and Rom’s study that employed the Campinha-Bacote model and an adaptation of the IAPCC-R questionnaire to evaluate an educational intervention’s effectiveness in strengthening the cultural competence of nursing students in Israel [30]. Nobel and Rom found that cultural knowledge among the students was low because they lacked an understanding of how cultural knowledge can be integrated with nursing interventions and applied in patient care. They also reported that employing a cultural competence program significantly enhances the level of cultural awareness among students, a realistic goal for undergraduate nursing students. Nobel and Rom also note that it may be more appropriate for faculty to expect a high level of cultural competence to occur after graduation [30]. Nobel and Rom also suggested that the usefulness of this approach was enhanced by allowing faculty who had experience with culturally competent care to share their expertise with faculty who were deficient in this respect [31,32].

The nursing program based on the Giger-Davidhizar transcultural assessment model was an appropriate guide for faculty to impart the skills necessary for culturally responsive and competent care with respect to six healthcare phenomena [10]. This simple and modern elaboration of the Leininger model is used to assess and strengthen nurses’ acknowledgment of cultural diversity. Giger and Davidhizar take an approach that is different than Lininger’s Sunrise Model, arguing that not every individual of the same culture or ethnicity behaves in the same manner. First developed in 2004, the model is used to help undergraduate nursing students provide and assess health care for individuals from varying cultural backgrounds. The current version of the model sets a framework that enables nurses to assess culture’s role in health and illness. It can also serve as an academic and clinical framework for developing cultural competence [21].Trans cultural Perspectives in Mental Health Nursing

In addition, the Purnell model is a framework that can be employed to incorporate trans cultural competence into nursing practice [11]. Lipson and Desantis noted that the Purnell model often is used in undergraduate communication and health assessment programs [22]. This model can be used by all healthcare professionals in both their practice and academic development. As a result, the model represents an organizing framework that utilizes precise questions and provides a helpful format for assessing culture in clinical settings. Flexibility is one of the strongest features of the Purnell model, enhancing its applicability in various healthcare contexts. Moreover, the model’s healthcare framework allows nurses to learn the different characteristics and concepts of cultural diversity. The model interlinks historical elements and their influence on a person’s international cultural perspective and elaborates on the chief relationships of culture, thus allowing culturally competent care [22]. The model’s framework encourages nurses to consider and reflect on the unique characteristics of every patient, including their views of illness, motivation, and healthcare. Finally, the model’s structure facilitates the analysis of cultural data, allowing nurses to cater to families, groups, and individuals in terms of their respective cultural uniqueness using various communication strategies [24].

Critical Appraisal of Trans cultural Models

Brathwaite compared several trans cultural nursing models using the following criteria: comprehensiveness, logical congruence, conceptual clarity, level of abstraction, clinical utility, and perspective [33]. Only the Campinha-Bacotecultural-competence process model met all of Brathwaite’s criteria. Brathwaite’s review indicated that the Campinha-Bacote model incorporates five components (cultural awareness, cultural skills, cultural knowledge, cultural encounters, and cultural desire) that build upon one another in a logical progression, providing concise outcomes for interventions, a clear description of processes, and an immediate clinical benefit in optimizing patient care planning. Furthermore, the nursing literature indicated that the Campinha-Bacote model is the one most often used as a framework for research and is frequently cited. In addition, several authors have indicated that Campinha-Bacote model is suitable as a framework for incorporating cultural competence into their practice [6,34,35].

Despite the criticisms of some transcultural nursing models, they remain a significant part of nursing education and practice. Nurses can benefit from the Leininger model by learning a simple method of exploring professional and societal culture [9]. Additionally, Giger and Davidhizar’s six components can enhance their understanding of the processes of observation and reflection [10]. On the other hand, the major assumptions of the Purnell model for cultural competence and their associated framework involves drawing on a broader perspective, which makes them applicable to all healthcare environments and practice disciplines [11]. Finally, the Campinha-Bacote model holds more immediate appeal, because it helps in addressing cultural competence with respect to healthcare delivery [12].Trans cultural Perspectives in Mental Health Nursing

Establishing Best Practice Standards in Cultural Competence Nursing Education. In order to establish quality nursing care, optimum standards for both local and global settings need to be developed in the nursing profession [36]. Nursing requires a distinct approach, one that involves reaching successful endpoints of traditional education and strategies necessary to achieve such goals. Salminen et al. point out the significance of acknowledging the demonstration of competency categories [37].

They offer recommendations for dealing with the future challenges pertaining to nursing education. For instance, they recommended requiring competency courses for nursing students and practicing nurses in their academic curricula and continuing education workshops, respectively. These courses and workshops may include subject-specific content, learning strategies, and assessments for acquired learning. In addition, successfully addressing the needs of culturally diverse populations ultimately requires the combination of theoretical research and clinical practice [38]. Ensuring the provision of high-quality nursing education is guided by local, national, and international guidelines that lead to universal standards of culturally sensitive healthcare practice to disseminate knowledge by means of cross-cultural activities and encourage the understanding of diverse populations [39].

Conclusion

This paper discussed the trans cultural nursing models of Leininger, Giger and Davidhizar, Purnell, and Campinha-Bacote. No particular model was deemed superior to the others; all four have made and can make significant contributions to nursing education and practice. Leininger developed her model to bring about the practice of culturally congruent nursing. Her research gave rise to the concept of transcultural competence in nursing. Giger and Davidhizar focuses on the individual, not just the cultural group, seeing each individual as culturally unique from the perspective of the six dimensions. Purnell created a diagrammatic representation containing twelve cultural domains, which determine variations in values, beliefs, and practices of an individual’s cultural heritage. Campinha-Bacote defines cultural competence as a process instead of merely an endpoint. Overall, the Campinha-Bacote model is sufficiently comprehensive to guide empirical research and the development of educational interventions. The model’s five components can be used to strengthen the cultural competence of nurses practicing in countries all over the world.

Diversity in the Nursing field is essential because it provides opportunities to administer quality care to patients. Diversity in Nursing includes all of the following: gender, veteran status, race, disability, age, religion, ethnic heritage, socioeconomic status, sexual orientation, education status, national origin, and physical characteristics. Communication with patients can be improved and patient care enhanced when healthcare providers bridge the divide between the culture of medicine and the beliefs and practices that make up a patient’s value system.Trans cultural Perspectives in Mental Health Nursing
When the Nursing workforce reflects its patient demographic, communication improves thus making the patient feel more comfortable. A person who has little in common with you cannot adequately advocate for your benefit. Otherwise, you might as well have a history teacher in charge of advanced algebra.
If you have Nurses who understand their patient’s culture, environment, food, customs, religious views, etc, they can provide their patients with ultimate care. Every healthcare experience provides an opportunity to have a positive effect on a patient’s health. Healthcare providers can maximize this potential by learning more about patient’s cultures. In doing so, they are practicing cultural competency or cultural awareness and sensitivity.

According to www.acog.org, Cultural competency, or cultural awareness and sensitivity, is defined as, “the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self-awareness, knowledge of a patient’s culture, and adaptation of skills.”
Our demographics are changing and our healthcare providers would be wise to hire Nurses from a variety of backgrounds that reflect their changing patient population. Usually health systems that value representation are more valuable to its patients. For centuries, the United States has incorporated diverse immigrant and cultural groups and continues to attract people from around the globe. Currently minorities outnumber whites in some communities in the United States.
Many cultural groups, including gay and lesbian individuals; individuals with disabilities; individuals with faiths unfamiliar to a practitioner; lower socioeconomic groups; ethnic minorities, such as African Americans and Hispanics; and immigrant groups receive no medical care or are grossly under-served for multiple reasons. Lack of diversity and inclusion of healthcare providers is one of the reasons these groups receive inadequate medical care.

Diversity and inclusion is the combination of different cultures, ideas, and perspectives that brings forth greater collaboration, creativity, and innovation, which leads to better patient care and satisfaction. This is the direction in which healthcare needs to go in order to better the health of our current and future demographics.
Diversity is an increasingly important factor in the provision of health care in the UK. As racial and cultural diversity increases, it becomes more likely that nurses will encounter patients from backgrounds other than their own (Davidhizar & Giger, 2004). This paper will present various definitions of diversity and its related terms. Then, the health care needs of a diverse group will be explored, along with the impact of prejudice and some suggestions as to how the multi-professional team can respond the care needs of diverse populations. Addressing diversity is likely to benefit not only patients, but also health care providers and organizations (Bullas, 2003).Trans cultural Perspectives in Mental Health Nursing

Diversity, Culture, Race, and Ethnicity
Diversity usually means a good thing, as in “community” or “equality” (Alexis, 2005). Diversity may include ethnicity, gender, disability, age, or sexuality and is related to social identity or membership in groups whose members share many common experiences and needs (Robb & Douglas, 2004). Diversity also means any difference putting one in a minority (Bullas, 2003).

The terms race, culture and ethnicity are often used interchangeably, but they define different characteristics of people (Watt & Norton, 2004). Culture is the set of rules, meanings and ideas shared by a group that informs their world view and dictates behavior (Watt & Norton). According to Davidhizar and Giger (2004), culture is “a patterned behavioural response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations” (pp. 48-49). Culture is both innate and a product of environment, is shaped by values, customs, and beliefs of the shared group, and is significant in influencing behaviors and giving meaning to phenomena (Davidhizar & Giger, 2004).

Ethnicity refers to cultural attitudes and practices characterizing a given group and distinguishing them from other groups based on a political and historical context (Watt & Norton, 2004). Ethnicity does not imply a biological basis for differences, but is based upon similarities derived from group membership (Robb & Douglas, 2004).
Race refers to the assumed differences in biological backgrounds, and is considered by some to be a contentious term (Watt & Norton, 2004). There are fewer genetic differences between racial groups than within them (Robb & Douglas, 2004). Racial and biological differences are much narrower than cultural differences which include varied values, beliefs, and interpretations of things (Davidhizar & Giger, 2004). For the purposes of this paper, diversity will refer to any difference putting one in a minority.
Factors affecting Health in Immigrants from Diverse Backgrounds

Health results from a complex combination of economic, political, biological, psychological spiritual and familial factors (Striepe & Coons, 2002). Thus health care providers need to assess all the underlying factors for the presenting health concern, and to respond to the relational or environmental factors that may influence health (Striepe & Coons, 2002).

People from distinct, special population groups are likely to have common cultural beliefs affecting their health including family values, reliance on alternative medicine, and religious or spiritual beliefs (Ramirez, 2003). Health may be low on the priority list of recent immigrants due to numerous other pressing needs (Hepinstall, Kralj & Lee, 2004). These individuals have often suffered trauma just getting to the UK, and then face major life changes once there—leaving them vulnerable to poor health (Hepinstall, Kralj & Lee, 2004). Furthermore, immigrants often have little control over their lives, live in poverty, and receive hostile, abusive treatment by others. Hepinstall and colleagues (2004) point out that the NHS may not be prepared to deal with the mental and physical sequelae of torture that many asylum seekers bring with them. Refugees and those seeking asylum likely experience various deprivations that can have a severe impact upon their health (Bullas, 2003). They may have certain illnesses based on country of origin, acquired during their flight to the UK, or acquired once they reach the UK (Hepinstall, Kralj & Lee, 2004). Furthermore, many people from different cultures will not have a frame of reference for the western health system, and thus will not know how to even begin to access care (Hepinstall, Kralj & Lee, 2004).
Honoring diversity means giving patients equal access to services, based on need, no matter what their differences (Bullas, 2003). Bullas (2003) described several cultural factors which may impact access to care. These include: rituals practiced around major life events; dietary habits; needs during times of cultural festivals or observances; presentation of symptoms and the response to assessment and treatment; language and communication; body language (e.g., eye contact and personal space); and the ability to access and use information (e.g., literacy, vision or hearing impairment, learning ability).
Language barriers can negatively impact access to quality health care (Ramirez, 2003). Trans cultural Perspectives in Mental Health Nursing

Cultural competence is partially related to the use of language in communication. Bullas (2003) reports that as many as 600,000 people are unable to communicate with health professionals because of inadequate English language skills. Differences in communication styles may become problems when they prevent the patient from asking questions or understanding her care, or when the patient herself is misunderstood (Robb & Douglas, 2004). Patient non-compliance with advised therapy may be an untoward consequence of discordance between health beliefs of the provider and the patient (Harmsen et al., 2003).

Such discordance may affect the way in which problems are presented and the outcome of the clinical visit (Harmsen et al., 2003). Research has shown that communication in consultation between GP’s and patients who do not speak the native language is less effective than in consultations with persons speaking the same language as the GP (Harmsen et al., 2003). In fact, communication in those with like backgrounds may be insufficient in 25% of cases, while in those with dissimilar backgrounds, it may be as high as 50% (Harmsen et al., 2003).

Better training of health care workers to communicate effectively with diverse individuals—both linguistically and culturally—is an important part of improving their care (Ramirez, 2003). More research and research funding is necessary in order to improve patient-provider communication with diverse populations (Ramirez, 2003). Interpreting services can be a valuable tool to use with non English speaking patients. There is a free, nationally available telephone interpreting service through NHS Direct at every NHS site (Hepinstall, Kralj & Lee, 2004). Use of family members (especially children) is to be avoided except for emergencies (Hepinstall, Kralj & Lee, 2004). The gender of the interpreter may be important for women from some cultures. In addition, one should keep in mind that two speakers of Arabic may be from rival cultures (Hepinstall, Kralj & Lee, 2004). When interpreting services are not available, providers should use careful listening, pay attention to body language, and even use mime or drawings to communicate (Hepinstall, Kralj & Lee, 2004). When caring for culturally diverse families, providers should use flexibility in verbal and non-verbal communication, should speak slowly and clearly, avoid the use of slang terms, and be patient yet observant for any misunderstandings created by a language or cultural barrier (Cioffi, 2002, p. 300).

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Health care providers may have to seek the services of a bi-lingual health care worker or interpreter (pp. 301-302). In addition, it may be beneficial to learn some basic words in other languages. For example, in the context of midwifery, one should learn words such as “push”, “don’t push”, “breathe”, etc. (p. 303).
It is almost impossible to unravel the effects of social deprivation, racism and social isolation that are so much a part of society today (Hutchinson & Hickling, 1999, p. 165). However, women immigrants have a dual burden of being both culturally diverse, and being female. Power over socioeconomic determinants of health is differentially distributed in women than in men. “Gender determines the differential power and control men and women have over the socioeconomic determinants of their…health and lives, their social position, status and treatment in society, and their susceptibility and exposure to specific mental health risks” (WHO, n.d., no pagination). Many of women’s gender based risks are connected to discrimination, exposure to poverty, and socioeconomic disadvantage (WHO, n.d., p. 3), as well as income and insurance status (WHO, n.d., p. 4), gender-based violence, subordinate social status, and a high level of required care for others. For example, there is a positive relationship between the frequency and severity of such social factors and the frequency and severity of mental disorders in women.

The traditional gender roles of women, stressing passivity, submission, and dependence, may increase susceptibility to mental illness (WHO, n.d., p. 3). The female gender role suggests “unremitting care of others and unpaid domestic and agricultural labour” (WHO, n.d., p. 3). Desirable feminine characteristics are similar to those of both depression and low social rank (WHO, n.d., p. 12). There is a need for gendered health policy and gender-specific health risk-reduction strategies. Also, there should be accessible, gender sensitive health services (WHO, n.d., p. 10). Accessibility to health care services for women can be increased by having short waiting times, providing evening and weekend hours, and being near public transportation routes (WHO, n.d., p. 10). Trans cultural Perspectives in Mental Health Nursing

Some have argued that the conventional health system may neglect the values of patients who prefer a non-individualist lifestyle to a more conventional, self-reliance based lifestyle (Leighton, 2005). Examples are those living in a pastoral-communal setting based on retreat, interdependence, and naturalism. Further, it should not be assumed that immigrant women do not share western attitudes about such topics as contraception (Hepinstall, Kralj & Lee, 2004). However, many women will be ambivalent about using contraception—not wanting to use it, but also not wanting to have more children.
Mental health is an especially important topic in immigrants—especially those seeking asylum. Care should be taken not to pathologise normal responses to trauma such as grief (Hepinstall, Kralj & Lee, 2004). “It is important to acknowledge the resilience of individuals and communities and not label people with diagnoses that may add to their stigma and powerlessness” (Hepinstall, Kralj & Lee, 2004, p. 51).

Impact of Assumptions, Prejudices, and Stereotyping upon Health Care Delivery
When caring for patients from different cultures, nurses and other care providers may make assumptions about the perspective and needs of these patients (Komaromy, 2004). When diversity is seen as “otherness” it can become seen as the other’s problem that the “non-diverse” individual does not have to deal with (Keys, 2005). The language associated with immigrants is often negative—such as flooding, overrunning, illegal, burden (Hepinstall, Kralj & Lee, 2004). Asylum seekers are often treated poorly and little consideration is given to their skills and potential to make positive contributions to the UK (Hepinstall, Kralj & Lee, 2004).
Individuals often make generalizations based on characteristics such as ethnicity or gender, while ignoring differences within groups and similarities between groups. This may lead to care provided based upon shared assumptions related to group membership (Robb & Douglas, 2004). Such generalizations or stereotypes are usually negative as they are defined by the majority or the group in power (Robb & Douglas, 2004). In addition, immigrants should not be seen as vectors of disease (Hepinstall, Kralj & Lee, 2004).

Responding to Diverse Health Care Needs
In addition to the above, several suggestions can be given for nurses, the multi-professional team, and health care agencies to improve care for diverse groups including immigrants from abroad. Some suggestions include: appreciation of variations in effective responses to illness; sensitivity to variations in communication styles and in the communication or lack of communication of negative signs and symptoms; having an understanding that the meaning if symptoms may vary between cultures; and having an understanding of common biological variations (Davidhizar & Giger, 2004). Interdisciplinary care will be most effective when team members communicate and synchronize interventions to offer contextual, gender and culture-specific assessment and treatment to help diverse patients make informed decisions about their health (Striepe & Coons, 2002).

Nurse managers in NHS Trusts should develop strategies emphasizing the importance of race and ethnic composition in relation to health in diverse populations (Chevannes, 1997). Care given should be based on objective assessment, ethnically derived, and not based upon assumptions of the care giver (Chevannes, 1997). Initiatives to improve communication with non-English speaking populations include providing interpreters and publishing literature in other languages (Robb & Douglas, 2004). Trans cultural Perspectives in Mental Health Nursing

Cultural differences need to be taken into account in nursing education, research and practice (Gerrish, 1998). Some suggestions for how nurses and agencies may respond to diverse care needs include providing immigrants with opportunities to volunteer in health clinics and consulting with community leaders to identify ongoing problems (Gerrish, 1998). According to Gerrish (1998), “For efficient and appropriate care, practitioners need to understand the values and cultural prescriptions operating within the patient’s culture, particularly those that may impinge upon the patient’s conception of health and illness Trans cultural Perspectives in Mental Health Nursing

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